Case Reports

Cervical Cytology of Recurrent Psammoma Bodies with

Atypical Cells in a Postmenopausal Woman
A Case Report

Paul Malcolm, B.Sc., M.B.Ch.B., Alison St. John, M.R.C.Path., Abiodun Oladipo, M.R.C.O.G., and
Joseph Mathew, F.R.C.Path.

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Background
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sammoma bodies (PBs) are laminated, calcified, extracellular
Psammoma bodies (PBs) are an unusual finding in cervical cytology prepa- structures that have been described in association with a wide
rations. They have been identified in association with a wide range of be- range of benign and malignant conditions, most commonly affect-
nign and malignant conditions within the female genital tract. Portents of ing the female genital tract and involving serous epithelium.1-7 It

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a significant underlying pathology include their occurrence in post- has been suggested that at least some may arise secondary to dys-
menopausal patients, the presence of unexplained vaginal bleeding and trophic calcification in necrotic papillary epithelial structures.7
their occurrence in association with atypical cells. They are a rare, but well-recognized finding in cervical cytology

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smear preparations, with a report-
Case ed incidence of 1:2,000–200,000

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PBs associated with atypical cells were examinations performed.1-4 The
detected in repeated cervical cytology An abnormal clinical examination andP most significant indicators of a sin-

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smears of an asymptomatic, 55-year- ister underlying pathology include
the presence of worrisome symptoms

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old postmenopausal woman over a 4- the occurrence of PBs in post-
year period. She was extensively in- (most commonly unexplained vaginal menopausal patients, the presence

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vestigated, and, in the absence of a of atypical or frankly malignant
definitive cause, she underwent total bleeding) have been found in mosta cells in the smear and an abnormal
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abdominal hysterectomy and bilateral women with PBs associated with a clinical examination with suspi-
salpingo-oophorectomy. Histologic ex- cious symptoms (most frequently
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malignant pathology.
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amination of the specimen demon- unexplained vaginal bleeding).1-4

strated the presence of bilateral benign
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ovarian serous cystadenofibromas with Case Report

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large numbers of PBs. Focally the PBs were closely apposed to the serosal The patient was a 55-year-old postmenopausal woman at first pres-
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surface and invested in a blanket of mesothelial cells. entation. Her last menstrual cycle occurred at age 51 years. She had
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two successful term pregnancies and was a lifelong cigarette smok-

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Conclusion er. Her medical history included recurrent bilateral renal calculi
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Caution is required when assessing the significance of PBs associated with with chronic bilateral pyelonephritis necessitating left nephroure-
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atypical cells in a cervical cytology specimen. Our case demonstrates the tectomy in 1986.
presence of ovarian mesothelial cells mimicking atypical glandular cells. A routine cervical smear in December 2000 demonstrated the
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(Acta Cytol 2007;51:575–577) presence of PBs and atypical glandular cells that were reported to be
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of possible endometrial origin (Figure 1). The woman was asymp-

Keywords: cystadenofibroma, serous; cervical cytology; glandular tomatic at the time the smear was obtained, and subsequent clinical
cells, atypical; psammoma bodies. examination was normal. A transvaginal ultrasound scan document-
ed normal-sized ovaries, a thin endometrium and a small, mobile
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cervix. No abnormal features were noted at hysteroscopy, and cer-

vical punch biopsy demonstrated mild chronic cervicitis only. She
remained in outpatient surveillance with repeat smears in 2002 and
2003, both of which contained further PBs and atypical glandular
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From the Departments of Obstetrics and Gynecology and Histopathology, Royal Cornwall Hospital, Truro, Cornwall, U.K.
Mr. Malcolm is Specialist Registrar, Department of Histopathology.
Ms. St. John is Consultant, Department of Histopathology.
Dr. Oladipo is Consultant, Department of Obstetrics and Gynecology.
Dr. Mathew is Consultant, Department of Histopathology.
Presented in poster form at the Joint Meeting of the British Division of the International Academy of Pathology and Pathological Society, July 2005.
Address correspondence to: Joseph Mathew, F.R.C.Path., Department of Histopathology, Royal Cornwall Hospital, Truro, Cornwall, U.K.
([email protected]).
Financial Disclosure: The authors have no connection to any companies or products mentioned in this article.
Received for publication January 30, 2006.
Accepted for publication July 7, 2006.

0001-5547/07/5104-0575/$19.00/0 © The International Academy of Cytology ACTA CYTOLOGICA 575

Malcolm et al

cells. In addition, the 2002 smear demonstrated the presence of Microscopically, both ovaries had a similar appearance, with mul-
moderately dyskaryotic squamous cells for which colposcopy and tiple cortical cysts lined by a single layer of focally attenuated serous
subsequent knife cone biopsy were undertaken. The cervix con- epithelium contained within a fibromatous stroma consistent with
tained a focus of CIN 2 arising within metaplastic squamous ep- the diagnosis of bilateral benign serous cystadenofibromata (Figure
ithelium. Tubal metaplasia was present within the endocervical ep- 2). PBs were dispersed throughout the stroma, although they were
ithelium. much more frequently observed in close proximity to either the
Examination under anesthesia identified a cystocele, a rectocele serous epithelium of the cysts or the ovarian serosa. Focally, the PBs
and a degree of cervical descent, but no worrisome features that could be seen closely apposed to the serosal surface invested in a
might have explained the PBs. A further transvaginal ultrasound blanket of mesothelial cells (Figure 3). Both fallopian tubes and the
scan demonstrated an anteverted uterus of normal size (60 × 26 × 38 cervix were normal. The uterus was lined by inactive atrophic en-
mm) containing a 16-mm fibroid in the posterior wall. The ovaries dometrium. PBs were not present in any of these structures. A sin-
were difficult to visualize but measured 24 × 16 × 21 mm on the left gle, benign uterine leiomyoma was also noted.

