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de Souza MLP, da Costa TP, de Freitas NP, de Souza MF, Athanazio DA. The many faces of endometriosis. Autops Case Rep 2022; 12:e2021409. [PMID: 36381229 PMCID: PMC9639587 DOI: 10.4322/acr.2021.409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 10/19/2022] [Indexed: 09/08/2023]
Abstract
Endometriosis is a common disease; however, unusual findings may cause diagnostic difficulties. We present herein three cases illustrating different morphological appearances of endometriosis: 1) endometriosis with atypical hyperplasia associated with bilateral ovarian carcinoma (mixed clear cell/endometrioid in the left ovary and endometrioid in the right ovary); 2) deep infiltrating endometriosis with intravascular spread, polypoid configuration in peritoneal surfaces, and involvement of a lymph node; and 3) decidualized endometriosis with prominent myxoid/mucinous change and multivacuolated (pseudoxanthoma) cells. Awareness of uncommon morphological manifestations of endometriosis is important to avoid improper consideration of malignancy.
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Affiliation(s)
| | - Talita Porto da Costa
- Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA, Brasil
| | | | - Maiara Ferreira de Souza
- Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA, Brasil
| | - Daniel Abensur Athanazio
- Imagepat, Laboratório de Patologia, Salvador, BA, Brasil
- Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA, Brasil
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2
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Jiayu H, Hanke Z, Ying G. The Role of Exosomes in Diseases Related to Infertility. Curr Stem Cell Res Ther 2019; 14:437-441. [PMID: 30674267 DOI: 10.2174/1574888x14666190123162842] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/07/2018] [Accepted: 01/09/2019] [Indexed: 12/12/2022]
Abstract
Exosomes, small extracellular vesicles with diameters of 40-100nm, are generated through the fusion of multivessel with plasma membrane and secreted by a variety of living cells. Exosomes contain lipid bilayer membrane and releasable functionally active proteins, mRNA and microRNAs (miRNAs). This article reviews the latest progress of researches on exosomes in diseases that lead to infertility.
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Affiliation(s)
- Huang Jiayu
- Department of Gynaecology and Obstetrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhang Hanke
- Department of Gynaecology and Obstetrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gao Ying
- Department of Gynaecology and Obstetrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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3
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D'Agostino C, Surico D, Monga G, Palicelli A. Pregnancy-related decidualization of subcutaneous endometriosis occurring in a post-caesarean section scar: Case study and review of the literature. Pathol Res Pract 2019; 215:828-831. [PMID: 30683477 DOI: 10.1016/j.prp.2019.01.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/05/2019] [Accepted: 01/17/2019] [Indexed: 11/30/2022]
Abstract
Endometriosis of surgical scars is a rare complication of caesarean sections (incidence: 0.03-0.4%) and other surgical procedures. As endometriosis could be responsive to hormonal stimulation, decidualization and other secondary changes may occur during pregnancy or progestin therapy, sometimes causing a clinically-evident increase in the size of the endometriotic nodules, which could be mistaken for malignant tumors. To our knowledge, we report the 8th subcutaneous case of a pregnancy-related decidualization occurring in a post-caesarean section scar endometriosis. A 33-year-old woman showed a painless, firm, subcutaneous nodule (size: 1 cm) located near the scar of a caesarean section performed 3 years before. Ultrasound examination revealed a well-delimited, hypoechogenic nodule showing perilesional inflammatory reaction without vascular signals. The nodule was considered a post-surgical granuloma: its size did not increase during 4 years of follow-up. Finally, the nodule was totally excised during a second caesarean section performed at 39 weeks of gestation. Histological examination showed nodules of decidualized stromal cells surrounding rare, small, atrophic endometrial glands. Nuclear atypia and mitoses were absent. On immunohistochemical examination, the epithelial cells were pan-CK(AE1/AE3)+/ER+/PR+/S100-/Calretinin-/Vimentin-, while the stromal cells were pan-CK(AE1/AE3)-/Vimentin+/ER+/PR+/CD10+/S100-/Calretinin-. We reviewed the literature, discussing the main clinic-pathological diagnostic pitfalls and the possible differential diagnoses.
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Affiliation(s)
- Cinzia D'Agostino
- Department of Obstetrics and Gynecology, "Maggiore della Carità" Hospital, University of Eastern Piedmont "Amedeo Avogadro", Novara, Italy
| | - Daniela Surico
- Department of Obstetrics and Gynecology, "Maggiore della Carità" Hospital, University of Eastern Piedmont "Amedeo Avogadro", Novara, Italy
| | - Guido Monga
- Unit of Pathology, Department of Health Sciences, University of Eastern Piedmont "Amedeo Avogadro", Novara, Italy
| | - Andrea Palicelli
- Unit of Pathology, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy.
