Benign and low grade variants of mixed mesodermal tumor (adenosarcoma) of the ovary and adnexal region

Prognostic factors for uterine adenosarcoma: a review

INTRODUCTION

Uterine adenosarcoma is a rare tumor with both epithelial and stromal components. Standard treatment is total abdominal hysterectomy and bilateral salpingo-oophorectomy. There is no defined role for adjuvant or neoadjuvant chemotherapy or radiation. There is a misconception that this is an indolent, low-grade sarcoma. In fact, at least 50% of patients will develop disease recurrence. Establishing prognostic factors is of paramount importance. Areas covered: This article reviews the current literature regarding adenosarcoma prognostic factors from case reports, case series, and retrospective series. An extensive review of the literature was undertaken via PubMed and Medline searches, relevant articles are included in this review. Expert commentary: The most important prognostic factors of uterine adenosarcoma are age, presence of sarcomatous overgrowth, presence of myometrial invasion, presence of lymphovascular invasion, and lymph node involvement. These factors can be used to accurately prognosticate for uterine adenosarcoma patients. Patients at low risk of disease recurrence can be identified. These patients require observation alone. Patients at high risk of disease recurrence can be identified and are candidates for aggressive therapy with adjuvant chemotherapy to reduce the risk of disease recurrence.

Primary extra-uterine and extra-ovarian mullerian adenosarcoma: case report and literature review

BACKGROUND

Extra-uterine mullerian adenosarcomas have varying biological behaviours depending on the presence of endometriosis or sarcomatous overgrowth. These behaviours manifest according to the tumours' histological characteristics and sites of origin. The best treatment and oncologic outcome have not been clarified because only a few cases of extra-uterine and extra-ovarian adenosarcoma have been described in the literature. Here, we report a case of primary peritoneal adenosarcoma with sarcomatous overgrowth and review all reported cases of adenosarcomas arising outside of the uterus and outside the ovaries to identify the best treatment options and clarify outcomes.

CASE PRESENTATION

A 79-year-old woman was referred to our Department with an abdominal mass resembling a fibroid with a haemorrhage. Her gynaecological history was negative. A transvaginal and transabdominal ultrasound examination revealed a multicystic mass resembling an ovarian tumour arising from the pelvis and extending up to the abdomen. At laparotomy a peritoneal mass arising from Douglas peritoneum was resected. The uterus and adnexa appeared normal, and a supra-cervical hysterectomy with bilateral salpingo-oophorectomy was performed. No macroscopic residual disease was present. Final pathology diagnosed a malignant peripheral nerve sheath tumors with divergent differentiation. Four weeks later a new, multicystic mass was found. Due to the progressive poor condition, the patient died four months after diagnosis. Histological slides were reviewed by external expert pathologists and the final diagnosis was of extra-genital adenosarcoma with sarcomatous overgrowth. Furthermore, we also collected and analysed articles written in English regarding extra-uterine and extra-ovarian adenosarcomas published between January 1974 and October 2016. PubMed was used as a database for this search. Clinical and pathological characteristics, treatments and outcomes were assessed.

CONCLUSIONS

Only 41 cases has been reported in literature. Previous endometriosis and sarcomatous overgrowth showed an inverse effect on prognosis. Endometriosis was confirmed to have a positive effect on disease free survival Complete surgical resection is the mainstay of treatment. A worldwide registry is urgently required to collect data to standardize treatment and to obtain reliable data on prognosis.

Uterine Adenosarcoma: a Review

Adenosarcomas are rare malignancies of the female genital tract, accounting for approximately 5 % of uterine sarcomas. Occasionally, adenosarcoma occurs in the ovaries or in extra-uterine tissue, which may be related to endometriosis. These tumors are characterized by benign epithelial elements and a malignant mesenchymal component. Pathologic diagnosis is dependent on the identification of the characteristic morphologic features. The most common immunohistochemical markers for adenosarcoma are CD10 and WT1, but these are not specific. The most frequent presenting symptom is abnormal uterine bleeding. The majority of patients present with stage I disease, with a 5-year overall survival of 60 to 80 %. Survival is influenced by the presence of myometrial invasion, sarcomatous overgrowth, lymphovascular invasion, necrosis, and the presence of heterologous elements including rhabdomyoblastic differentiation. Patients with sarcomatous overgrowth have significantly increased risk of recurrence 23 versus 77 % and decreased 5-year overall survival 50 to 60 %. Standard of care treatment is total hysterectomy with bilateral salpingo-oophorectomy without lymphadenectomy, as the incidence of lymph node metastasis is rare. Retrospective data does not support the use of adjuvant pelvic radiotherapy in uterine adenosarcomas as no survival benefit is seen. Insufficient data exists to recommend routinely neoadjuvant or adjuvant chemotherapy for uterine adenosarcomas. Limited evidence exists for the role of hormonal therapy in uterine adenosarcomas. The PIK3/AKT/PTEN pathway is mutated in ∼70 % of adenosarcomas, and this may represent a possible therapeutic target. This article reviews the current state of knowledge concerning uterine adenosarcoma and discusses the management of this rare tumor.

