The significance of psammoma bodies on cervical cytology smears

Primary peritoneal low-grade serous carcinoma detected in cervical smear: Pitfalls mitigated by clinicocytopathologic clues and cellblock immunocytochemistry

Pap smears play a role in detecting extrauterine serous tumours in asymptomatic women. Certain cytopathologic and histopathologic findings combined with relevant clinical and radiologic findings indicate the possibility of primary peritoneal serous tumours. Cellblock immunohistochemistry is a valuable confirmatory diagnostic tool.

Early-Stage, BRCA-Associated Ovarian Cancer Detected by Papanicolaou Smear: A Case Report

Historically known as a "silent killer", ovarian cancer is often diagnosed at an advanced stage. We describe an unusual case of stage I, ovarian, high-grade serous carcinoma detected by a routine Papanicolaou (PAP) smear, with no abnormal physical, imaging, or laboratory findings. A 53-year-old woman with newly diagnosed triple-negative breast cancer received a screening Pap smear, which showed malignant cells not coming from the breast or uterine cervix. Pelvic examination, cervical biopsy, and gynecologic ultrasonography found no abnormality. Endometrial curettage yielded free-floating adenocarcinoma cells. The immunohistochemical stain result indicated ovary or fallopian tube cancer. Complete cytoreductive surgery was performed, and high-grade serous carcinoma of bilateral ovaries, FIGO stage IB, was diagnosed. Although extremely rare, when malignant cells not originating from the uterine cervix are detected on a Pap smear, it may lead to an early diagnosis of ovarian cancers, and this warrants further comprehensive workup.

Psammoma bodies in Papanicolaou tests and associated factors to predict an underlying malignancy: a clinicopathological analysis of 10 cases

INTRODUCTION

Psammoma bodies (PBs) are rarely encountered in Papanicolaou tests. They have been described in benign and malignant conditions of the gynecologic tract and peritoneum. The aim of our study was to reveal the associated factors with PBs in Papanicolaou tests to predict an underlying malignancy, particularly in the absence of atypical glandular cells (AGCs).

MATERIALS AND METHODS

From 1987 to 2018, all gynecologic cytology reports with PBs were identified from the computerized pathology database of Baystate Medical Center, Springfield, Massachusetts. Patients with previous history of gynecologic and/or peritoneal malignancy were excluded. Clinical information and follow-up data were obtained from chart review.

RESULTS

PBs were found in 10 of the 1,497,540 Papanicolaou tests (0.0006%). Six patients with age ranging from 19 to 58 years (mean age, 37.6 years) had benign outcome (eg, endometritis, ovarian serous cystadenofibroma). Four patients with age ranging from 31 to 54 years (mean age, 41.7 years) had borderline/malignant outcome (eg, ovarian borderline serous tumor, peritoneal serous psammocarcinoma). All patients with borderline/malignant outcome had family history of cancer and/or gene mutation (eg, sister with breast cancer, father with BRCA-1 mutation). PBs were accompanied by AGCs in 2 of 4 borderline/malignant cases.

CONCLUSIONS

PBs should not be ignored in Papanicolaou tests because of their possible association with an underlying malignancy. To our knowledge, this is the first study demonstrating that relevant family history of cancer and/or gene mutation may be a helpful clue regarding an underlying malignancy, especially in the absence of accompanied AGCs with PBs.

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.

Prevalence and significance of psammoma bodies in cervicovaginal smears in a cervical cancer screening program with emphasis on a case of primary bilateral ovarian psammocarcinoma

BACKGROUND

The purpose of our study was to determine the prevalence and significance of psammoma bodies (PBs) in the cervicovaginal smears of the screening population of Trento district (Italy), with the description of the cytological presentation of an asymptomatic bilateral ovarian psammocarcinoma.

METHODS

From 1993 to 2006, women with PBs detected on consecutively screened cervical smears were identified from the computerized pathology database of Rovereto Hospital. The follow-up period was set from the time of cytological diagnosis to May 31st, 2007. Clinical information was obtained from retrospective review of women's medical records. The source of PBs was identified with adequate diagnostic procedures.