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4
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Hernandez A, Chiaffarano J, Mittal K, Marcus A. Arias-Stella Reaction With Signet Ring-Like Cell Histomorphology. Int J Surg Pathol 2017; 26:283-286. [PMID: 29172819 DOI: 10.1177/1066896917741368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cells with their nucleus pushed to the periphery in a crescent-like fashion by intracytoplasmic vacuole(s) are referred to as signet ring cells when the vacuole(s) contain mucin and signet ring-like cells when they are empty or contain a material other than mucin. Signet ring cells are commonly associated with adenocarcinomas. These cells are uncommon in the endometrium and have been found to be associated with both malignant and benign processes. We report the first case of signet ring-like cells within endometrial glands with Arias-Stella reaction.
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Hejmadi RK, Chaudhri S, Ganesan R, Rollason TP. Morphologic Changes in the Endometrium Associated With the Use of the Mirena Coil: A Retrospective Study of 106 Cases. Int J Surg Pathol 2016; 15:148-54. [PMID: 17478768 DOI: 10.1177/1066896906299120] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study outlines the histologic changes seen in 106 endometrial specimens after use of the Mirena coil (levonorgestrel) and compares these changes with previous studies. The variables assessed include nature of the endometrial glands, metaplastic glandular changes, nuclear atypia, hobnail change, and endometrial hyperplasia. Stromal changes include pseudodecidualization, mucinous change, ulceration, and infiltration by granulocytes, neutrophils, and plasma cells, and stromal hyaline nodules, a feature not described previously. Additional changes include superficial micropapillary change, infarcted decidua, dystrophic calcification, hemosiderophages, polypoid indentations, cervical microglandular hyperplasia and endocervical pseudodecidualization. These variables are compared with a similar previous study. Significant differences in the incidence of glandular metaplasia, dystrophic calcification, plasma cell infiltrates, hemosiderophages, and presence of nuclear atypia are noted. With increased use of the Mirena coil, histopathologists need to be aware of the characteristic and constant endometrial changes due to progestogenic and mechanical effects, despite a wide variation in the duration of usage.
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Affiliation(s)
- Rahul K Hejmadi
- Department of Histopathology, University Hospital Birmingham, Edgbaston, Birmingham, United Kingdom.
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6
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Atkins HM, Lombardini ED, Caudell DL, Appt SE, Dubois A, Cline JM. Decidualization of Endometriosis in Macaques. Vet Pathol 2016; 53:1252-1258. [PMID: 27281017 DOI: 10.1177/0300985816646433] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The decidua is the superficial portion of endometrium that transforms, or decidualizes, under the influence of progesterone to nourish the early embryo during pregnancy. Deciduae outside the uterus are found in nearly 100% of human pregnancies. This condition, known as deciduosis, may mimic malignancy, resulting in additional diagnostic procedures that place the mother, baby, or both at risk. Deciduosis has been described in both Old World and New World nonhuman primates in conjunction with pregnancy and after treatment with exogenous progestins. Here the authors present 6 cases of deciduosis associated with endometriotic lesions in female rhesus and cynomolgus macaques (Macaca mulatta and Macaca fascicularis). Full diagnostic necropsies with histologic analyses were performed on all animals. Deciduae were stained with hematoxylin and eosin and by immunohistochemistry for vimentin, CD10, progesterone receptor, estrogen receptor, desmin, cytokeratin, kermix P8, chorionic gonadotropin, human placental lactogen, and calretinin. The most common clinical signs were abdominal pain (4 of 6) and anorexia (2 of 6). At necropsy, macaque uteri were often enlarged or disfigured (4 of 6) with abundant fibrous adhesions (5 of 6). Affected tissue consisted of epithelial-lined cysts and decidualized stroma with scattered gamma/delta T cells. Decidualized stromal cells were large and polyhedral with abundant cytoplasm and round vesicular nuclei. They stained positive for vimentin, CD10, progesterone, and estrogen. In summary, these cases illustrate deciduosis in 6 nonhuman primates with endometriosis. Understanding decidualization in nonhuman primates will aid in elucidating the pathophysiology of deciduosis during pregnancy or endometriosis and potentially lead to new interventions.
