Recommendation
In this particular case, we believe that the presence of benign endometrial tissue and postcoital bleeding is explained by the emergence of atypical glandular cells but not due to the foci of calcification.
Clinical Expertise
According to Misdraj et al. (1), the appearance of psammoma bodies can be associated equally with malign and benign conditions. In her research, it has been proved that women with benign outcomes do not have atypical glandular cells and any signs of malignancy, like bleeding or mass. In addition, the women with benign outcomes have no other malignancies. In their turn, postmenopausal women have a higher rate of occurrences of malign tumors.
It has been also researched that the presence of psammoma bodies cannot cause carcinomas and related malignant neoplasm. Instead, they are just defined as the calcification concentration associated with benign endometrial tissue, polyps, postpartum, marked atrophy, and follicular cervicitis (2).
Pathology
As the patient is a female woman of 37 years old, she is not in her menopausal period. However, the presence of postcoital bleedings during six months cannot be considered as the result of psammoma bodies alone but as related outcomes of their presence. The pathology, hence, is observed, since the identified neoplasm in benign endometrial is not associated with postcoital bleeding.
The previous three smears turned out to be negative, which also contradicts the absence of malignant tumors in endometrial tissues. As proof, Lynge and Paul (3) have revealed that women who had from 2 to 4 previous negative smears had a low risk of developing cervical cancer in the course of two years from the last negative smear. In our case, 3 negative smears denote that the patient still has the probability of the appearance of malignant neoplasm.
Cytology
Infrequent cases, benign conditions can be a potential reason for a false presentation of the borderline tumor, or adenocarcinoma (4). In order to avoid a pseudo-interpretation of the results, the malignancy identification should not be based only on the presence of psammoma bodies, since they are considered to be secondary findings among the asymptomatic women.
- Differential Diagnosis
- List of possible diagnoses:
- Adenocarcinoma;
- Cervical cancer;
In the first case, adenocarcinoma is the result of the development of atypical glandular cells associated with psammoma bodies in benign endometrial. This type of tumor can appear in the cervix. Such pathology is mostly observed among women with postmenopausal bleedings (5). However, our patient does not belong to the 45-50 age group; therefore, this diagnosis cannot be considered true.
Cervical cancer is a malignant tumor causing vaginal bleedings. This cancer can be asymptomatic; this is why it is difficult to diagnose the patient. Cancer appears as the result of pathological tumors connected with the presence of psammoma bodies (6). In our case, most symptoms are presented, including the asymptomatic condition and ambiguous nature of bleedings.
Conclusion to the Case
The possible reason for bleedings and the presence of negative smears can be the development of cervical cancer. It explains why the final diagnosis is NAD with the presence of psammoma bodies. The appearance of psammoma bodies is also a sign of malign neoplasm development negatively affecting glandular cells. Besides, post-coital bleedings can be an actual cause of infection. Therefore, the patient has a false-positive benign endometrial disease that requires further histological analysis.
References
- Misdrai J, Vaidya A, Tambouret RH, Duska L, Bell DA. Psammoma bodies in cervicovaginal cytology specimens: a clinicopathological analysis of 31 cases. Gynecol Oncol. 2006 ;103(1):238-46.
- Muntz HG, Goff BA, Isacson C. The significance of psammoma bodies in screening cervical cytologic smears. Am J Obstet Gynecology. 2003, 188(6):1609-14.
- Lynge E, Paul P. Incidence of cervical cancer following negative smear: a cohort study from maribo county, Denmark. Americal Journal of Epidemiology. 1986:124(3):345-352.
- Cibas ES, Ducatman BS. Cytology: diagnostic principles and clinical correlates. Australia: Elsever Health Sciences, 2009.
- Cheng L, Bostwick DG. Essential of anatomic pathology. US: Spinger, 2006.
- Rohah TE, Shah KV. Cervical cancer: from etiology to prevention. US: Springer, 2004.