Aluminum silicate-containing psammoma bodies in a cervicovaginal smear (Pap): cytological, ultrastructural, and radiographic microprobe studies

Diffuse Malignant Peritoneal Mesothelioma Presenting with Psammomatous Calcification on a Cervical Smear

BACKGROUND

Psammoma bodies in cervical smears are rare but may be associated with benign and malignant diseases of the female genital tract.

CASE

A 52-year-old nulliparous woman presented with a 2-month history of intermittent vaginal spotting and post-coital bleeding. A cervical smear showed an inconclusive high-grade glandular lesion with psammomatous calcification. Previous cervical smears had been normal. This smear contained papillary tissue fragments, occasional spheres of gland-like cells and frequent psammoma bodies. The patient underwent a laparoscopic hysterectomy, bilateral salpingo-oophorectomy and omentectomy. The surface of the omentum and both ovaries contained psammoma bodies with groups of cells identical to those in the cervical smear. Within the omentum, there were invasive malignant epithelioid cells positive for CK7, CK5/6, calretinin, D2-40, WT-1, CK5/6, p16 and EMA. Desmin and PAX-8 immunostains were negative. There was also evidence of BRCA1-associated protein 1 (BAP1) dysfunction compatible with diffuse malignant peritoneal mesothelioma (DMPM).

CONCLUSION

We describe the first reported case of DMPM presenting with an abnormal cervical smear, a rare but important differential diagnosis to consider in abnormal cervical smears showing psammomatous calcification.

Psammoma bodies in cervicovaginal cytology specimens: A clinicopathological analysis of 31 cases

BACKGROUND

Psammoma bodies in cervicovaginal cytology specimens are associated with malignant and benign conditions. Few studies have evaluated which features distinguish patients with underlying malignancy from those with benign conditions.

METHODS

Pathology files were searched for cervicovaginal specimens having psammoma bodies. The cytology specimen was assessed for the background, glandular atypia, squamous atypia, and presence of non-psammomatous calcifications. Clinical data was obtained from chart review.

RESULTS

Nineteen women (mean age 42.7 years) had benign outcomes. None had signs or symptoms suggesting malignancy. None had highly atypical or malignant appearing glandular cells. Twelve women had malignant neoplasms (mean age 56 years), including 6 with recurrent disease. Four women without prior malignancy had worrisome signs including bleeding or mass. All six women with prior malignancy had signs of recurrent disease. All specimens contained highly atypical or malignant glandular cells.

CONCLUSIONS

The only cytologic feature predictive of outcome was the presence of highly atypical glandular cells in the specimen (P = 0.001), but these cells may be few. Women with underlying malignancy were older than those with benign outcome (P = 0.014) and more likely to be postmenopausal (P = 0.05). Women with malignancy had signs that warranted additional investigation whereas those with benign outcome were usually asymptomatic (P = 0.001).

Psammoma bodies in cervicovaginal smears: significance and practical implications for diagnostic cytopathology

The traditional association of psammoma bodies with some malignancies of the gynecologic tract raises potentially significant management difficulties when such bodies are identified on routine cervicovaginal smears. This review summarizes the reported cases of psammoma bodies identified on cervicovaginal smears in the world literature (a total of 140 cases, 113 (81%) of which had sufficient clinicopathologic information). Our conclusions are as follows: (1) The finding of psammoma bodies in this setting is distinctly unusual with an incidence of less than 0.001% on consecutively screened smears. (2) On consecutively screened smears, patients with psammoma bodies have an associated malignancy or ovarian borderline tumor 0-22.7% of the time, depending on the series; this figure climbs to 38% when all the case reports and small series in the literature are included. (3) The most reliable predictor of a malignancy in these patients is the finding of cells on the smear that by themselves are diagnostic of malignancy on cytologic grounds. (4) Other factors that, on a purely statistical basis, appear to increase the likelihood of a synchronous or metachronous malignancy or borderline tumor include an older age at diagnosis and/or clinical presentations such as postmenopausal bleeding. (5) When 1 or more psammoma bodies are identified on a cervicovaginal smear, this finding should not be ignored and should generate some clinical investigation to identify its source.

Psammoma bodies in cervicovaginal smears: incidence and significance

Psammoma bodies (PB) are seen in a wide variety of gynecologic conditions. However, only a few reports address the incidence or significance of PB in cervicovaginal smears (CVS). Twenty patients with PBs in CVS were identified over a 5-yr period during which time 82,840 CVS were screened. Nine cases were associated with malignancy: six uterine serous/clear cell carcinoma, two serous ovarian carcinoma, and one fallopian tube carcinoma. The remaining 11 were benign: one had an ovarian cystadenofibroma and one had PB associated with benign endometrium and endosalpingiosis. In the remaining nine cases, PB were not found on additional studies, although four gave a history of oral contraception and one each had chronic endometritis and IUD in place. The presence of atypical glandular cells diagnostic of carcinoma was the only single feature that predicted carcinoma (7/7). A combination of clinicopathologic features were helpful predictors of malignancy: postmenopausal bleeding (8/9 cases), age over 45 (9/9 cases), and abnormal clinical examination (5/9 cases). Conversely, benignancy was associated with postmenopausal bleeding in 1/11 cases, age over 45 in 3/11 cases and abnormal clinical examination in 2/11 cases. The incidence of PB in our series consecutively screened smears is 8 per 82,840 smears (0.009%). Unlike prior reports, we found that the presence of PB on CVS is not as ominous a finding as previously indicated, as only 12.5% (1/8) of patients with PB on their CVS harbor carcinoma. PB in a CVS in a young patient merits a thorough examination, but not surgical exploration in the absence of additional clinical findings or atypical cells on the CVS. Older patients (>45 yr) have a higher incidence of malignancy, even in the absence of clinical findings or atypical cells on CVS, and may warrant a surgical exploration.