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Affiliation(s)
- H M Atkins
- Department of Pathology, Section on Comparative Medicine, School of Medicine, Wake Forest University, Medical Center Boulevard, Winston-Salem, NC, USA
| | - E D Lombardini
- Division of Comparative Pathology, Armed Forces Radiobiology Research Institute, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - D L Caudell
- Department of Pathology, Section on Comparative Medicine, School of Medicine, Wake Forest University, Medical Center Boulevard, Winston-Salem, NC, USA
| | - S E Appt
- Department of Pathology, Section on Comparative Medicine, School of Medicine, Wake Forest University, Medical Center Boulevard, Winston-Salem, NC, USA
| | - A Dubois
- Department of Medicine, F. Edward Hébert School of Medicine, Laboratory of Gastrointestinal and Liver Studies, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - J M Cline
- Department of Pathology, Section on Comparative Medicine, School of Medicine, Wake Forest University, Medical Center Boulevard, Winston-Salem, NC, USA
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7
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Harp D, Driss A, Mehrabi S, Chowdhury I, Xu W, Liu D, Garcia-Barrio M, Taylor RN, Gold B, Jefferson S, Sidell N, Thompson W. Exosomes derived from endometriotic stromal cells have enhanced angiogenic effects in vitro. Cell Tissue Res 2016; 365:187-96. [PMID: 26841879 PMCID: PMC4917586 DOI: 10.1007/s00441-016-2358-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 12/30/2015] [Indexed: 02/07/2023]
Abstract
Our objective has been to establish a pro-angiogenic role for exosomes in endometriosis and to determine whether a differential expression profile of cellular and exosomal microRNAs (miRNAs) exists in endometriosis. We performed an in vitro study of human primary endometrial stromal cells (ESCs) and human umbilical vein endothelial cells (HUVECs). We isolated and characterized exosomes from ESCs from five endometriosis patients and five phase-matched controls. Exosomes were characterized by transmission electron microscopy and NanoSight technology. MiRNA was assessed by deep sequencing and reverse transcription with quantitative polymerase chain reaction. Exosome uptake studies were achieved by means of confocal microscopy. The pro-angiogenic experiments were executed by treating HUVECs with ESC-derived exosomes. We observed differential profiles of exosomal miRNA expression between exosomes derived from endometriosis lesion cells and diseased eutopic stromal cells compared with exosomes derived from control ESCs. We also demonstrated autocrine cellular uptake of exosomes and paracrine functional angiogenic effects of exosomes on HUVECs. The results of this study support the hypothesis that exosomes derived from ESCs play autocrine/paracrine roles in the development of endometriosis, potentially modulating angiogenesis. The broader clinical implications are that Sampson’s theory of retrograde menstruation possibly encompasses the finding that exosomes work as intercellular communication modulators in endometriosis.
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Affiliation(s)
- Djana Harp
- Department of Obstetrics and Gynecology, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA 30310, USA.
| | - Adel Driss
- Department of Obstetrics and Gynecology, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA 30310, USA
| | - Sharifeh Mehrabi
- Department of Obstetrics and Gynecology, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA 30310, USA
| | - Indrajit Chowdhury
- Department of Obstetrics and Gynecology, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA 30310, USA
| | - Wei Xu
- Department of Obstetrics and Gynecology, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA 30310, USA
| | - Dong Liu
- Cardiovascular Research Institute, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA 30310, USA.,Department of Physiology, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA 30310, USA
| | - Minerva Garcia-Barrio
- Cardiovascular Research Institute, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA 30310, USA.,Department of Physiology, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA 30310, USA
| | - Robert N Taylor
- Department of Obstetrics and Gynecology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Bert Gold
- Center for Cancer Research, National Cancer Institute, Frederick, MD 21702, USA
| | | | - Neil Sidell
- Department of Gynecology & Obstetrics, Emory University School of Medicine, 1639 Pierce Dr., WMB 4303, Atlanta, GA 30322, USA
| | - Winston Thompson
- Department of Obstetrics and Gynecology, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA 30310, USA.,Department of Physiology, Morehouse School of Medicine, 720 Westview Drive, SW, Atlanta, GA 30310, USA
