A.J.C.P. • May 1981
STRAND AND DUBOIS
746
2. Hall MM, Warren E, Ilstrup D, et al: Comparison of sodium
amylosulfate and sodium polyanetholsulfonate in blood culture media. J Clin Microbiol 3:212-213, 1976
3. Kocka FE, Arthur EJ, Searcy RL, et al: Clinical evaluation of
sodium amylosulfate in human blood cultures. Appl MicroAcknowledgment. Dr. George Lombard and Dr. Clyde Thornsberry
biol
26:421-422, 1973
from the Center for Disease Control assisted in determining the
4. Schell RF, Babu JP, Le Frock JL: Evaluation of ten anaerobic
morphologic and biochemical characteristics of the P. acnes isoblood culture media. Am J Clin Pathol 72:199-203, 1979
lates and in performing the antimicrobial susceptibility tests,
respectively.
5. Washington JA II: Comparison of two commercially available
media for detection of bacteremia. Appl Microbiol 22: 604References
607, 1971
6. Washington JA II: The detection of septicemia. West Palm
1. Babu JP, Schell RF, Le Frock JL: Evaluation of twenty-three
blood culture media. J Clin Microbiol 8:288-292, 1978
Beach, CRC Press, 1978, pp 47-69
emphasizes the extreme importance of good communication between the clinical services and the diagnostic
microbiology laboratory.
Carcinomesenchymoma
of the Uterus
KARL T. K. CHEN, M.D., AND JAMES M. VERGON, M.D.
Chen, Karl T. K., and Vergon, James M.: Carcinomesenchymoma of the uterus. Am J Clin Pathol 75: 746-748, 1981. A
unique case of intramural uterine tumor composed of malignant epithelium and benign smooth muscle, adipose tissue,
and cartilage is reported. This tumor, which the authors
designated "carcinomesenchymoma," apparently represents
an example of a previously unreported variant of mixed
mullerian tumor that is composed of malignant epithelium
and benign mesenchymal elements. (Key words: Mullerian
tumor; Uterine tumor; Carcinomesenchymoma.)
NEOPLASMS of the uterus composed of both epithelial and mesenchymal elements are considered mixed
mullerian tumors. 4 We encountered an unusual uterine
tumor composed of malignant epithelium and benign
mesenchymal elements. This tumor, which we designated "carcinomesenchymoma," apparently represents
an example of a theoretically possible but yet to be
documented variant of mixed mullerian tumor.
Report of a Case
A 50-year-old primipara woman was evaluated for an eight-month
history of intermittent vaginal bleeding. Her menopause occurred at
the age of 46 years. The pelvic examination showed globular
enlargement of the uterus with the uterine fundus reaching the
level of the umbilicus. The chest roentgenograms and results of
barium enema examination were normal. After one week of progesterone treatment, an endometrial curettage was done and showed
benign endometrial tissue with stromal pseudodecidual changes.
Three weeks later, hysterectomy and bilateral salpingo-oophorectomy were performed. There was no evidence of disease six months
after the surgery.
Received July 1, 1980; received revised manuscript and accepted
for publication August 7, 1980.
Address reprint requests to Dr. Chen: Department of Pathology,
Fresno Community Hospital and Medical Center, P. O. Box 1232,
Fresno, California 93715.
Department of Pathology, Fresno Community
Hospital and Medical Center,
Fresno, California
Pathologic Findings
The resected uterus weighed 1,210 g. The posterior
uterine wall contained a well-circumscribed tumor
measuring 12 cm in diameter. The tumor was separated
from the endometrium and serosal surface by compressed myometrial tissue. It had pale-gray whorled cut
surfaces (Fig. 1). The ovaries were atrophic. The
fallopian tubes were normal. Histologically, the margin
of the uterine tumor was sharply demarcated. The
tumor was composed predominantly of interlacing
bundles of smooth muscle cells with frequent areas of
myxoid changes. There were frequent islands of mature
adipose tissue and several islands of cartilage (Figs. 2
and 3). None of the mesenchymal elements showed
mitotic activity or significant nuclear pleomorphism.
In scattered areas, there were nests of epithelial cells
exhibiting features of a moderately differentiated
adenocarcinoma. Most of the epithelial cells were low
columnar in shape and showed a moderate degree of
nuclear pleomorphism. Many nuclei had prominent
nucleoli. Mitoses could easily be found. In some areas,
three mitoses per high-power field were seen. Frequent glandular and occasional papillary structures
were formed. Within the larger epithelial nests, a
cribriform pattern was seen (Fig. 4). There were frequent single cell necroses and scattered psammoma
bodies (Fig. 5). A mucicarmine stain showed both
intraluminal and intracellular mucin within the epithelial nests.
0002-9173/81/0500/0746 $00.65 © American Society of Clinical Pathologists
Vol. 75 • No. 5
747
CASE REPORTS
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FIG. 1 {upper, left). Gross photograph of a sagittal section of the uterus showing the large intramural tumor of the uterine corpus.
FIG. 2 (upper, right). Low-power view showing bundles of smooth muscle cells and scattered groups of mature fat cells. Hematoxylin and
eosin. x40
FIG. 3 (lower, left). An island of benign-appearing cartilage. Hematoxylin and eosin. x40. Inset: high-power view of the cartilage.
Hematoxylin and eosin. xlOO.