RESULTS

PBs were found in six of the 201,231 Papanicolaou screening smears (0.0029%). Benign conditions (intrauterine device, inclusion ovarian cysts and ovarian cystoadenofibroma with PBs) were found in four patients. In two cases, PBs were associated with malignant cells; a bilateral ovarian malignancy was diagnosed in both cases, a serous adenocarcinoma and a psammocarcinoma.

CONCLUSION

PBs in the cervicovaginal smears are a rare finding, associated more often with benign conditions than with malignancies. Moreover, to our knowledge, our case of primary ovarian psammocarcinoma is the first report in which the presence of malignant cells and PBs in the cervicovaginal and endometrial smears represents the first manifestation of disease.

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.

Significance of psammoma bodies in serous cavity fluid

BACKGROUND

Psammoma bodies (PBs) are encountered only rarely in body cavity fluids (BCF). Although to the authors' knowledge their presence in certain neoplasms (e.g., those of the thyroid, ovary, lung, brain, etc.) is established, their significance in BCF has not been well defined.

METHODS

Diagnoses concerning 3335 BCF samples were reviewed from the cytopathology files for the presence of PBs over an 8-year period. Cytologic preparations included cytospin preparations and Millipore filters stained with the Papanicolaou stain. Clinicopathologic correlation was performed on any subsequent surgical studies.

RESULTS

Of the 3335 BCF samples studies (2444 pleural samples, 688 peritoneal samples, and 203 pericardial samples), PBs were noted in 123 cases (3.7%). Of these 123 cases, 112 were the peritoneal fluid (91%), 10 were the pleural fluid (8.1%), and 1 was in the pericardial fluid (0.81%). All 11 cases of pleural and pericardial effusions with PBs were malignant (carcinomas of the thyroid, lung, and ovary) compared with 62 of 112 peritoneal fluid samples (55.4%) (carcinoma of the ovary and uterus and mesothelioma). Nine of the remaining 50 cases of cytologically benign peritoneal fluids with PBs detected on follow-up tissue biopsy demonstrated peritoneal metastases from ovarian or endometrial carcinoma. Therefore, 41 of 112 cases of peritoneal fluid with PBs remained benign even after clinical follow-up and/or tissue biopsy (36.6%) and demonstrated ovarian cystadenoma/cystadenofibroma, papillary mesothelial hyperplasia, endosalpingiosis, endometriosis, and other miscellaneous benign diagnoses.

CONCLUSIONS

PBs in BCF is a rare finding. Although in the authors' experience their presence in pleural and pericardial effusions signifies carcinomatous involvement, in the current study, peritoneal fluids with PBs were found to be benign in a significant number of cases (36.6%). In the latter scenario and in the absence of an obvious malignancy, attempts should be made to rule out the above-mentioned benign lesions.

The significance of psammoma bodies in screening cervical cytologic smears

OBJECTIVE

Although the presence of psammoma bodies in cervical cytologic smears has been associated previously with gynecologic malignancies, the clinical significance of this finding in asymptomatic women who undergo routine cervical cytologic screening has not been well defined.

STUDY DESIGN

For this retrospective clinicopathologic study, a search of the Virginia Mason Medical Center computerized cytology registry from 1993 through March 2002 identified 25 evaluable cervical cytologic smears that contained psammomatous calcifications. Slides were reviewed, and clinical information was obtained from medical records.

RESULTS

The median patient age was 36 years (range, 22-72 years). Nine women were postmenopausal. All cytologic smears were obtained for routine screening, and no abnormal cells that were diagnostic of malignancy were identified. Possible explanations for the psammoma bodies was determined for 11 women, including foci of calcifications in benign endometrial or endocervical tissue (4 women), polyps (3 women), marked atrophy (3 women), postpartum (2 women), and follicular cervicitis (1 woman). None of the 25 women had cancer. After excluding 1 woman who was to lost to follow-up, the remaining 24 women were followed up for a median of 3 years (range, 6 months-7 years) without the subsequent detection of cancer.

CONCLUSION

Cancers that were reported in previous studies usually were diagnosed in women with malignant background cytology or abnormal symptoms, such as postmenopausal bleeding. In contrast, our study suggests that the presence of psammoma bodies in normal cytologic smears of asymptomatic women is an incidental finding.