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Leone Roberti Maggiore U, Ferrero S, Mangili G, Bergamini A, Inversetti A, Giorgione V, Viganò P, Candiani M. A systematic review on endometriosis during pregnancy: diagnosis, misdiagnosis, complications and outcomes. Hum Reprod Update 2015; 22:70-103. [PMID: 26450609 DOI: 10.1093/humupd/dmv045] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 09/14/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Traditionally, pregnancy was considered to have a positive effect on endometriosis and its painful symptoms due not only to blockage of ovulation preventing bleeding of endometriotic tissue but also to different metabolic, hormonal, immune and angiogenesis changes related to pregnancy. However, a growing literature is emerging on the role of endometriosis in affecting the development of pregnancy and its outcomes and also on the impact of pregnancy on endometriosis. The present article aims to underline the difficulty in diagnosing endometriotic lesions during pregnancy and discuss the options for the treatment of decidualized endometriosis in relation to imaging and symptomatology; to describe all the possible acute complications of pregnancy caused by pre-existing endometriosis and evaluate potential treatments of these complications; to assess whether endometriosis affects pregnancy outcome and hypothesize mechanisms to explain the underlying relationships. METHODS This systematic review is based on material searched and obtained via Pubmed and Medline between January 1950 and March 2015. Peer-reviewed, English-language journal articles examining the impact of endometriosis on pregnancy and vice versa were included in this article. RESULTS Changes of the endometriotic lesions may occur during pregnancy caused by the modifications of the hormonal milieu, posing a clinical dilemma due to their atypical appearance. The management of these events is actually challenging as only few cases have been described and the review of available literature evidenced a lack of formal estimates of their incidence. Acute complications of endometriosis during pregnancy, such as spontaneous hemoperitoneum, bowel and ovarian complications, represent rare but life-threatening conditions that require, in most of the cases, surgical operations to be managed. Due to the unpredictability of these complications, no specific recommendation for additional interventions to the routinely monitoring of pregnancy of women with known history of endometriosis is advisable. Even if the results of the published studies are controversial, some evidence is suggestive of an association of endometriosis with spontaneous miscarriage, preterm birth and small for gestational age babies. A correlation of endometriosis with placenta previa (odds ratio from 1.67 to 15.1 according to various studies) has been demonstrated, possibly linked to the abnormal frequency and amplitude of uterine contractions observed in women affected. Finally, there is no evidence that prophylactic surgery would prevent the negative impact of endometriosis itself on pregnancy outcome. CONCLUSIONS Complications of endometriosis during pregnancy are rare and there is no evidence that the disease has a major detrimental effect on pregnancy outcome. Therefore, pregnant women with endometriosis can be reassured on the course of their pregnancies although the physicians should be aware of the potential increased risk of placenta previa. Current evidence does not support any modification of conventional monitoring of pregnancy in patients with endometriosis.
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Affiliation(s)
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynaecology, IRCCS AOU San Martino - IST, Largo R. Benzi 10, 16132 Genova, Italy Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy
| | - Giorgia Mangili
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milano, Italy
| | - Alice Bergamini
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milano, Italy
| | - Annalisa Inversetti
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milano, Italy
| | - Veronica Giorgione
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milano, Italy
| | - Paola Viganò
- Reproductive Sciences Laboratory, Division of Genetics and Cell Biology, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milano, Italy
| | - Massimo Candiani
- Obstetrics and Gynecology Unit, Vita-Salute San Raffaele University and IRCCS San Raffaele Hospital, Via Olgettina 58, 20132 Milano, Italy
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10
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Natale KE, Royer MC, Rush WL, Lupton GP. Cutaneous deciduosis: a report of two cases of an unusual pseudomalignancy. J Cutan Pathol 2012; 39:777-80. [DOI: 10.1111/j.1600-0560.2012.01907.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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11
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12
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Abstract
Incisional endometriosis (IE) is a rare entity reported in 0.03–1.08% of women following obstetric or gynecologic surgeries. Most cases reported in literature have appeared after cesarean sections and were often clinically mistaken for hernia, abscess, suture granuloma or lipoma. We hereby report a case of IE following a second trimester hysterotomy, which was diagnosed by fine needle aspiration cytology (FNAC). Our patient was 26 years old, presenting with a mass over anterior abdominal wall, associated with incapacitating pain during each menstrual cycle. FNAC showed epithelial cells, stromal cells and hemosiderin laden macrophages. Based on the typical history, clinical and cytological features, the diagnosis of IE was established. Wide surgical excision was done and the resulting rectus sheath defect was repaired. Patient was followed for 6 months during which time she was symptom free. This article also reviews the spectrum of cytological features and the rare possibility of malignant transformation that can occur in IE.