FIG. 4 (lower, center). Nests of epithelium within the lesion. Hematoxylin and eosin. x40. Inset: high-power view showing cribriforming of
the epithelial structures. Hematoxylin and eosin. x 100.
FIG. 5. (lower, right). Psammoma bodies associated with the epithelial structures. Hematoxylin and eosin. x 100.
CHEN AND VERGON
748
Discussion
This intramural uterine tumor, which was composed
of histologically malignant epithelium and several
types of benign mesenchymal elements, cannot readily
be classified into any of the specific tumor types of the
female genital tract. There were no ectodermal or neuroectodermal derivatives to suggest a teratomatous
nature of the tumor. The possibility of a collision tumor
can be excluded by the absence of endometrial involvement. There were no tumors at extrauterine sites
to suggest the possibility of a benign uterine mesenchymal tumor to which an extrauterine carcinoma had
metastasized. After excluding these possibilities, it is
evident that this tumor belongs to the broad category of
biphasic uterine tumors called mixed miillerian tumors. 4 The individual components of this tumor have
all been observed in other examples of mixed miillerian tumors. However, the intramural location and
the combination of malignant epithelium and benign
mesenchyme are unusual for mixed miillerian tumors.
Most mixed miillerian tumors of the uterus arise from
totipotential endometrial stromal cells, which are capable of transformation to not only a variety of mesenchymal elements but also epithelial structures. 0 7
Smooth muscle cells and other mesenchymal cells of
the myometrium, like endometrial stromal cells, are
derived from the mesenchyme that surrounds the fused
distal segments of the miillerian ducts. Because of their
common origin, it is not surprising to encounter
myometrial tumors, such as the present case, that
express the same totipotentiality as observed in tumors of endometrial stromal origin. This explains the
intramural location of occasional adenosarcomas 1 and
the occurrence of several unusual tumor types of the
uterine wall, including leiomyoma with adipose tissue, 3 1 0 uterine tumors resembling ovarian sex-cord
tumor, 2 and leiomyoma with epithelial tubules. 5 Mazur
and Kraus have observed transitional cells with both
smooth muscle and epithelial characteristics in their
ultrastructural studies of a leiomyoma with epithelial
tubules. 5 This totipotentiality of the neoplastic smooth
muscle cells of the uterus is fully expressed in the
present case, in which unequivocal epithelial elements
and heterologous mesenchymal elements (adipose tissue and cartilage) were present in an otherwise benign
smooth muscle tumor of the uterine wall.
Because both epithelial and mesenchymal elements
can be benign or malignant in mixed miillerian tumors,
four combinations are theoretically possible. 4 However, only three of these four possible variants have so
far been established. 4 Malignant mixed miillerian
tumor 8 represents the variant in which both epithelial
and mesenchymal elements are malignant. Adenofibroma,9 leiomyoma with epithelial tubules, 5 and pos-
A.J.C.P. • May 1981
sibly "uterine tumors resembling ovarian sex-cord
tumor," 2 are examples of the variant in which both
elements are benign. Adenosarcoma, 1 which represents
the third variant, is composed of malignant mesenchymal elements and benign epithelium. The tumor in
the present case, which the authors designated "carcinomesenchymoma," appears to be an unequivocal
example of the theoretically possible fourth variant of
mixed miillerian tumor—that composed of benign
mesenchymal elements and malignant epithelium.
Although not considered as such, one of the five cases
of uterine adenofibroma reported by Vellios and
associates, 9 in which one focus of adenocarinoma was
present, can also be regarded as another example of
this variant of mixed miillerian tumor. Some endometrial adenocarcinomas accompanied by proliferating
stroma may also represent additional examples; however, it is often difficult to ascertain the reactive or
neoplastic nature of the stroma in these cases. 4
The case reported here appears to broaden the morphologic spectrum that may be encountered in mixed
miillerian tumors. Although the epithelial components
in this tumor are histologically malignant, the prognosis is excellent because of the sharp circumscription
of the lesion. The elucidation of the exact biologic
behavior of such tumors awaits accumulation of
additional cases.
Acknowledgment. Dr. Robert E. Scully reviewed the sections
of this uterine tumor. He stated that he has not encountered cases
exactly like this case, nor seen reports of similar cases in the
literature, and that the mitotic activity and cribriforming of the
glandular structures indicate a low-grade malignant potential for
this tumor.
References
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uterus. Cancer 34:1138-1149, 1974
2. Clement PB, Scully RE: Uterine tumors resembling ovarian sexcord tumors. Am J Clin Pathol 66:512-525, 1976
3. Demopoulous RI, Denarvaez F, Kaji V: Benign mixed mesodermal tumors of the uterus. Am J Clin Pathol 60:377383, 1973
4. Hendrickson MR, Kempson RL: Surgical pathology of the
uterine corpus, Series of major problems in pathology.
Volume 12. Edited by J L Bennington. Philadelphia, WB
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6. Norris HJ, Taylor HB: Mesenchymal tumors of the uterus. I.
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8. Sternberg WH, Clark WH, Smith RC: Malignant mixed miillerian tumor. A study of 21 cases. Cancer 7:704-724, 1954
9. Vellios F, Ng ABP, Reagan JW: Papillary adenofibroma of the
uterus: a benign mesodermal mixed tumor of miillerian origin.
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10. Willen R, Grad A, Willen H: Lipomatous lesions of the uterus.
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