Advanced Mesodermal (Müllerian) Adenosarcoma of the Ovary: Metastases to the Lungs, Mouth, and Brain

Background. A malignant mixed Müllerian tumor (MMMT) is a malignant neoplasm found in the uterus, the ovaries, the fallopian tubes, and other parts of the body that contains both carcinomatous (epithelial tissue) and sarcomatous (connective tissue) components. Outcome of MMMTs is determined primarily by depth of invasion and stage. The metastatic background of these lesions is controversial and unknown. Case Report. A 75-year-old woman was admitted to the hospital with anorexia, weakness, and persistent coughing. The imaging exams revealed a solid, promiscuous lesion of 16 × 14 cm in dimensions located into the small pelvis, surrounding the uterus and the ovaries. The patient underwent exploratory laparotomy. The mass was removed and the histological examination of the specimen revealed an advanced mesodermal adenocarcinoma of the ovary (MMMT). Nine days after the operation the patient presented with metastatic lesions in the mouth as well as the lungs. Within a month after the discharge from the hospital metastatic lesions of the MMMT were also depicted in the CT brain scan. Conclusion. Despite the fact that sarcomas have a long-term metastatic potential, to our knowledge this is the first case of Müllerian adenosarcoma presenting with such extraperitoneal metastases.

Extragenital müllerian adenosarcoma in the pouch of douglas

BACKGROUND

Extragenital Müllerian adenosarcomas are extremely rare tumours characterised by a stromal component of low-grade malignancy and by a benign glandular epithelial component.

CASE REPORT

A 26-year-old woman was admitted to our clinic because of lower abdominal distension and left lower quadrant pain. Clinical and radiological examinations suggested an ovarian malignancy. Laparotomy revealed a cystic mass in the pouch of Douglas, originating from the left sacrouterine ligament. A total excision of the tumour was performed and showed low-grade adenosarcoma without sarcomatous overgrowth. Follow-up at 24 months after the surgery showed no evidence of recurrence.

CONCLUSION

Mullerian adenosarcoma located in the pouch of Douglas is rare. For treatment, success may be achieved with only excision of the tumour if there is no sarcomatous overgrowth or spread to adjacent tissues.

Mullerian adenosarcoma with sarcomatous overgrowth of the cervix presenting as cervical polyp: a case report and review of the literature

An aggressive variant of adenosarcoma, mullerian adenosarcoma with sarcomatous overgrowth (MASO) in the cervix is extremely rare. This variant contains obvious, high-grade sarcoma in addition to a low-grade form. In this report, we describe a case of MASO of the uterine cervix and review the clinical and pathological features of these tumors. The patient was a 37-year-old woman with a cervical polypoid mass, which was morphologically considered as a benign endocervical polyp. Microscopically, polypoid cervical mass showed diffuse and dense malignant spindle cell proliferation around the benign endocervical glands and also an area of markedly anaplastic and pleomorphic spindle cell proliferation, so called, sarcomatous overgrowth. Total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic lymph node dissection were performed. The patient has been followed-up and neither chemotherapy nor other adjuvant therapies have been administered. At present, she has been clinically free of disease for 9 months since she received surgery. It is extremely rare that MASO of the uterine cervix is presented in premenopausal woman. Gynecologists and pathologists should be aware of the difficulties associated with a delay in the diagnosis of MASO when the tumor is present as a benign looking cervical polyp.

Malignant female adnexal tumor of probable wolffian origin relapsing after pregnancy

BACKGROUND

Female adnexal tumors of probable wolffian origin (FATWO) represent a rare gynecologic tumor and display in the majority of cases a benign behavior.