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Affiliation(s)
- P Veda
- Department of Pathology, India
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13
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Val-Bernal JF, Val D, Gómez-Aguado F, Corcuera MT, Garijo MF. Hypodermal Decidualized Endometrioma With Aberrant Cytokeratin Expression. A Lesion Mimicking Malignancy. Am J Dermatopathol 2011; 33:e58-62. [DOI: 10.1097/dad.0b013e3181f704f6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Pitfalls in the diagnosis of endometriosis: a condition characterized by a plethora of unusual histological features. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.mpdhp.2011.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Tang K, Lyons S, Valmadre S, Russell P. Endometriosis with myxoid change mimicking pseudomyxoma peritonei. Pathology 2009; 42:95-7. [PMID: 20025493 DOI: 10.3109/00313020903434702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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16
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KARPF EVAF, POETSCH BERNHARD, LANGNER CORD, NOGALES FRANCISCOF, REGAUER SIGRID. Endometrial stromal nodule embedded into term placenta. APMIS 2007; 115:1302-5. [DOI: 10.1111/j.1600-0643.2007.00740.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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17
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Clement PB. The pathology of endometriosis: a survey of the many faces of a common disease emphasizing diagnostic pitfalls and unusual and newly appreciated aspects. Adv Anat Pathol 2007; 14:241-60. [PMID: 17592255 DOI: 10.1097/pap.0b013e3180ca7d7b] [Citation(s) in RCA: 194] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Although the histologic diagnosis of endometriosis is usually straightforward, many diagnostic problems can arise as a result of alterations or absence of its glandular or stromal components. The diagnostic difficulty in such cases can be compounded by tissue that is limited to a small biopsy specimen. The appearance of the glandular component can be altered by hormonal and metaplastic changes, as well as cytologic atypia and hyperplasia. Although the last 2 findings are often referred to collectively as "atypical endometriosis," they should be separately recognized as their premalignant potential likely differs. In some cases, the endometriotic glands are sparse or even absent (stromal endometriosis). The stromal component can be obscured or effaced by infiltrates of foamy and pigmented histiocytes, fibrosis, elastosis, smooth muscle metaplasia, myxoid change, and decidual change. Occasional findings in endometriosis that may raise concern for a neoplasm include necrotic pseudoxanthomatous nodules, polypoid growth (polypoid endometriosis), bulky disease, and venous, lymphatic, or perineural invasion. Inflammatory and reactive changes within, adjacent to, or at a distance from foci of endometriosis can complicate the histologic findings and include infection within endometriotic cysts, pseudoxanthomatous salpingitis, florid mesothelial hyperplasia, peritoneal inclusion cysts, and Liesegang rings. The histologic diagnosis of endometriosis can also be challenging when it involves an unusual or unexpected site. Five such site-specific problematic areas considered are endometriosis on or near the ovarian surface, superficial cervical endometriosis, vaginal endometriosis, tubal endometriosis, and intestinal endometriosis, including the important distinction of an endometrioid carcinoma arising from colonic endometriosis from a primary colonic adenocarcinoma. Finally, endometriotic foci can occasionally be intimately admixed with another process, such as peritoneal leiomyomatosis or gliomatosis, resulting in a potentially confusing histologic appearance.
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Affiliation(s)
- Philip B Clement
- Department of Pathology, Vancouver General Hospital, Vancouver, BC, Canada.
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18
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Kazakov DV, Ondic O, Zamecnik M, Shelekhova KV, Mukensnabl P, Hes O, Dvorak V, Michal M. Morphological variations of scar-related and spontaneous endometriosis of the skin and superficial soft tissue: A study of 71 cases with emphasis on atypical features and types of müllerian differentiations. J Am Acad Dermatol 2007; 57:134-46. [PMID: 17572279 DOI: 10.1016/j.jaad.2006.11.036] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2006] [Revised: 10/04/2006] [Accepted: 11/27/2006] [Indexed: 11/22/2022]
Abstract
BACKGROUND Seventy-one cases of scar-related and spontaneous endometriosis of the skin and superficial soft tissue were studied, with a focus on atypical features and types of müllerian differentiation. All patients were women, whose ages ranged from 22 to 65 years (median, 32 years). METHODS Histological, immunohistochemical, and electronmicroscopic studies were performed. Clinical information was ascertained via a questionnaire solicited by the referring physicians. RESULTS All types of metaplastic changes of müllerian epithelium were found, including tubal (61%), oxyphilic (15%), hobnail (10%), mucinous (4%), and papillary syncytial (3%) metaplasia. Atypical features included reactive atypia (23%) and atypical mitoses in glandular epithelium (6%). Stromal changes included smooth muscle metaplasia (31%), decidualization (<1%), stromal endometriosis (<1%), and elastosis (<1%). Other features recognized included lipoblast-like cells (15%), some with intranuclear inclusions; atypical/degenerative myocytes (10%); spiral arteries (4%); and perineurial invasion (<1%). CD56 staining identified large granular lymphocytes in 15 of 20 studied specimens. Ultrastructurally, these cells showed cytoplasmic granules, some with a delimiting membrane. LIMITATIONS This study utilizes tissue specimens that mainly were received as consultations; therefore some inherent selection bias exists. Specimens were randomly selected for CD56 immunostaining, leading also to potential sampling error. CONCLUSIONS All types of müllerian metaplasia can be encountered in cutaneous endometriosis. In addition, so-called atypical features described in endometriosis affecting other anatomic sites may be seen in the skin. Some features may represent a diagnostic pitfall.
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Affiliation(s)
- Dmitry V Kazakov
- Sikl's Department of Pathology, Charles University Medical Faculty Hospital, Pilsen, Czech Republic.
