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대한병리학회지: 제 37 권제6 호 2003 The Korean Journal of Pathology. 2003; 37: 438-41

Endometrial Mucinous with Extensive Squamous Differentiation - A Case Report -

Ho-chang Lee∙Pil Gyu Hwang Endometrial mucinous adenocarcinoma occurs in 1-9% of endometrial and Soo Youn Cho∙Young S. Park adenocarcinoma with squamous differentiation in approximately 25%. We report a rare case In Ae Park of mucinous adenocarcinoma with squamous differentiation in a 53-year-old woman. Curetting biopsies of the endometrial lesion were taken twice after hormone replacement therapy, which Department of Pathology, Seoul lasted for four months. Because the squamous differentiation was so extensive, the initial diag- National University College of Medicine, nosis based on each curetting specimen was squamous . A total was Seoul, Korea performed and the tumor was revealed to be a mucinous adenocarcinoma with squamous dif- Received : September 18, 2003 ferentiation. We subsequently discussed the pathogenesis and prognosis of this type of tumor. Accepted : November 14, 2003

Corresponding Author In Ae Park, M.D. Department of Pathology, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-799, Korea Tel: 02-760-2788 Fax: 02-743-5530 E-mail: [email protected] Key Words : Adenocarcinoma, Mucinous-Endometrial -Squamous Metaplasia

Endometrial mucinous adenocarcinoma (EMAC), which is at fifty years old. After the cervicovaginal smear, which was composed of the columnar epithelial cells containing intra- negative for , she took Cliane (estradiol hemihy- cellular mucin, occurs in 1-9% of endometrial adenocarcino- drate 2 mg and norethisterone acetate 1mg) for four months. mas.1,2 To qualify as a mucinous adenocarcinoma, at least half Her bleeding, however, did not subside. Computed tomog- of the tumor cells must contain intracytoplasmic mucin.3 En- raphy on the pelvis showed an ill-defined, well-enhanced mass dometrial adenocarcinoma (EAC) with squamous differenti- confined to the body of the (Fig. 1). There was no evi- ation or metaplasia (SQ), in which the squamous element con- dence of to other pelvic organs, regional lymph node stitutes 10% or more of the tumor,3 is observed in about 25% enlargement or distant . Curettage biopsies were of total endometrial adenocarcinomas.4 However, SQ in EMAC taken twice and the specimens were papillary which as a dominant feature is very rare.2 were mainly composed of squamous cells with mild nuclear We report a case of EMAC with extensive SQ and discuss pleomorphism. Many columnar cells with intracytoplasmic the pathogenesis of SQ in mucinous adenocarcinoma and the mucin were scattered within the squamous cells forming mu- prognosis of this type of tumor. cin pools within their glandular lumens. There were some neutrophils in the glandular lumens, in mucin pools, within the squamous cells and along the basement membrane. Each CASE REPORT curetting specimen was diagnosed with squamous papilloma of the endocervix. A 53-year-old, gravida 6, para 3 woman visited our hospital A total vaginal hysterectomy was done with the clinical with vaginal bleeding for six months. She had not received impression of endometrial . Grossly, the tumor mea- hormone replacement therapy (HRT) since her menopause sured 3×2.5 cm, was located to the fundus and showed a vil-

438 Endometrial Mucinous Adenocarcinoma with Squamous Differentiation 439

Fig. 1. On computed tomography, an ill-defined mass is located Fig. 2. A villous mass is present in the fundus of the uterus. There to the right posterior side of the uterine body (arrow). There is no is no definite involvement of this tumor on the other part of endometri- evidence of extrauterine invasion. um and endocervix.