CASE

A 27-year-old woman underwent a laparotomy for a left adnexal mass. Pathologic examination showed a FATWO. Three years later, 1 month after a vaginal delivery, a recurrence of the disease was observed. Immunohistochemistry revealed the presence of progesterone receptors that may explain recurrence after pregnancy.

CONCLUSION

In light of this case, hormone dependency of FATWO may be suggested.

Extragenital mullerian adenosarcoma with sarcomatous overgrowth arising in an endometriotic cyst in the pouch of Douglas

Mullerian adenosarcoma is a neoplasm composed of benign mullerian epithelium and a sarcomatous stroma. This tumor classically occurs in the endometrium of postmenopausal women and less frequently in the extrauterine genital tract. Rare cases of extragenital adenosarcoma have been reported. We present the case of a 23-year-old female who presented with an extragenital adenosarcoma arising in an endometriotic cyst in the pouch of Douglas. The patient was treated with local excision, chemotherapy and radiotherapy. At 2 years follow-up she was disease-free. The literature on extragenital adenosarcoma is reviewed. These tumors are clinically more aggressive than their uterine counterparts. Surgical excision is the initial treatment modality for these patients. Little information is available regarding the efficacy of adjuvant chemotherapy or radiotherapy. This is an area that requires further study.

Mesodermal (müllerian) adenosarcoma of the ovary: a clinicopathologic analysis of 40 cases and a review of the literature

Forty cases of mesodermal adenosarcoma of the ovary occurred in women 30-84 years of age (mean 54 years). Abdominal discomfort and distension were the usual complaints. All the patients were treated with an oophorectomy, which was accompanied by a hysterectomy in 85%, a contralateral oophorectomy in 65%, and nonsurgical therapy in 28%. Tumor rupture occurred at or before the operation in 67% of the cases. Twenty-six tumors were stage I, 11 stage II, and 3 stage III. The tumors were unilateral in 97.5% of the cases and 5.5-50 cm (mean 14 cm) in greatest dimension; most of the tumors were predominantly solid but contained numerous small cysts. Microscopic examination revealed sarcomatous overgrowth in 12 tumors. Sex cord-like elements were present in six tumors (including four with sarcomatous overgrowth) and heterologous elements in five (including two with sarcomatous overgrowth). The highest mitotic index of the sarcomatous component was 1-25 (mean 6) mitotic figures per 10 high power fields. Only 6 of 26 women (23%) who were followed postoperatively for > or=5 years were free of tumor. In the other 20 patients recurrent tumor appeared at 0.4-6.6 years (mean 2.6 years) after operation as pure sarcoma (low grade or high grade) or adenosarcoma (with or without sarcomatous overgrowth). Eight women had additional recurrences, and four women had blood-borne metastases. One patient was alive at 15.7 years after the excision of pulmonary metastases. The 5-, 10-, and 15-year survival rates were 64%, 46%, and 30%, respectively. Age <53 years, tumor rupture, a high grade, and the presence of high-grade sarcomatous overgrowth appeared to be associated with recurrence or extraovarian spread. Ovarian adenosarcomas have a worse prognosis than uterine adenosarcomas, presumably because of the greater ease of peritoneal spread. Many of the tumors caused problems in differential diagnosis.

Primary Peritoneal Mesodermal Adenosarcoma: Report of a Case and Review of the Literature

BACKGROUND

Mesodermal (müllerian) adenosarcoma arising from the peritoneum is rare and is thought to arise from pluripotent mesothelial and mesenchymal cells of the pelvic cavity or from endometriotic deposits.

CASE

A case of primary peritoneal mesodermal adenosarcoma arising from the omentum is described. A 50-year-old woman presented with sudden abdominal distension. Initial laparotomy revealed a 13-kg mass arising from the omentum, which was determined from frozen and paraffin sections to be serous cystadenofibroma. The tumor recurred within 10 months and weighed 18 kg at a second laparotomy. Histopathology and review of the original tumor established the correct diagnosis of mesodermal adenosarcoma. The patient died from disseminated disease 6 months later.

CONCLUSION

Adenosarcomas are difficult to differentiate from adenofibromas or endometriosis histologically because of the presence of large areas of low cellularity and infrequent mitotic figures. In such cases, stromal nuclear atypia and periglandular stromal cuffing are features that are diagnostic of adenosarcoma.