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19
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Biedrzycki OJ, Arnaout A, Coppen MJ, Shepherd NA. Isolated intramucosal goblet cells in subacute ischaemic enteritis: mimicry of signet ring cell carcinoma. Histopathology 2005; 46:460-2. [PMID: 15810958 DOI: 10.1111/j.1365-2559.2004.02015.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- O J Biedrzycki
- Department of Histopathology, Mayday Hospital, Thornton Heath, UK
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20
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Ciani S, Merino J, Vijayalakhsmi S, Nogales FF. Acquired uterine arteriovenous malformation with massive endometrial stromal component. Histopathology 2005; 46:234-5. [PMID: 15693900 DOI: 10.1111/j.1365-2559.2004.01986.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
BACKGROUND The deposition of extracellular mucin has not been described in Spitz nevus and herein such a case is reported. METHODS A 6-year-old male presented with a growing 1.0-cm pigmented lesion on his left anterior knee. The lesion was excised. RESULTS The histologic sections demonstrated a symmetrical and dome-shaped proliferation of spindle and epithelioid melanocytes with sharp lateral demarcation at the dermal-epidermal junction and within the superficial dermis. Features of Spitz nevus such as retraction from the epidermis, eosinophilic bodies, and uniform cytologic atypia were seen. Of interest, there was marked mucin deposition within the epidermal clefts and between the neoplastic cells. The mucin was highlighted by alcian blue and colloidal iron stains, and it was negative with mucicarmine and periodic acid-Schiff stains. CONCLUSION Awareness that soitz nevi can rarely have extracellular mucin helps in avoiding diagnostic pitfalls.
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Affiliation(s)
- Mai P Hoang
- Department of Pathology, The University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
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Phillips V, Graham CT, Manek S, McCluggage WG. The effects of the levonorgestrel intrauterine system (Mirena coil) on endometrial morphology. J Clin Pathol 2003; 56:305-7. [PMID: 12663645 PMCID: PMC1769918 DOI: 10.1136/jcp.56.4.305] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS The Mirena coil is a levonorgestrel releasing intrauterine device that is in widespread use. This study aims to document the endometrial morphology associated with this device. METHODS Endometrial specimens from 75 women with the Mirena coil were reviewed and the histological features detailed. RESULTS Morphological features found in most of the endometria were decidualisation of stroma (72 of 75 cases), atrophy of endometrial glands (65 of 75 cases), a surface papillary pattern (38 of 75 cases), and a stromal inflammatory cell infiltrate (59 of 75 cases). Additional common histological features were the presence of foci of stromal myxoid change (29 of 75 cases) and stromal haemosiderin pigment (24 of 75 cases). Reactive atypia of surface glands, glandular metaplastic changes, stromal necrosis, and stromal calcifications were found in small numbers of cases. CONCLUSION The endometrial features are characteristic and relatively constant and are in keeping with the effects of both a progestogenic compound and a mechanical device. Pathologists should be aware of these histological features because the Mirena coil is in widespread use.
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Affiliation(s)
- V Phillips
- Department of Pathology, Royal Group of Hospitals Trust, Grosvenor Road, Belfast BT12 6BL, Northern Ireland, UK
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23
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Iezzoni JC, Mills SE. Nonneoplastic endometrial signet-ring cells. Vacuolated decidual cells and stromal histiocytes mimicking adenocarcinoma. Am J Clin Pathol 2001; 115:249-55. [PMID: 11211614 DOI: 10.1309/rl5h-vc5d-9we2-x71h] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
We describe 5 patients (mean age, 50 years; all had uterine bleeding) whose routine endometrial biopsy and curettage specimens contained prominent signet-ring cells. Each specimen contained loose aggregates of signet-ring cells scattered within the endometrial stroma that were characterized by peripherally displaced, small, uniform nuclei with indistinct nucleoli and showed no mitotic activity. The central portion of the cytoplasm was occupied by single or multiple cytoplasmic vacuoles. In all cases, the signet-ring cells were reactive for vimentin and negative for epithelial membrane antigen and cytokeratin. Four cases were focally positive for muscle-specific actin or smooth muscle actin and negative for CD68, Mac387, periodic acid-Schiff, mucicarmine, and alcian blue. In these 4 cases, the surrounding endometrial stroma showed decidual changes, and the signet-ring cells demonstrated a morphologic continuum with more typical decidualized stroma. As such, the signet-ring cells in these cases were vacuolated, decidualized endometrial stromal cells. In the remaining case, the vacuolar contents of the signet-ring cells were periodic acid-Schiff-positive and resistant to diastase predigestion, and the cells reacted with Mac387 and CD68. The surrounding stroma showed no decidual reaction. Thus, the signet-ring cells in this case were of histiocytic differentiation. Endometrial stroma occasionally may contain nonneoplastic signet-ring cells that closely mimic adenocarcinoma. At least 2 directions of differentiation, decidual and histiocytic, are possible.
