Images in Cytopathology
Incidental detection of psammoma bodies in cervico-vaginal smears A 30-year-old married Indian female presented with discharge per vaginuum and menorrhagia. She had no significant past general or gynecological disease. She had no history of oral or intrauterine contraceptive use. Her per vaginuum and per speculum examinations were within normal limits. Her Pap smears were taken for screening purpose, fixed, stained, and examined. Microscopic examination of the Pap smears showed ectocervical and endocervical cell clusters, with no morphological abnormalities. Several concentric psammoma bodies, scattered amongst the ectocervical epithelial cells were identified [Figures 1a-e]. Individual foci of calcification were also seen [Figure 1f]. No malignant or dysplastic cell were observed. Psammoma bodies are calcified structures with concentric laminations, mixed with proteins. They are a rare finding in cervico-vaginal smears (CVS), the incidence being less than 0.001 to 0.009% on consecutively screened smears.[1] Psammoma bodies may be associated with several neoplastic diseases of the female reproductive tract, including benign ovarian serous cystadenofibromas, malignant serous epithelial tumors of ovary, endometrial carcinoma, squamous cell carcinoma, papillary adenocarcinoma and neuroendocrine carcinoma of cervix, tubal serous carcinoma, and peritoneal psammocarcinoma. Psammoma bodies have also been reported in association with benign lesions including inclusion cysts of the ovary,[2] endosalpingiosis, vaginal malakoplakia, chronic endometritis, and the use of oral[1] and intrauterine contraceptives. Rarely, they have also been reported with foci of calcifications in benign endocervical and endometrial tissue polyps, endometrial atrophy, follicular cervicitis, chronic Access this article online Quick Response Code Website: www.jcytol.org
DOI: 10.4103/0970-9371.126665
a
c
b
d
e
f
Figure 1: (a) Psammoma bodies in cervico-vaginal smears (Pap, x100); (b) to (e) (Pap, x400); (f) A calcified focus in the same smear (Pap, x400)
salpingitis, tuberculous endometritis, and tubo-ovarian adhesions. A case has been on record where CVS psammoma bodies were consequent to the metastatic focus in the pouch of Douglas from primary carcinoma of the breast.[3] Potential mechanism for appearance of psammoma bodies, particularly in primary ovarian neoplasms, may be the accumulation of calcium around the nidus of a single degenerated tumor cell.[4] However, according to histologic and histochemical observations of Fujimoto et al.,[3] psammoma bodies seem to be secretory rather than degenerative in origin. Pathogenesis of CVS psammoma bodies in benign inclusion cysts may be rupture of the cyst, followed by aspiration of its contents and of minute parietal fragments with psammoma bodies by the fallopian tube.[2] Presence of psammoma bodies on cervico-vaginal smears assumes significance because of their association with malignant disease. Therefore, one must look for atypical or malignant cells in cervical samples with psammoma bodies. The dilemma arises when psammoma bodies are the only findings on CVS with no trace of atypical cells, as in our case. In the absence of malignant background cytology
Ankit Seth, Kusum Gupta, Anjali Mathur, Leela Pant Department of Pathology, Kasturba Hospital, Daryaganj, Delhi, India Address for correspondence: Dr. Ankit Seth, 80, Thomson Road, New Delhi – 110 002, India. E-mail: [email protected]
272
Journal of Cytology / October 2013 / Volume 30 / Issue 4
Seth, et al.: Psammoma bodies in cervico-vaginal smear
or clinical symptoms, presence of psammoma bodies in normal cytologic smears might be due to benign conditions like polyps, cervicitis, or pregnancy-related conditions. In up to half of the cases, the psammoma bodies seem to be incidental findings without any obvious pathology.[5] However, such patients should be extensively investigated to rule out malignancy, including CA-125 estimation, endometrial aspiration, hysteroscopy, uterine curettage, abdominal, and trans-vaginal ultrasonography and laparoscopy. Random non-specific calcifications should be distinguished from the psammoma bodies by adhering strictly to the morphological characteristics of psammoma bodies. However, sometimes, both calcifications and psammoma bodies are detected in the same CVS, as in our case. Also, psammoma bodies should not be confused with other calcified structures like Michaelis-Gutmann bodies, which are intracellular and found in rare cases of vaginal malakoplakia.[6]
References 1. 2. 3.
4. 5.
6.
Parkash V, Chacho MS. Psammoma bodies in cervicovaginal smears: incidence and significance. Diagn Cytopathol 2002;26:81-6. Luzzatto R, Brücker N. Benign inclusion cysts of the ovary associated with psammoma bodies in vaginal smears. Acta Cytol 1981;25:282-4. Fujimoto I, Masubuchi S, Miwa H, Fukuda K, Yamaguchi S, Masubuchi K. Psammoma bodies found in cervicovaginal and/or endometrial smears. Acta Cytol 1982;26:317-22. Johannessen JV, Sobrinho-Simoes M. The origin and significance of thyroid psammoma bodies. Lab Invest 1980;43:287-96. Muntz HG, Goff BA, McGonigle K, Isacson C. The significance of psammoma bodies in screening cervical cytologic smears. Am J Obstet Gynecol 2003;188:1609-12. Chalvardjian A, Carydis B, Cohen S. Cytologic diagnosis of extravesical malacoplakia. Diagn Cytopathol 1985;1:216-20.
How to cite this article: Seth A, Gupta K, Mathur A, Pant L. Incidental detection of psammoma bodies in cervico-vaginal smears. J Cytol 2013;30:272-3. Source of Support: Nil, Conflict of Interest: None declared.
