Intravascular endometrium (IEM) is a rare finding that can pose a significant diagnostic dilemma, especially in cases of known carcinoma where the possibility of vascular invasion must be entertained. The distinction between IEM and intravascular invasion of malignancy can be made based on histologic findings and immunohistochemical profile. We report a case of IEM in a hysterectomy specimen removed from a 38 year old patient with invasive cervical adenocarcinoma and adenomyosis. Histologically, the lumen and intima of large muscular vessels contained well-developed glands with high nuclear to cytoplasmic ratio and endometrial stroma with spindled nuclei associated with hemorrhage and hemosiderin-laden macrophages. By immunohistochemistry, the benign glands within vascular spaces were positive for vimentin, ER and PR, but only rare cells were positive for p16. The stroma surrounding the intravascular glands was positive for CD10. These results confirmed the presence of IEM. The presence of IEM may be confused with vascular invasion which may affect staging and treatment of the patient. Introduction Endometrial tissue found within the myometrial vessels during menstruation is an uncommon, benign finding which was initially described by Sampson in 1927.1 Subsequently, there have been reports of endometrial tissue in myometrial vessels that was not associated with menstruation, although all of these cases were found in association with extensive, and frequently multifocal, adenomyosis.2 A case of cervical dysplasia in association with intravascular menstrual endometrium has also been reported.3 We are not aware of literature describing IEM in association with invasive adenocarcinoma. We present a case of IEM, not associated with menstruation, in a hysterectomy specimen removed from a patient with invasive cervical adenocarcinoma. We discuss the histologic and immunohistochemical findings used to distinguish between vascular invasion of cervical adenocarcinoma and IEM. Materials and Methods This case is from the surgical pathology files of the Department of Pathology of the University of California San Diego Medical Center (San Diego, California). Tissue sections were formalin-fixed, embedded in paraffin and stained with hematoxylin-eosin (H&E). Four μm thick, formalin-fixed, paraffin-embedded tissue sections were stained with ER, PR, CD10, p16, or vimentin (Table 1). Clinical History At the time of initial evaluation, the patient was a 38 year old nulligravida with a prior history of iron deficiency anemia, depression, gastric bypass and abdominoplasty. There was no prior history of malignancy. She had an unremarkable physical exam. On a routine cervical Papanicolau screen, she was diagnosed with cervical adenocarcinoma in situ (AIS). A subsequent cervical biopsy and endocervical curettage confirmed the diagnosis. The endometrial biopsy was negative for malignancy. A cervical cone biopsy was done, which was consistent with invasive cervical adenocarcinoma with a background of AIS and focal squamous dysplasia. Repeat endocervical curettage and endometrial biopsy at the time were negative for malignancy. A radical hysterectomy and pelvic lymphadenectomy were then performed. The patient is doing well two years after the operation. Results The initial pap screen, cervical biopsy and endocervical curretings were diagnosed as AIS without vascular invasion but with a suspicion of stromal invasion due to the unoriented specimens. The cone biopsy demonstrated invasive, well differentiated adenocarcinoma (Fig 1A) with a depth of invasion of 4.5 mm, and maximum length of 9 mm. The adenocarcinoma cells were hyperchromatic with crowding, architectural complexity and loss of polarity. No vascular invasion was detected and margins were negative. The cervix of the hysterectomy specimen measured 2.6 cm in diameter and no gross tumors were seen. On microscopic examination, there was focal residual adenocarcinoma in situ with widely clear margins.
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