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.

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)

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 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 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]