Journal of Cytology / October 2013 / Volume 30 / Issue 4
273
Copyright of Journal of Cytology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Incidental detection of psammoma bodies in cervico-vaginal smears A 30-year-old married Indian female presented with discharge per vaginuum and menorrhagia. She had no significant past general or gynecological disease. She had no history of oral or intrauterine contraceptive use. Her per vaginuum and per speculum examinations were within normal limits. Her Pap smears were taken for screening purpose, fixed, stained, and examined. Microscopic examination of the Pap smears showed ectocervical and endocervical cell clusters, with no morphological abnormalities. Several concentric psammoma bodies, scattered amongst the ectocervical epithelial cells were identified [Figures 1a-e]. Individual foci of calcification were also seen [Figure 1f]. No malignant or dysplastic cell were observed. Psammoma bodies are calcified structures with concentric laminations, mixed with proteins. They are a rare finding in cervico-vaginal smears (CVS), the incidence being less than 0.001 to 0.009% on consecutively screened smears.[1] Psammoma bodies may be associated with several neoplastic diseases of the female reproductive tract, including benign ovarian serous cystadenofibromas, malignant serous epithelial tumors of ovary, endometrial carcinoma, squamous cell carcinoma, papillary adenocarcinoma and neuroendocrine carcinoma of cervix, tubal serous carcinoma, and peritoneal psammocarcinoma. Psammoma bodies have also been reported in association with benign lesions including inclusion cysts of the ovary,[2] endosalpingiosis, vaginal malakoplakia, chronic endometritis, and the use of oral[1] and intrauterine contraceptives. Rarely, they have also been reported with foci of calcifications in benign endocervical and endometrial tissue polyps, endometrial atrophy, follicular cervicitis, chronic Access this article online Quick Response Code Website: www.jcytol.org
DOI: 10.4103/0970-9371.126665
a
c
b
d
e
f
Figure 1: (a) Psammoma bodies in cervico-vaginal smears (Pap, x100); (b) to (e) (Pap, x400); (f) A calcified focus in the same smear (Pap, x400)
salpingitis, tuberculous endometritis, and tubo-ovarian adhesions. A case has been on record where CVS psammoma bodies were consequent to the metastatic focus in the pouch of Douglas from primary carcinoma of the breast.[3] Potential mechanism for appearance of psammoma bodies, particularly in primary ovarian neoplasms, may be the accumulation of calcium around the nidus of a single degenerated tumor cell.[4] However, according to histologic and histochemical observations of Fujimoto et al.,[3] psammoma bodies seem to be secretory rather than degenerative in origin. Pathogenesis of CVS psammoma bodies in benign inclusion cysts may be rupture of the cyst, followed by aspiration of its contents and of minute parietal fragments with psammoma bodies by the fallopian tube.[2] Presence of psammoma bodies on cervico-vaginal smears assumes significance because of their association with malignant disease. Therefore, one must look for atypical or malignant cells in cervical samples with psammoma bodies. The dilemma arises when psammoma bodies are the only findings on CVS with no trace of atypical cells, as in our case. In the absence of malignant background cytology
Ankit Seth, Kusum Gupta, Anjali Mathur, Leela Pant Department of Pathology, Kasturba Hospital, Daryaganj, Delhi, India Address for correspondence: Dr. Ankit Seth, 80, Thomson Road, New Delhi – 110 002, India. E-mail: [email protected]
272
Journal of Cytology / October 2013 / Volume 30 / Issue 4
Seth, et al.: Psammoma bodies in cervico-vaginal smear
or clinical symptoms, presence of psammoma bodies in normal cytologic smears might be due to benign conditions like polyps, cervicitis, or pregnancy-related conditions. In up to half of the cases, the psammoma bodies seem to be incidental findings without any obvious pathology.[5] However, such patients should be extensively investigated to rule out malignancy, including CA-125 estimation, endometrial aspiration, hysteroscopy, uterine curettage, abdominal, and trans-vaginal ultrasonography and laparoscopy. Random non-specific calcifications should be distinguished from the psammoma bodies by adhering strictly to the morphological characteristics of psammoma bodies. However, sometimes, both calcifications and psammoma bodies are detected in the same CVS, as in our case. Also, psammoma bodies should not be confused with other calcified structures like Michaelis-Gutmann bodies, which are intracellular and found in rare cases of vaginal malakoplakia.[6]
References 1. 2. 3.
4. 5.
6.
Parkash V, Chacho MS. Psammoma bodies in cervicovaginal smears: incidence and significance. Diagn Cytopathol 2002;26:81-6. Luzzatto R, Brücker N. Benign inclusion cysts of the ovary associated with psammoma bodies in vaginal smears. Acta Cytol 1981;25:282-4. Fujimoto I, Masubuchi S, Miwa H, Fukuda K, Yamaguchi S, Masubuchi K. Psammoma bodies found in cervicovaginal and/or endometrial smears. Acta Cytol 1982;26:317-22. Johannessen JV, Sobrinho-Simoes M. The origin and significance of thyroid psammoma bodies. Lab Invest 1980;43:287-96. Muntz HG, Goff BA, McGonigle K, Isacson C. The significance of psammoma bodies in screening cervical cytologic smears. Am J Obstet Gynecol 2003;188:1609-12. Chalvardjian A, Carydis B, Cohen S. Cytologic diagnosis of extravesical malacoplakia. Diagn Cytopathol 1985;1:216-20.
How to cite this article: Seth A, Gupta K, Mathur A, Pant L. Incidental detection of psammoma bodies in cervico-vaginal smears. J Cytol 2013;30:272-3. Source of Support: Nil, Conflict of Interest: None declared.
Journal of Cytology / October 2013 / Volume 30 / Issue 4
273
Copyright of Journal of Cytology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