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Affiliation(s)
- J C Iezzoni
- Robert E. Fechner Laboratory of Surgical Pathology, University of Virginia Health Sciences Center, Charlottesville, VA 22908, USA
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24
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Abstract
Cutaneous deciduosis is an exceedingly rare manifestation of endometriosis potentially mistaken for malignancy and thus far documented solely within surgical scars. We describe two additional cases, one occurring in a pregnant 21-year-old woman as a solitary flat erythematous vulvar papule, an extraordinary location not previously recorded. Histologic examination in that case revealed a subepithelial nodular aggregate of atypical large dyscohesive cells with accompanying edema and inflammation. An immunohistochemical panel showed positivity of the cells for vimentin and Ki-1 (CD30). Intracellular sulfated mucin and glycogen were also demonstrated. In a second case, a 27-year-old woman had a nodule at the umbilicus, removed incidentally during the course of cesarean section. Microscopically there were several circumscribed, multilobulated, intradermal nodules with variably sized lumens formed by crowded large epithelioid cells. The disparate histologic appearance of these examples highlights an essential challenge in their diagnosis. Clinical recognition is difficult unless suggested by more characteristic history or location.
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Affiliation(s)
- K P Fair
- Departments of Pathology and Dermatology, University of Virginia Health Science Center, Charlottesville 22908-0214, USA
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25
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McCluggage WG, Kirk SJ. Pregnancy associated endometriosis with pronounced stromal myxoid change. J Clin Pathol 2000; 53:241-2. [PMID: 10823149 PMCID: PMC1731157 DOI: 10.1136/jcp.53.3.241] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
A case of endometriosis presenting as a mass in the groin of a pregnant woman is described. The mass increased in size during the pregnancy and the radiological features were suspicious of malignancy. Histological examination showed atrophic glands set in an abundant stroma. This was not typical of normal endometrial stroma but had a pronounced myxoid appearance with areas of decidualization. The atypical site of the endometriosis together with the unusual stromal changes resulted in diagnostic confusion. Although stromal decidualization is well recognized in endometriosis in pregnancy, pronounced myxoid change appears unusual. The myxoid change in this case may be a degenerative phenomenon related to pregnancy.
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Affiliation(s)
- W G McCluggage
- Department of Pathology, Royal Group of Hospitals Trust, Belfast, Northern Ireland, UK
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26
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Hitchcock MG, McCalmont TH, White WL. Cutaneous melanoma with myxoid features: twelve cases with differential diagnosis. Am J Surg Pathol 1999; 23:1506-13. [PMID: 10584704 DOI: 10.1097/00000478-199912000-00008] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Substantial myxoid change can occur in malignant melanoma, but its importance in primary disease has not been systematically evaluated. This report describes the clinical, microscopic, histochemical, and immunohistochemical findings in 12 patients with primary cutaneous malignant melanoma with myxoid features. The tumors presented as solitary lesions situated on the limbs (six lesions), trunk (four lesions), and head and neck (two lesions). The patients included six women and six men, whose ages ranged from 26 to 95 years, with a mean of 63 years. Breslow thickness varied from 0.48 mm to more than 12 mm, with a mean of more than 3.2 mm. Clinical follow-up for an average of 22 months showed one local recurrence, but no evidence of metastases yet. In all cases, there was a combination of myxoid and nonmyxoid areas. A minimum of 15% myxoid cross-sectional area was required for inclusion in the study, and up to 80% was observed. The pale blue mucin identified on hematoxylin and eosin staining was sensitive to hyaluronidase and positive for alcian blue in the 10 cases stained. Immunohistochemical staining was positive for S-100 in all 9 cases stained, positive for HMB-45 in 9 (90%) of 10, and negative for cytokeratin in all 9 cases in which myxoid melanoma remained in the block after previous sections. The presence of myxoid stroma did not define a biologically significant subgroup of melanoma. Only in cases with extensive (>50%) myxoid stromal effacement of the melanoma was there a major diagnostic hurdle. The diagnosis of primary cutaneous melanoma with myxoid features was seldom as problematic as metastatic myxoid melanoma. Positive S-100 stains, negative cytokeratin immunohistochemical stains, and hyaluronidase-sensitive alcian blue staining assisted in the diagnosis of this entity.
