Low grade endometrial stromal sarcoma in a premenopausal woman
A 39-year-old female, reported with complaints of irregular bleeding per vaginum on and off for the past 2 months and retention of urine since the past 2 days. The patient was pale and ill looking. Per speculum examination revealed a large shaggy mass, 8 cm in diameter protruding out from the cervical os. The cervical rim was felt all around and the pedicle was high up. Uterus was 8 weeks in size, soft, anteverted, and both fornices were clear.\nUltrasound of the pelvis suggested a cervical mass lesion measuring 9 × 8 × 8 cm, well defined outline and heterogenous echogenicity. The uterus was bulky with the endometrial cavity pushed anteriorly and bilateral adnexae were normal. The clinical impression was that of a leiomyomatous polyp with the base in the posterior uterine wall. Polypectomy was done and sent for histopathological examination.\nGross examination of the polyp showed a globular mass measuring 6 × 5.5 × 4 cm. Cut surface was fleshy, grayish pink in color. [] Outer surface had a ragged appearance. Microscopic examination of the polyp showed a cellular tumor with a close morphological resemblance to nonneoplastic proliferative-phase endometrial stromal cells. The tumor cells were small uniform looking with dark staining round to oval nuclei, granular chromatin, and inconspicuous nucleoli [] Areas of sex cord-like differentiation [] were also seen. Mitosis was minimal and less than three mitotic figures per high power field were seen. Stromal myometrial interface was not provided hence myometrial invasion could not be commented upon. These histological features were suggestive of endometrial stromal tumor and the possibilities considered were endometrial stromal nodule (ESN) and LGESS. Subsequently, 9 days after the polypectomy, the patient was operated again and a hysterectomy with bilateral salpingo-oophorectomy was undertaken. On laparotomy, uterus was noted to be enlarged to 8 weeks size, with bilateral cystic ovaries and no enlarged regional lymph nodes were present. A polyp was seen protruding into the endometrial cavity from posterior wall of the uterus which measured 4 × 5 × 3 cm, with a fleshy, gray-white cut surface []. Microscopic examination of the polyp showed a similar histological picture as described. These tumor cells were arranged concentrically around spiral arteriole like vessels with cord-like projections into the myometrium. Lymphovascular invasion was not seen. Both ovaries showed luteal cysts and the tumor was restricted to the uterine wall. Immunohistochemical analysis showed neoplastic endometrial stromal cells, which were immunoreactive for CD10 monoclonal antibody [], while staining for Desmin was negative, thereby ruling out a smooth muscle origin. There were areas of sex cord-like differentiation that showed reactivity for Inhibin, which was not detected in the other stromal areas. The final histological diagnosis was LGESS with sex cord-like differentiation, International Federation of Gynecology and Obstetrics (FIGO) Stage IB.[]