Malignant mixed mullerian tumor of ovary-scrape cytology: Findings with review of literature.

Sir,

Malignant Mixed Mullerian tumor (MMMT) or carcinosarcoma are rare tumors comprising less than 2% of all ovarian neoplasms and have a poor outcome.[1] Ovarian tumors are frequently subjected to scrape smears (SS) in frozen section (FS) for an intraoperative diagnosis. Here, we document the cytomorphology of a rare neoplasm, MMMT ovary, on SS.

A 37-year-old female presented with an abdominal lump, palpable per abdomen, and adnexal mass on per vaginal examination. Contrast-enhanced computed tomography (CECT) showed a well-defined lobulated solid cystic ovarian mass 8 × 8 × 12 cm in size. Cancer Antigen-125 (CA-125) and Carcinoembryonic Antigen (CEA) levels were elevated. Complete left ovarian mass was excised and submitted for intraoperative examination. The mass received measured 10 × 8 × 7 cm in size and was solid cystic with areas of hemorrhage. Based on gross findings, FS and SS stained with toluidine blue [Figure 1a] and rapid hematoxylin and eosin, overall diagnosis of poorly-differentiated carcinoma was suggested. Total abdominal hysterectomy with other side salpingoophorectomy with omentectomy and lymph node resection was performed.

Figure 1

(a) Malignant glandular component (MGG ×100). Inset: Toluidine blue stain: loosely cohesive clusters of atypical cells suggestive of malignant neoplasm (MGG ×100). (b) Sarcomatous component (MGG ×200). (c) H and E: Section shows malignant neuroendocrine component (arrow) and glandular component (dotted arrow) (H and E ×100) Inset: Immunohistochemistry: Neuroendocrine component expresses chromogranin (IHC : chromogranin ×100)

On routine histopathological examination, tumor was diagnosed as MMMT of ovary that had epithelial components [Figure 1c] (squamous, malignant glandular, papillary and neuroendocrine areas; confirmed by immunohistochemical reactivity with cytokeratin, Epithelial Membrane Antigen (EMA) and chromogranin [Figure 1c, inset], respectively, along with sarcomatous areas immunoreactive for Vimentin.

Because the cytological features of MMMT ovary has rarely been described in literature,[2345] the toluidine blue smears were destained and stained with Giemsa stain for further evaluation for all the components seen in histopathology. The smears were representative of both the carcinomatous and sarcomatous areas [Figure 1a and b]. On close examination of all smears, malignant glandular as well as sarcomatous component were identified admixed with each other. Squamous or neuroendocrine differentiation was not discernible. The glands comprised large cells arranged in an acinar manner as well as singly scattered. The cells had high nucleocytoplasmic ratio, scant-to-minimal cytoplasm, dense chromatin, irregular nuclear borders, and single prominent nucleolus. The sarcomatous component comprised plump spindled out pleomorphic cells having a hyperchromatic nucleus admixed with stromal fragments and blood vessels. Presence of frequent mitosis and tumor diathesis in the background also favored malignant lesion.

Neuroendocrine features are rarely identified in MMMT ovary and all three malignant epithelial components (glandular, squamous, and neuroendocrine) have been rarely reported together.[234]

Scrape cytology is an inexpensive, rapid technique to evaluate multiple heterogeneous areas from ovarian neoplasms and has been rarely studied for MMMT ovary. The fact that FS may only show epithelial or only sarcomatous areas, a diagnosis is precisely made after examining the routine histopathological sections. In the present case, the retrospectively reviewed SS showed both the malignant epithelial and mesenchymal areas. Carcinomatous component is mostly more represented in cytology smears as compared to sarcomatous because it easily exfoliates and usually predominates in the tumors.[5] Sentija et al. have attempted to describe fine needle and intraoperative cytology of MMMT ovary, which they diagnosed initially as clear cell carcinoma.[1]

To conclude, we present this case to detail the morphology of MMMT ovary on SS to facilitate an early intraoperative diagnosis, which has not been described the available literature.

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Conflicts of interest

There are no conflicts of interest.