Case 1 -

Psammoma Bodies in a Pap Test Terence J. Colgan

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Clinical History A 42 year old woman, G2P2, had a routine screening Pap test taken. She was on the 9th day of her menstrual cycle. The cervix was visualized and appeared normal. No other clinical history was available. Case 1 - Figure 1 Four dense bodies/cellular clumps are noted on a cellular background consisting of squamous cells and rare endocervical fragment. Case 1 - Figure 2 An endocervical epithelial fragment is present (right), immediately adjacent to a dense, laminated body with a peripheral rim of cohesive cells. Case 1 - Figure 3 Each figure shows a central dense basophilic acellular body. Definite internal, concentric laminations are evident in several foci. The peripheral cells form a rim about the body, have a moderate amount of cytoplasm, and show only mild cytologic atypia, a finely granular chromatin pattern, and small nucleoli. No mitoses are seen. Case 1 - Figure 4 Each figure shows a central dense basophilic acellular body. Definite internal, concentric laminations are evident in several foci. The peripheral cells form a rim about the body, have a moderate amount of cytoplasm, and show only mild cytologic atypia, a finely granular chromatin pattern, and small nucleoli. No mitoses are seen. Case 1 - Figure 5 Each figure shows a central dense basophilic acellular body. Definite internal, concentric laminations are evident in several foci. The peripheral cells form a rim about the body, have a moderate amount of cytoplasm, and show only mild cytologic atypia, a finely granular chromatin pattern, and small nucleoli. No mitoses are seen. Case 1 - Figure 6 Each figure shows a central dense basophilic acellular body. Definite internal, concentric laminations are evident in several foci. The peripheral cells form a rim about the body, have a moderate amount of cytoplasm, and show only mild cytologic atypia, a finely granular chromatin pattern, and small nucleoli. No mitoses are seen. Case 1 - Figure 7 Each figure shows a central dense basophilic acellular body. Definite internal, concentric laminations are evident in several foci. The peripheral cells form a rim about the body, have a moderate amount of cytoplasm, and show only mild cytologic atypia, a finely granular chromatin pattern, and small nucleoli. No mitoses are seen. Cytologic Diagnosis: Psammoma bodies, numerous, with associated atypical glandular cells not otherwise specified. Histologic Diagnosis: Serous tumour of low malignant potential, of ovary. Cytologic Findings: This Pap test exhibits numerous calcified, concretions with concentric laminations, conforming to Psammoma bodies. Epithelial cells are seen about the periphery of these Psammoma bodies. These epithelial cells show some nuclear variability but generally they have a finely granular chromatin pattern and small nucleoli. They do not show conclusive features for malignancy. The background fails to identify any abnormal cells, and consists of squamous and reactive endocervical cells. Histologic and Clinical Follow-up: One month following this Pap test, a fractional uterine dilatation and curettage was undertaken. The endocervical curettings showed no diagnostic abnormality while the endometrial curettings showed Psammoma bodies and a secretory phase endometrium. Four months following the Pap smear, a pelvic ultrasound was performed and the only abnormality detected was a 1.5 cm paraovarian cyst, in addition to a suspicion of uterine adenomyosis. Nevertheless, an MRI was recommended. Five months post-Pap test, an MRI identified a 3.8 x 5.1x 4.5 right-sided pelvic mass of possible ovarian origin. Two months following this MRI, a laparoscopic salpingo-oopherectomy was undertaken, and on pathologic examination a surface serous low malignant potential tumour was diagnosed, along with non-invasive implants of the fallopian tube and ovarian serosa. Discussion: The origin of the word Psammoma or "sand tumour" is usually attributed to Virchow, following his observations on tumours with small calcifications. The presence of Psammoma bodies in a Pap test is extremely unusual with a prevalence of less than 0.02%. Psammoma bodies may be derived from both benign and malignant sources. It is likely reporting bias has lead to a disproportionate representation of malignant cases within the literature. Malignancy is probably found in less than half of all cases with Psammoma bodies in a Pap test. Possible sites of origin of Psammoma bodies in Pap tests include cervix, endometrium, fallopian tube, ovary, and peritoneum. The two most common malignant origins for Psammoma bodies are endometrial and ovarian carcinomas. Psammoma bodies may also have their origin from cervicitis and cervical carcinoma. Other endometrial origins include benign endometrium, IUCDs and tuberculous endometritis. Fallopian tubal origins include tubal carcinoma (including in-situ carcinoma), and chronic salpingitis. Ovarian origins for Psammoma bodies in addition to adenocarcinoma, include low malignant potential tumours, surface and cystic adenofibromas, and ovarian inclusion cysts. Mesothelial hyperplasia, peritoneal endosalpingiosis, endometriosis, mesothelioma, and well differentiated mesothelial papillary tumours may also give rise to Psammoma bodies from a peritoneal site. Finally, in some cases the origin of Psammoma bodies in a Pap test remains unestablished. The most useful pathologic predictor of malignancy in a Pap test showing Psammoma bodies is the finding of malignant cells in association with the Psammoma body. The number of Psammoma bodies and background inflammation are not useful pathologic predictors. Clinical features may be useful predictors of malignancy, as well, and include the presence of post-menopausal bleeding, an age greater than 45, and the presence of abnormal clinical or imaging findings. In conclusion, the finding of Psammoma bodies in a Pap test is a very rare event. These bodies may originate from a variety of sites, and have either benign or malignant origins. The best predictor of the likelihood of malignancy is an assessment of the cells accompanying the Psammoma bodies. Clinical investigation of a woman with Psammoma bodies in her Pap test is warranted, although the extent of investigation may vary with age, symptomatology, and imaging findings. References: Fadare O, Chacho M, Parkash V. Psammoma bodies in cervicovaginal smears. Significance & practical implications for diagnostic cytopathology. Adv Anat Pathol 2004; 11: 250-61. Fujimoto I, Masubuchi S, Miwa H, et al. Psammoma bodies found in cervicovaginal and/or endometrial smears. Acta Cytol 1982 ;26: 317-22. 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