Ascitic fluid cytology of adenosarcoma of the ovary: a case report

Extrauterine adenosarcoma is very rare and originates in the ovary, adnexa, or myometrium. Cytologic study of ascites is very important to determine clinical staging of malignant ovarian tumors and provide adequate therapy for recurrence. The cytomorphologic features of adenosarcoma have been only rarely described. A 77-yr-old woman visited a hospital with a complaint of lower abdominal pain for 1 mo. A tumor originating from the right adnexa in the pelvis, and involving the rectum, was found in surgery. In the ascitic fluid cytology, a few dispersed tumor cells with large cytoplasm and nuclei were oval-shaped, with nuclear invagination. The chromatin was finely granular; one or two nucleoli were conspicuous. To our knowledge, this is the fifteenth reported case of adenosarcoma of the ovary, and there have been no prior reports describing the cytological features of ascitic fluid cells in adenosarcoma of the ovary.

Extrauterine Müllerian adenosarcoma of the peritoneum with an extensive rhabdomyosarcomatous element and a marked myxoid change

A case of extrauterine Müllerian adenosarcoma of the peritoneum in a 20-year-old woman is reported. The tumor was widely based on the abdominopelvic wall and there were no unusual features in the genital organs. The cut surface of the tumor showed a marked gelatinous appearance. The tumor was composed of an admixture of benign Müllerian-type epithelium and sarcomatous stroma. The predominant element of the sarcomatous area was rhabdomyosarcoma, which showed a close resemblance to well-differentiated embryonal rhabdomyosarcoma. In another sarcomatous area, fibroblastic cells without myoblastic properties diffusely proliferated in a marked myxoid background with some collagen bundles. Both the mitotic count and Ki-67 proliferative index of these cells were lower than those of rhabdomyoblastic cells. On follow up, the patient was disease free for 1 year postoperatively, without any subsequent treatment. The present case indicates that extrauterine adenosarcoma can also show histological heterogeneity as do uterine adenosarcomas. The remarkable myxoid change of this tumor seemed to be more largely due to a fibromyxoid element than a rhabdomyosarcomatous element, and the coexistence of the former may be related to the less aggressive behavior of this tumor.

Epithelial-mesenchymal transformation of a newly established cell line from ovarian adenosarcoma by transforming growth factor-beta1

We report on 2 cell lines (designated OVAK-I and OVAK-II) established from an adenosarcoma, a rare variant of a malignant Mullerian mixed tumor, of the ovary. OVAK-I was not tumorigenic in nude mice and showed no responsiveness to transforming growth factor (TGF)-beta1, whereas OVAK-II was tumorigenic and had various biological properties. Light- and electron-microscopic studies showed that the morphology of the cells was converted from an epithelial to a mesenchymal form by TGF-betaI. Furthermore, the protein and mRNA expressions of the epithelial marker carcinoembryonic antigen and the mesenchymal marker vimentin were down- and up-regulated, respectively, by TGF-beta1. These findings suggested that TGF-beta1 plays a role in epithelial-mesenchymal transformation and support the single-stem-cell theory which explains the origin of malignant Mullerian mixed tumors: that the epithelial and mesenchymal components of these tumors are of common stem-cell origin.

Adenosarcomas originating from sites other than uterine endometrium

We report three cases of adenosarcomas arising from extraendometrium of the uterus: one arising from the ovary, one from the paracolpium and one from the endocervix of the uterus. Microscopically, they consisted of an admixture of benign-appearing epithelial and mesenchymal components with hypercellularity and minimal atypia. Two of the tumors were initially misdiagnosed as endometriosis and one was diagnosed as adenofibroma. One patient had several recurrences and died 7 years after the initial laparotomy and another patient had sarcomatous overgrowth which invaded the muscular tissues of the large intestine. Thus it appears that adenosarcoma occasionally shows grave clinical behavior, despite the benign or low-grade appearance of its microscopic features. Problems of diagnosis and management of this tumor are discussed. An aggressive therapeutic approach including wide surgical excision is recommended even in questionable cases.

Müllerian adenosarcoma of the uterus with pure angiosarcoma: case report

We report a case of müllerian adenosarcoma of the uterus with benign endometrioid epithelial component and histologically pure angiosarcoma. This seemingly unique sarcomatous ingredient, among uterine and extrauterine adenosarcomas reported in the English literature, is considered to be a homologous component of the tumor. The patient, a 71-year-old woman with a several-month history of intermittent vaginal bleeding, was found at abdominal hysterectomy to have a large polypoid intrauterine tumor with superficial extension into the myometrium. The patient was treated with 6,000 rad of adjuvant radiation but died a few months after of what clinically appeared to be massive abdominal bleeding. The literature regarding uterine tumors classified as angiosarcoma or malignant hemangioendothelioma is briefly reviewed.

