Author Information
Shruti Kulkarni*, Parulekar SV**, Pragati Sathe***
(*Third
Year Resident, ** Professor and Head of Department. Department
of Obstetrics and Gynecology, *** Assistant Professor, Department of Pathology
Seth GS Medical College and KEM Hospital , Mumbai ,
India
Abstract
A 60 years old postmenopausal
woman presented with a complaint of postmenopausal bleeding for 6 months. She
was a known diabetic on insulin. She had a small 1x1 cm polyp protruding from
os. Ultrasonography (USG) showed a 3x3 cm hourglass shaped polyp extending from
within the uterine cavity to external os. A fractional curettage with
polypectomy was done. While histopathology report was still awaited she came back
with complaints of heavy bleeding per vaginam in 2 weeks’ time, She was found
to have a polyp at the os. Histopathology report of curettage specimen was
suggestive of endometrial stromal tumor (EST). Immunohistochemistry showed CD10
positive cells suggestive of endometrial stromal tumor. A total abdominal hysterectomy
with bilateral salpingo-oophorectomy was done. Histopathology revealed a benign
endometrial stromal nodule (ESN).
Introduction
Endometrial stromal
tumors comprise of 0.2% of all uterine malignancies. They account for less than
10% of all such tumours.[1]
They usually present as peri- and postmenopausal menorrhagia or postmenopausal
vaginal bleeding. Very rarely they can be present in young women with puberty
menorrhagia. By WHO classification they are divided into three groups - benign
endometrial stromal nodule (ESN), low grade endometrial stromal sarcoma (ESS),
and undifferentiated endometrial sarcoma (UES). We present here an unusual case
of ESN treated by abdominal hysterectomy.
Case Report
A 60 year old with four
full term normal deliveries in the past presented with complaints of
postmenopausal bleeding for 6 months. She was a known diabetic for 18 years.
She had undergone tubal ligation 25 years ago. General and abdominal
examination showed no abnormality. On per speculum examination there was a 1x1cm
soft to firm polyp protruding from os, bleeding on touch. Ultrasonography (USG)
showed an hourglass shaped mass measuring 3x3 cm, extending from within uterine
cavity to protrude from the external os. Her blood sugars were controlled with
insulin therapy Polypectomy and fractional curettage were performed. While the
histopathology and immunohistochemistry report was still awaited patient came
after 2 weeks with heavy bleeding per vaginum with soakage of 6-7 pads per day,
with passage of clots. She was examined and was diagnosed to have a polyp
protruding from external os, bleeds to touch. USG showed a large polypoidal
lesion arising from left posterolateral wall of uterus. Histopathology report
of curettage specimen was suggestive of endometrial stromal tumor. Immunohistochemistry
revealed CD10 positive cells. A total abdominal hysterectomy with Bilateral
Salpingo-oophorectomy was performed. Histopathology of specimen revealed endometrial
stromal nodule.
Figure 50.1. histology
of fractional curettage specimen showing well defined non-infiltrative margin
suggestive of benign endometrial stromal tumor.
Figure 50.2. Immunohistochemistry
showing CD10 positive cells.
Figure 50.3. cut surface
of uterus showing endometrial stromal nodule within uterine cavity with well
defined margins.
Discussion
Endometrial stromal
tumors (EST) constitute less than 5% of uterine tumors. Benign ESN accounts for
about 25% of the EST. ESN is a solitary, well-circumscribed, round, fleshy nodule
measuring 4 cm in diameter (range 0.8 to 15 cm), with a yellow to tan cut
surface. It may have focal irregularities or finger-like projections into the
adjacent myometrium less than 3 in number and none them exceeding 3 mm in the
largest dimension.[2] It has expansile, noninfiltrative margins which
compress the surrounding endometrium and myometrium. Low grade ESSs often show
an irregular nodular growth in the endometrium, myometrium or both. There is
varying degrees of permeation of the myometrium, worm-like plugs of tumor which
distend myometrial and often parametrial veins.[3] A dumbbell shaped
EST is usually not seen. This patient had a dumbbell shaped EST, one part of
the dumbbell being in the endo- and myometrium, and the other projecting into
the uterine cavity, a part of which had extruded out of the cervix as a polyp.
It is impossible to differentiate between an ESN and a low-grade ESS on the
basis of curettage specimens in most cases, and a hysterectomy is required to
make the differentiation. This is not difficult in a peri- or postmenopausal
woman, but may not be possible if the woman is younger and desires to retain
her uterus. Low-grade EST is distinguished from high-grade EST by the
resemblance of the neoplastic cells to proliferative endometrial stroma. The
diagnosis of high-grade ESS is made only in cases where a component of low-grade
ESS may be recognized; in the absence of which it is UES.[4] UESs
are diagnosed only exclusion of smooth or skeletal muscle differentiation (high-grade
leiomyosarcoma or rhabdomyosarcoma). Small foci of carcinoma admixed with the
sarcomatous component suggest a malignant mixed mullerian tumor. CD10
expression is not helpful in this differentiation as high-grade ESS,
leiomyosarcomas, rhabdomyosarcomas, malignant mixed mullerian tumors and highly
cellular leiomyomas express CD10.[5,6] A perivascular epithelioid
cell tumour (PEComa) may resemple a ESN on gross and microscopy. It differs in
that it shows a predominantly nested growth often associated with a focal fascicular
growth of cells arranged in a radial fashion around the vessels, with elongated
nuclei as in smooth‐muscle tumors. There are
no areas that resemble the normal endometrial stroma with arterioles.[7]
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Kulkarni S, Parulekar SV, Sathe P. Endometrial Stromal Tumor-A Case Report. JPGO
2014 Volume 1 Number 6 Available from: http://www.jpgo.org/2014/06/endometrial-stromal-tumor.html