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Affiliation(s)
- M G Hitchcock
- Department of Pathology, The Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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27
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Michal M, Chlumska A, Mukensnabl P. Signet-ring cell aggregates simulating carcinoma in colon and gallbladder mucosa. Pathol Res Pract 1998; 194:197-200. [PMID: 9587939 DOI: 10.1016/s0344-0338(98)80023-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We describe three cases of benign signet-ring cell aggregates in the colon associated with pseudomembranous colitis, adenomatous polyp of the colon and ulcerated mucosa of the gallbladder excised for gallstones. In all cases, we found loose, benign signet-ring cell aggregates overlying the ulcerated mucosa surface, simulating signet ring-cell carcinoma. The most important sign of the benign signet-ring cell aggregates is that they are always confined to the surface of the mucosa of the intestine or gallbladder mucosa or crypts of the intestinal epithelium. In no case did we see an invasion of these cells into the lamina propria of the mucosa. In all cases, the benign signet-ring cell aggregates were immunohistochemically positive with antibodies to cytokeratins. The occurrence of benign signet-ring cell aggregates is a rare and very misleading diagnostic pitfall which must be differentiated from signet-ring cell carcinoma of the colon and gallbladder.
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Affiliation(s)
- M Michal
- Medical Faculty, Charles University Pilsen, Czech Republic.
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28
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Ying AJ, Copeland LJ, Hameed A. Myxoid change in nondecidualized cutaneous endometriosis resembling malignancy. Gynecol Oncol 1998; 68:301-3. [PMID: 9570985 DOI: 10.1006/gyno.1998.4952] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cutaneous endometriosis infrequently arises in the absence of pelvic disease. Rare features such as myxoid change can resemble malignancy and may pose a challenging histological diagnosis. We are not aware of any previous cases involving nondecidualized cutaneous endometriosis with myxoid change associated with an abdominal surgical scar. We report the first such case in which a 24-year-old woman presented with a steadily growing, firm, tender, painful, subcutaneous cicatrical mass that had appeared shortly after cesarean section 1 year previously. The mass was removed and permanent sections revealed foci of large, irregular endometrial glands embedded within prominent myxoid stroma and acellular mucin pools, with fibrosis and pseudoinfiltration of the fascia. No evidence of malignancy was identified. This case demonstrates that nondecidualized cutaneous endometriosis with myxoid change should be considered in the differential diagnosis of histologically similar malignancies such as mucinous adenocarcinoma and pseudomyxoma peritonei.
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Affiliation(s)
- A J Ying
- Department of Pathology, Ohio State University Medical Center, Columbus 43210, USA
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29
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Abstract
While undergoing a repeat Caesarian section, a 21-year-old woman was found to have a subcutaneous, 3.5-cm tumor-like lesion in the abdominal wall. It had a lobulated contour and consisted of gelatinous tan nodules with intervening fibrous septa. It had a composite histology, including a solid pattern of large glassy cells with a predominant perivascular and pericystic/cisternal topography (35% surface area); a pattern of dyscohesive, vacuolated cells including physaliphorous-like forms (35% surface area); and a myxoid pattern of spindle to stellate cells showing frequent cell contact and lying within an optically clear or pale eosinophilic and bubbly extracellular matrix with a prominent capillary framework. A strong and diffuse cytoplasmic expression of vimentin (only) was present in all cytoarchitectural patterns. The extracellular matrix and intracytoplasmic vacuoles contained abundant acid mucosubstance, mostly hyaluronic acid. No distinct endometrial gland, stigma of hemorrhage, or nuclear estrogen/progesterone receptor protein expression was observed. There were variously sized and shaped cystic spaces lined by a flat to cuboidal cytokeratin-positive cell lining and focally containing neutral and acid mucosubstance. These spaces are interpreted as dilated endometrial glands rather than mechanically entrapped inclusions of mesothelial origin. In this setting, florid decidual reaction represents a potential diagnostic pitfall because it could be confused with more commonly encountered myxoid or epithelioid tumors of mesenchymal, epithelial, or melanocytic cell lineage.
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Affiliation(s)
- L R Bégin
- Department of Pathology, McGill University, Quebec, Canada
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30
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Abstract
After being treated for pneumonia with antibiotics, an 82-year-old man with a history of colonic carcinoma developed pseudomembranous colitis with toxic megacolon. In addition to the classic features of pseudomembranous colitis, the colon displayed signet-ring cells confined to the surface epithelium and crypts. A misdiagnosis of recurrent carcinoma was avoided after a review of the history and the endoscopic findings and by noting the location of the signet-ring cells.
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Affiliation(s)
- R Schiffman
- Department of Pathology, Pennsylvania Hospital, PA 19107-6192, USA
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31
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Abstract
In cutaneous metastatic disease the histologic pattern may be specific or nonspecific. Carcinoma cutis most often shows only the nonspecific pattern of an adenocarcinoma, a squamous cell carcinoma, or an undifferentiated metastatic tumor. However, certain clinical and histologic characteristics may suggest a primary tumor site and type. In addition, special histologic stains and the use of immunohistochemical and electronmicroscopic techniques may also prove valuable in the diagnosis of carcinoma cutis and other cutaneous metastatic diseases.
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Affiliation(s)
- R A Schwartz
- New Jersey Medical School, Newark 07103-2714, USA
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