Mullerian adenosarcoma of the uterus: a clinicopathologic analysis of 100 cases with a review of the literature

One hundred cases of mullerian adenosarcoma of the uterus were encountered in patients 14 to 89 years of age (median, 58 years), who usually had the symptom of abnormal vaginal bleeding. An enlarged uterus and tissue protruding from the external os were the most common findings on pelvic examination. Five patients presented on multiple occasions with "recurrent polyps" that were interpreted retrospectively as adenosarcomas. Primary treatment, known in 97 cases, included some form of hysterectomy in 93 of them, and conservative resection in four cases. Gross examination of the excised uteri disclosed polypoid masses, some of which had spongy cut surfaces, usually filling the endometrial cavity; less commonly, the tumors were confined to the endocervix or the myometrium or involved more than one site. Histologic examination revealed benign or atypical neoplastic glands within a sarcomatous stroma, which typically formed periglandular cuffs of increased cellularity, intraglandular polypoid projections, or both. The sarcomatous stroma was homologous in 78% of the cases and contained heterologous elements in the remainder. The stromal mitotic rate varied from 1 to 40 mitotic figures (MFs) (mean 9) per 10 high-power fields (HPFs). Extensive areas of stromal fibrosis that focally imparted a deceptively benign appearance to the tumor were common. Myometrial invasion was present in 15 cases, but was deep in only four. Recurrent tumor developed in 23 cases at postoperative intervals of 0.5 to 9.5 years (mean 3.4); in one third of such cases, the interval was 5 years or longer. Recurrent tumor was almost always confined to the vagina, pelvis, or abdomen; hematogenous spread occurred in only two cases. The only feature associated with an increased risk for recurrence was the presence of myometrial invasion. Criteria found useful in separating mullerian adenosarcomas from mullerian adenofibromas included, alone or in combination: two or more stromal MFs per 10 HPFs, marked stromal cellularity, and significant stromal cell atypia.

Primary carcinoma of the broad ligament. Report of four cases and review of the literature

The clinical and pathologic features of four new and eight previously reported primary carcinomas of the broad ligament have been reviewed. The patients' ages ranged from 29 to 70 years (average, 46) and the most common clinical presentations were vague lower abdominal pain, a palpable pelvic mass, and an associated disorder such as pelvic endometriosis. The tumors ranged from 4.5 to 13 cm in greatest dimension and were solid, cystic, or mixed. All of them were unilateral. Review of the pathologic descriptions and illustrations of the cases in the literature and microscopic review of one reported case revealed that four of the tumors were endometrioid carcinomas, four were clear cell carcinomas, one was probably a mucinous adenocarcinoma, two were papillary adenocarcinomas of undetermined cell type, and one was a serous papillary cystadenoma of borderline malignancy with microinvasion. Three patients were treated by excision of the tumor alone. Seven of them were treated by total abdominal hysterectomy and salpingo-oophorectomy; three patients received postoperative radiation therapy, and one of them also received chemotherapy. Eight patients were free of disease 6 months to 7 years postoperatively, and one patient with distant metastasis (rib) at the time of operation lived for 27 months. In three cases no follow-up data were available. Three of the four patients in current series were found to have pelvic endometriosis at the time of operation. Three of their carcinomas were endometrioid and one was of clear cell type, suggesting the possibility of an origin from endometriotic tissue in the broad ligament.

Mullerian adenosarcoma of the uterine cervix

The management of cervical adenosarcoma in a 14-year-old girl is described. The tumor had an exceptionally violent biological nature and did not respond to a variety of customary and unorthodox therapeutic measures. These included conventional intravenous chemotherapy, radiation therapy, surgery, intraarterial chemotherapy, colostomy, and peritoneovenous shunt for untreatable ascites. The patient died within 16 months of diagnosis. This is the fifth case of cervical adenosarcoma in the English literature. This tumor usually has a better prognosis and none of the previous four cases succumbed to the disease. The unusual virulence of the present case is discussed and the literature reviewed.

