Ovarian low-grade serous carcinoma involving the cervix mimicking a cervical primary

Anais Malpica, Michael T Deavers
International Journal of Gynecological Pathology 2011, 30 (6): 613-9
We describe the clinicopathologic and immunohistochemical features of the first reported case of an ovarian low-grade serous carcinoma metastatic to the cervix mimicking a cervical primary. The patient, a 55-year-old woman, was found to have an abnormal cervix and an abnormal Pap smear during a preoperative workup for a rectocele repair. A subsequent cervical biopsy contained moderately differentiated adenocarcinoma and the patient underwent a cold knife conization. An infiltrating adenocarcinoma was found in the anterior cervical lip, the neoplasm reached the surface of the endocervical canal and was composed of mildly to moderately atypical, eosinophilic or amphophilic columnar cells arranged in glands and papillae. Mitotic figures were rare and no apoptotic bodies were seen. Psammoma bodies and intraglandular mucinous material were also noted. There was extensive vascular/lymphatic invasion. The tumor extended to all margins and was interpreted as a moderately differentiated (grade 2) adenocarcinoma of the uterine cervix with a linear spread of at least 1.4 cm and a depth of at least 0.6 cm (FIGO stage 1B1). The patient was treated with radiotherapy and cisplatin. Six months later, surveillance imaging studies showed that the patient's ovaries seemed to be enlarging. The patient underwent exploratory laparotomy, bilateral salpingo-oophorectomy, right pelvic lymph node sampling, omentectomy, peritoneal biopsies, and pelvic washings. The ovaries contained bilateral cystic tumors. There was gross tumor involving multiple peritoneal sites. Microscopic examination of the ovaries showed the typical features of low-grade serous carcinoma associated with a serous neoplasm of low malignant potential with a cribriform pattern. Metastatic low-grade serous carcinoma was detected in multiple peritoneal sites and in the pelvic washings. A consultation was obtained, with the consultant concurring that the tumors represented independent primaries. The patient received carboplatin and taxol. Two and 4 years after the initial diagnosis, she experienced recurrences and was treated with carboplatin and taxol each time. After the second recurrence, the patient decided to seek additional advice about treatment options. The latter prompted a re-review of her histologic material. Upon this re-review, it was noted that the tumor in the cervix had some rather unusual features for a primary cervical adenocarcinoma, such as the lack of conspicuous mitotic activity, extensive vascular/lymphatic invasion in the context of a tumor with no solid areas, and only mild-to-moderate cytologic atypia. In addition, the tumor in the cervix had areas that were similar to the metastatic tumor present in the omentum. Immunoperoxidase staining for WT-1, estrogen receptor, and p16 was performed on the tumor in the cervix and on the ovarian tumor. The neoplastic cells in both tumors stained in a similar manner; the tumor cells were diffusely positive for WT-1 and estrogen receptor (90%) and focally positive for p16. No detectable signal for high-risk human papillomavirus was seen in the in-situ hybridization performed on the section of the tumor in the cervix. In summary, the histologic and immunohistochemical features and the in-situ hybridization results were in keeping with a diagnosis of metastatic ovarian low-grade serous carcinoma involving the cervix. This case underscores the importance of attentive histopathologic examination and the use of ancillary tests to ensure the recognition of the site of origin of a neoplasm involving the cervix.

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