lous growth pattern (Fig. 2). In microscopic examination, this DISCUSSION tumor was morphologically similar to the curettage specimens, including the two types of epithelial cells, squamous and muci- EMAC is a rare type of malignancy showing mucinous dif- nous, except that a definite well-differentiated adenocarci- ferentiation similar to that of the endocervix. Because of its noma component was found (Fig. 3A). The squamous cells rarity, its pathogenesis has not been elucidated yet. Its asso- accounted for about 70% of the tumor cells. No endometri- ciation with the exposure to estrogen, however, may be less oid-type were found in this tumor. Mucin in colum- clear than that of endometrioid adenocarcinoma. In 18 cases nar cells and mucin pools was positive for Alcian blue, muci- of EMAC reported by Melhem and Toubon,2 all patients were carmine, and periodic acid Schiff, and was diastase-resistant postmenopausal and ten had received HRT. In the report by (Fig. 3B). Both of the tumor components, squamous epithe- Tiltman,5 all three patients were postmenopausal, at least 60 lial cell nest and mucinous adenocarcinoma, showed negative years old, and none had received HRT. The patient in our case reactivity for vimentin (V9, 1:100, DAKO, Glostrup, Den- had received Cliane as HRT for four months. The clinical man- mark), estrogen receptor (1D5, 1:50, DAKO, Glostrup, Den- ifestations of EMAC, including prognosis, are not different mark), and progesterone receptor (1A6, 1:50, DAKO, Glo- from those of endometrioid type of adenocarcinoma. However, strup, Denmark). Carcinoembryonic antigen (CEA) (II-7, 1: most cases are well-differentiated and confined to the endo- 100, DAKO, Glostrup, Denmark) and cytokeratin 7 (OV-TL metrium, so the overall prognosis of EMAC is good.1,2 12/30, 1:300, DAKO, Glostrup, Denmark) were positive only Mucinous adenocarcinoma is more commonly found in the in columnar epithelial cells (Fig. 3C). No human papilloma endocervix than in the endometrium. The distinction between virus (HPV) DNA was detected in this tumor. No focus of endometrial and endocervical mucinous adenocarcinomas is myometrial invasion was found. The endometrium, which was important but often difficult to make, especially in a curet- not involved by the tumor, was atrophic. The uterine cervix, tage specimen. Ross et al.1 noted that intracytoplasmic mucin both the fallopian tubes and ovaries were all free of tumor. cannot be a hallmark of distinguishing between the two car- There was no metastasis in the pelvic lymph nodes. The pa- cinomas, so they suggested that their distinction should rely tient did not undergo or after on anatomic localization. Recently, vimentin was revealed to the hysterectomy. There was no evidence of recurrence or dis- be the most useful antibody for the differentiation of EAC from tant metastasis two years after the hysterectomy. an endocervical origin for both the mucinous and endometri- 440 Ho-chang Lee∙Pil Gyu Hwang∙Soo Youn Cho, et al.

A B

Fig. 3. (A) Metaplastic squamous epithelial cell clusters are admixed with adenocarcinoma cell nests with intracytoplasmic mucin. (B) The columnar cells lining the luminal surface and mucin pools have abundant intracytoplasmic mucin (periodic acid Schiff staining). (C) C Only mucinous cells are positive for carcinoembryonic antigen. oid subtypes. In contrast to vimentin, CEA was not useful to adenocarcinoma. However, recent studies have demonstrated distinguish between endometrial and endocervical mucinous that the 5-year survival of women with AA and AS was iden- adenocarcinomas.6 In our case, however, vimentin was nega- tical when stratified by the histologic grade of the glandular tive. Thus, the distinction between them should be made component and myometrial invasion.11-13 Moreover, the dif- topographically only, as suggested by Ross et al.1 ferentiation of the squamous component closely paralleled EAC with SQ had been previously subclassified into ade- that of the glandular component, and the outcome of EAC noacanthoma (AA) and adenosquamous carcinoma (AS) ac- with SQ was predicted better by determining the grade of cording to the squamous cell component, which was benign the glandular component. It was therefore recommended that or malignant. It had been stated that the prognosis of AS was the terms AA and AS be replaced by the term EAC with SQ.13 worse than that of conventional adenocarcinoma,7-9 while that The prognosis of EAC with SQ was the same11,12 or better13 of AA was similar to7 or better than8,10 that of conventional than that of conventional adenocarcinoma. Endometrial Mucinous Adenocarcinoma with Squamous Differentiation 441