Malignant müllerian tumours of the uterus

Thirty-two cases of malignant Müllerian tumours of the uterus of the mixed mesodermal type were investigated. Histological examinations were performed on tissue obtained during curettage or biopsy and/or surgical removal of the uterus; in 4 cases postmortem examination was also carried out. The biphasic tumours of the uterus were classified into four groups and comprised 44% of alle uterine sarcomas. In 10 of the 28 cases in which uterine curettage or cervical biopsy was carried out, the final diagnosis was clarified when the tumorous uterus was removed. The prognosis was poorer for heterologous than for homologous tumours. In the heterologous group, the prognosis was better for the form with chondrosarcomatous features (2 patients are still alive after more than 5 years) than for the form containing striated muscle tissue (all 5 patients died within 1 year). Attention is drawn to the fact that the adenosarcoma should be considered a separate type; its prognosis was relatively good (2 such patients are still alive after more than 5 years).

Malignant fibrous histiocytoma of the broad ligament: a case report and literature review

A case of malignant fibrous histiocytoma arising primarily in the broad ligament is described. This entity has not been previously reported. The patient's presentation and clinical course, including her partial response to Adriamycin and DTIC chemotherapy, are outlined. Clinical and pathologic features of tumors arising in the broad ligament are discussed.

On the histogenesis and morphology of ovarian carcinomas

The modern classification of ovarian tumors based on histogenetic principles is clinically important in the evaluation of prognosis and differential therapy. Ninety percent of malignant ovarian tumors belong to the category of "common carcinomas." All of these tumors originate from the coelomic epithelium at any of various stages of its differentiation into the derivatives of the Müllerian duct, giving rise to a large group of tumors that can be subdivided into serous papillary cyst-adenocarcinomas arising from surface-like epithelium, mucinous cystadenocarcinomas arising from endocervical-like epithelium, endometrioid carcinomas from endometrium-like epithelium, clear-cell carcinomas from endocervical or endometrium-like epithelium, malignant cystadenofibromas from undetermined pluripotent Müllerian epithelium, and (malignant) Brenner tumors from heterotopic epithelium resembling Wolffian differentiation, as seen in the urothelium. The well differentiated stages of these carcinomas can be readily distinguished by comparing them with the derivates of the Müllerian epithelium. The poorly differentiated types, on the other hand, may provide no criteria for comparison, but can still be classified as belonging to the group of common epithelial tumors. Adenocarcinomas of one type may also contain portions of another related type, e.g., serous papillary carcinomas may contain mucinous glands or groups of clear cells and vice versa. Serous papillary carcinomas form the largest group containing about 50% of all ovarian carcinomas. The endometrioid carcinomas comprise roughly 20%, the mucinous carcinomas 10%, and the VXGHb-cell carcinomas roughly 10%. Five percent of all carcinomas are unclassifiable and the remaining 5% constitute the group of rare ovarian carcinomas: the malignant cystadenofibromas, adenosarcomas, malignant mesenchymal mixed tumors, and malignant Brenner tumors. The three main groups can be histologically subdivided into three grades: those of high, moderate and poor differentiation. In addition, a borderline tumor representing a pre-stage of invasion and metastasis has been recognized. The prognosis with serous papillary carcinomas is poor, with an overall 5-year survival rate of 20%; the 5-year survival rate for mucinous carcinomas is 40%-60%, for endometrioid carcinomas 55%, and for clear-cell carcinomas 40%. Statistically significant data for predicting the prognosis for rare carcinomas are not available.

Uterine adenosarcoma: a clinicopathologic study of 11 cases with a reevaluation of histologic criteria

