Thames Valley Cytology Society

Psammoma bodies in Adenocarcinoma - Case study

Presented by Carol Woodman, QE II Hospital, Welwyn Garden City

Case presentation at Northwick Park Hospital 27th May 2002 by Carol Woodman

Patient born in 1948.
1999 - Patient went to GP suffering from abdominal cramps due to a long term IBS.
Cervical smear taken as it was due.

Smear report: "Abundant papillary groups of dyskaryotic glandular cells with associated psammoma bodies.The appearance is suggestive of primary metastatic endometrial or ovarian malignancy. Advise urgent referral for colposcopy and gynae opinion."

The following information was not given on the smear request form and was obtained at a later date.

• Mother, maternal aunt and grandmother had all died of ovarian cancer between 46 and 53 years of age.
• This patient had been investigated in 1994 at an Ovarian Cancer-Screening Unit by physical exam, scan and CA125 levels, all of which were normal. A prophylactic oopherectomy was declined.
• She had been followed up yearly with scans and CA125 levels. The last follow up was 11 months before the above smear. Although the CA125 was 28 IU/ml (normal range 0-23) the 2 scans done at this time showed no abnormality.

On referral to Gynae clinic the examinations included a MRI scan which was unremarkable. The CA125 level was 99 IU/ml. At laparotomy the uterus and tubes were unremarkable but seedlings were found all over the ovaries and pelvic peritoneum and on the sigmoid colon.

TAH, bilateral salpingo-oopherectomy, omenectomy and biopsies of tumour deposits on the sigmoid colon were carried out. Histology revealed a poorly differentiated serous papillary carcinoma accompanied by scattered psammoma bodies (especially in nodules of sigmoid colon) on the surface of the myometrium of uterus, and the surface of ovary and infiltration of the omental tissue.(Figure3) The cervix, endometrium, tubes and ovarian stroma were all normal.

Figure 3.H&E. x 40.

Surface of uterus showing psammoma bodies surrounded by adenocarcinoma.

Histological diagnosis: "A tumour of peritoneal origin with secondary involvement of the ovarian surface."

Points of discussion mentioned in the presentation included:

• Psammoma bodies
  they are found in both benign (IUCD, combined OC, endometrial TB, post partum, granulomatous reactions) and malignant conditions (especially meningioma, papillary Ca of ovary, thyroid and pancreas). The type of cells they are associated with and the quantities present are the key factors.
• Screening tests for ovarian cancer.
  * CA125 levels are the subject of ongoing trials as a screening tool. 80% of women have raised CA125 at time of diagnosis, 20% of women with ovarian carcinoma will never have a raised CA125 level. False positives can occur in premenapausal patients. It is recommended that this test should only be used with other tests such as ultra sound, transvaginal sonography and recto vaginal pelvic exam. It has been stated that the gain in life expectancy is 0.3 to 1.7 yr. and that there is still a risk as high as 1 in 2 of developing Ca after a prophylactic oopherectomy.
  *A new development in screening since this case has been the identification of BRCA1 gene mutations. The gene has been identified as being associated with 5-10% of breast and ovarian cancers as a familial inheritance.
  A sister has just developed breast cancer, and the other sister is undergoing screening for BRCA1 mutation.
• Tumour typing.
  This case was diagnosed as peritoneal origin rather than endometrial or ovarian as the tumour deposits were on the surface of the latter organs. There is a common oncogenic origin for serous papillary Ca from ovary, endometrium and peritoneal cavity.

There is similar prognosis and management for all these tumour types.

The patient had a course of taxol treatment and is doing very well 3 years on.