Studies have attempted to determine the etiologic factors 5. Tiltman AJ. Mucinous carcinoma of the endometrium. Obstet Gynecol of SQ in adenocarcinoma. Unopposed estrogen stimulation 1980; 55: 244-7. has been suggested as an important factor.14 However, Zaino 6. Castrillon DH, Lee KR, Nucci MR. Distinction between endometrial et al.4 commented that it had not been established that estro- and endocervical adenocarcinoma: an immunohistochemical study. gen exposure had a significant role in the development of en- Int J Gynecol Pathol. 2002; 21: 4-10. dometrial SQ. The association of progesterone exposure with 7. Ng AB, Reagan JW, Storaasli JP, Wentz WB. Mixed adenosquamous EAC with SQ has also been studied. Down-regulation of bcl- carcinoma of the endometrium. Am J Clin Pathol 1973; 59: 765-81. 2 expression was closely related with SQ and bcl-2 expression 8. Silverberg SG, Bolin MG, DeGiorgi LS. and mixed was markedly decreased by progesterone therapy in EAC.15 The adenosquamous carcinoma of the endometrium. A clinicopathologic relationship between EAC with SQ and HPV has been sug- study. 1972; 30: 1307-14. gested but remains still controversial. Some authors demon- 9. Alberhasky RC, Connelly PJ, Christopherson WM. Carcinoma of the strated HPV in the squamous cells,16,17 while others disagre- endometrium. IV. Mixed adenosquamous carcinoma. A clinical-pa- ed.18 Moreover, Kealy et al.17 revealed the presence of HPV in thological study of 68 cases with long-term follow-up. Am J Clin squamous and glandular cells, but they stated that it may exist Pathol 1982; 77: 655-64. in the tumor as a passenger rather than an etiologic agent. No 10. Connelly PJ, Alberhasky RC, Christopherson WM. Carcinoma of the studies on vitamin A deficiency and EAC with SQ have yet endometrium. III. Analysis of 865 cases of adenocarcinoma and ade- been reported, although in one report the deficiency of vita- noacanthoma. Obstet Gynecol 1982; 59: 569-75. min A induced SQ in the normal uterine .19 In our 11. Salazar OM, DePapp EW, Bonfiglio TA, Feldstein ML, Rubin P, case, we suspect that hormone exposure may contribute to the Rudolph JH. Adenosquamous carcinoma of the endometrium. An development of SQ, although this hypothesis is not definite entity with an inherent poor prognosis? Cancer 1977; 40: 119-30. because we didn’t obtain any specimen from the patient before 12. Pekin T, Yildizhan B, Eren F, Pekin O, Yildizhan R. Adenocarcinoma, HRT. adenoacanthoma, and mixed adenosquamous carcinoma of the In summary, we report a rare case of EMAC with extensive endometrium. Eur J Gynaecol Oncol 2001; 22: 151-3. SQ. We suspect that this carcinoma may have been associated 13. Zaino RJ, Kurman R, Herbold D, et al. The significance of squamous with hormone exposure, although this was not conclusive. We differentiation in endometrial carcinoma. Data from a Gynecologic postulate that the prognosis for EMAC with SQ is similar to Group study. Cancer 1991; 68: 2293-302. that for conventional endometrioid adenocarcinoma because 14. Robboy SJ, Bradley R. Changing trends and prognostic features in the prognosis for both EMAC and EAC with SQ is similar to associated with exogenous estrogen therapy. that for endometrioid adenocarcinoma. Obstet Gynecol 1979; 54: 269-77. 15. Saegusa M, Okayasu I. Down-regulation of bcl-2 expression is closely related to squamous differentiation and progesterone therapy in REFERENCES endometrial . J Pathol 1997; 182: 429-36. 16. O’Leary JJ, Landers RJ, Crowley M, et al. Human papillomavirus 1. Ross JC, Eifel PJ, Cox RS, Kempson RL, Hendrickson MR. Primary and mixed epithelial tumors of the endometrium. Hum Pathol mucinous adenocarcinoma of the endometrium. A clinicopathologic 1998; 29: 383-9. and histochemical study. Am J Surg Pathol 1983; 7: 715-29. 17. Kealy WF, Annis PG, Barry JA, Hogan JM. Adenoacanthoma of the 2. Melhem MF, Toubon H. Mucinous adenocarcinoma of the endometri- endometrium: morphological changes induced by human papillo- um: a clinico-pathological review of 18 cases. Int J Gynecol Pathol mavirus. J Clin Pathol 1990; 43: 554-9. 1987; 6: 347-55. 18. Czerwenka K, Lu Y, Heuss F, Manavi M, Kubista E. Human papil- 3. Ronnett BM, Zaino RJ, Ellenson LH, Kurman RJ. Endometrial carci- lomavirus detection of endometrioid carcinoma with squamous dif- noma. In: Kurman RJ ed. Blaustein’s pathology of the female genital ferentiation of the uterine corpus. Gynecol Oncol 1996; 61: 210-4. tract. 5th ed. New York: Springer-Verlag New York, Inc., 2002; 501-60. 19. Jetten AM, De Luca LM, Nelson K, Schroeder W, Burlingame S, Fuji- 4. Zaino RJ, Kurman RJ. Squamous differentiation in carcinoma of the moto W. Regulation of cornifin alpha expression in the vaginal and endometrium: a critical appraisal of adenoacanthoma and adenosqua- uterine epithelium by estrogen and retinoic acid. Mol Cell Endocrinol mous carcinoma. Semin Diagn Pathol 1988; 5: 154-71. 1996; 123: 7-15.