Eleven biphasic uterine tumors with epithelial components and homologous stroma were reevaluated. Originally these were diagnosed as adenofibroma, adenosarcoma, carcinosarcoma, or mixtures thereof, but were now reclassified as adenosarcomas of which seven were "pure" and four mixed with foci of carcinosarcoma. Nine of the tumors arose in the endometrium and two in the endocervix. The mean patient's age was 55 years. The most common complaint was vaginal bleeding. Macroscopically these tumors presented as polypoid masses. The epithelial component consisted mainly of endometrial, endocervical, ciliated, and clear cells. Squamous metaplasia and focal hyperplasia were occasionally observed. Malignant epithelial change was only present in foci of carcinosarcoma. The stroma showed prominent cellular periglandular cuffs, occasionally round solid or perivascular nodules, and areas of focal or diffuse stromal hypercellularity. In all these areas stromal cells were atypical and/or pleomorphic. Stromal foam cells were seen in three cases. Mitotic activity was low ranging from one to three mitoses per 10 high power fields (HPF). Follow-up was negative exept in two cases with recurrence and abdominal metastases. It was concluded that stromal hypercellularity with atypism and pleomorphism in periglandular, perivascular location as well as of focal or diffuse nature, is characteristic of uterine adenosarcoma. Adenofibromas present a fibro-collagenous stroma lacking the crowded cellular areas. Mitotic activity is too variable to serve as a reliable diagnostic criterion. Uterine adenosarcomas are usually tumors of low grade malignancy but the lack of correlation between histologic appearance and biologic behaviour precludes prognostication in the individual patient.

[Heterologous Müllerian adenosarcoma of the uterus--a rare tumor. Light- and electron-microscopic findings, biological behavior (author's transl)]

A case of heterologous Müllerian adenosarcoma of the uterus is presented with emphasis on morphologic differentiation, clinical course, prognosis, and treatment. This tumor was described first by Clement and Scully in 1974. Since that time 36 cases have been reported in the literature. The neoplasm consists of benign epithelial and malignant mesenchymal elements. The latter are composed of tissue with homologous and heterologous differentiation. Our microscopic and ultrastructural studies suggested that the heterologous elements were rhabdomyoblasts with a variable degree of differentiation. According to the literature the prognosis of Müllerian adenosarcoma is better than that of malignant mixed Müllerian tumor. The location of the tumor - whether intrauterine or extrauterine - seems to be more important as regards prognosis than the differentiation of the sarcomatous elements. The clinical course in our patients was not different from those described in the literature. Surgical removal of the tumor remains the treatment of choice. Some authors report a better survival rate when surgical treatment is followed by radiotherapy. Chemotherapy may be useful in cases of local or distant metastasis, and in cases of incomplete excision of the tumor mass.

Adenofibroma and adenosarcoma of the uterus: a clinicopathologic study of 35 cases

The clinical and histopathologic features of ten adenofibromas and 25 adenosarcomas of the uterus were studied. The most useful criterion for distinguishing adenofibroma from adenosarcoma was the frequency of mitotic figures found in the stroma. Adenofibromas had fewer than four mitotic figures per 100 HPF in the most active areas; adenosarcomas had four or more. Myometrial invasion, histologically malignant heterologous mesenchymal elements, and marked atypia of stromal cells were histologic features detected only in adenosarcoma. Of the women with adenosarcoma, ten (40%) had recurrences, with a median interval to recurrence of five years. The only morphologic feature that correlated with aggressive behavior of adenosarcoma was deep myometrial invasion. Adenofibroma and adenosarcoma are in the family of mixed mesodermal tumors, but are distinct clinical and pathologic entities.

Benign and low grade variants of mixed Müllerian tumour of the uterus

The clinico-pathological features of 11 examples of a rare group of uterine neoplasms composed of both epithelial and stromal components are reported. The patients complained of abnormal vaginal bleeding or discharge. Two of the tumours arose in the cervix, seven in the endometrium and two from both, forming large polypoid masses projecting from the cervix and/or filling the uterine cavity. Microscopically, the epithelial elements ranged from benign to adenocarcinoma. A similar range of stromal elements was also seen, varying from entirely bland to low grade to high grade sarcoma. The variable histology of the tumours is reflected in their biologic behaviour. Of the three tumours with the highest histological grade of malignancy, one recurred and killed the patient. One tumour, in which both components were regarded histologically as benign, recurred twice before hysterectomy. Our findings lend support to the concept that these tumours are variants of mixed Müllerian tumour. We advocate the acceptance of the latter term so that all grades of this tumour can be accommodated under one designation.

Malignant mixed mesodermal tumor of the ovary

Mixed mesenchymal and epithelial tumors are highly malignant neoplasms most commonly found in the uterus. Rarely, histologically identical tumors occur in the ovary. We report a 70-yr-old woman with a malignant mixed Müllerian tumor of the ovary. The tumor contained heterologous foci of immature cartilage and striated muscle, in addition to carcinosarcomatous areas. Postoperative chemotherapy was administered, but she died within 5 mth with recurrent and metastatic tumor. A review of the literature concerning extrauterine malignant mixed Müllerian tumors is added.