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and 25 × 15 × 24 mm on the right. Both ovaries contained multiple
echogenic foci suggestive of punctate calcification. No mass lesions Discussion
were identified. The occurrence of PBs in cervical cytology smears has traditionally
In the absence of an explanation for the PBs, she proceeded to been regarded as ominous, based on a number of individual case re-
elective total abdominal hysterectomy and bilateral salpingo- ports and small patient series, within which approximately 60% of

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oophorectomy early in 2004. At operation, the uterus and both fal- cases were associated with malignancy. Recent studies have shown
lopian tubes were noted to be normal, with both ovaries being of either a reduced strength of association (23%,3 45%2) or no associ-
normal size but firm in consistency. No suspicious deposits were ation.4 However, caution must be exercised in interpreting these

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present on the peritoneum, omentum, liver or diaphragm. more recent studies due to the strong representation of pre-
menopausal women in the study groups. Most studies published to
Pathologic Findings date have found postmenopausal status to be a significant predictor

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Macroscopically, the excision specimen weighed 83 g. The left of the likelihood of PBs being associated with malignant pathology.1-3
ovary measured 28 × 15 × 12 mm and the right 35 × 25 × 12 mm. The presence of frankly malignant cells in the background of the
Both were described as having nodular surfaces with a white, nodu- smear has been suggested to be a strong indicator of a malignant

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lar cortex containing multiple small cystic spaces upon sectioning. source for the PBs.1-3 The interpretation is complicated by 2 case
The uterus contained a pale, circumscribed mass with a trabeculat- P reports in which the finding of PBs and “atypical cells diagnostic for

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ed surface and a maximum diameter of 13 mm. The cervix and fal- adenocarcinoma” were associated with endosalpingiosis.8 In both of

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lopian tubes were unremarkable. The omentum showed no focal le- these cases the women were in their thirties and doubt has been ex-
sions. pressed with regard to the classification of the associated cells as di-

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Figure 1 Psammoma bodies associated with (A) a thin layer of flattened cells and (B) a sheet of “atypical cells” suspicious for endometrial cells (Papanicolaou stain,
× 400).

576 ACTA CYTOLOGICA Volume 51 Number 4 July–August 2007

 Cytology of Recurrent Psammoma Bodies

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A B

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Figure 2 Histology demonstrates (A) a small ovary with multiple cystic spaces and a fibromatous stroma (B) lined by bland serous epithelium (hematoxylin-eosin
stain; A, × 2; B, × 400).

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agnostic for malignancy.2 The situation with atypical glandular cells ian serous cystadenofibromata. This contrasts with other reported
is even more confusing, and while Zreik and Rutherford1 found cases in which PBs associated with benign pathology were not iden-

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“atypical glandular cells of uncertain significance” in all 7 of the tified in repeat smears.1,4 In our opinion, the “atypical cells” seen in
cases associated with malignancy, 1 case with benign pathology and
P association with the PBs in this case reflect an investment of

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1 case subsequently found to have CIN II also had atypical cells in mesothelial cells that associate with the PBs as they are extruded

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their smears. from the ovarian stroma. This is significant because it represents a
An abnormal clinical examination and the presence of worrisome potential pitfall in the assessment of “atypical glandular” cells with-

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symptoms (most commonly unexplained vaginal bleeding) have in smears in patients with PB, and it potentially provides a means of
been found in most women with PBs associated with a malignant a identifying PBs of ovarian origin, facilitating the subsequent target-
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pathology.1,2 Two studies have confirmed that whereas 20% of the ed investigation of the patient.
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general population with postmenopausal bleeding have a gyneco- This case reiterates the complexity of attempting to predict the
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logic malignancy, this figure rose to 83% and 89% in patients in nature of the underlying pathology in cases of PB found in cervical
whom postmenopausal bleeding and PBs were present. cytology smears. The emphasis needs to be on a thorough investi-
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In our case of recurrent PBs with atypical cells in an asympto- gation of the patient until an explanation for the source of the PBs
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matic postmenopausal woman with a normal clinical examination is found. The report also demonstrates a possible pitfall in the as-
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but abnormal radiology, the definitive pathology was bilateral ovar- sessment of the cytologic smear in which the PBs are of ovarian ori-
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gin, with PBs acquiring a mantle of mesothelial cells as they migrate

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through the serosal surface with their subsequent interpretation as

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atypical glandular cells.

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References
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1. Zreik TG, Rutherford TJ: Psammoma bodies in cervicovaginal smears.

Obstet Gynecol 2001;5:693–695
2. Parkash V, Chacho MS: Psammoma bodies in cervicovaginal smears: In-
cidence and significance. Diagn Cytopathol 2001;26:81–86
3. Nicklin JL, Perrin L, Obermair A, McConachie I, Cominos D: The sig-
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nificance of psammoma bodies on cervical cytology smears. Gynecol

Oncol 2001;83:6–9
4. Muntz HG, Goff BA, McGonigle K, Isacson C: The significance of psam-
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moma bodies in screening cervical cytologic smears. Am J Obstet Gynecol

2003;188:1609–1614
5. Fausett MB, Zahn CM, Kendall BS, Barth WH: The significance of psam-
moma bodies that are found incidentally during endometrial biopsy. Am J
Obstet Gynecol 2002;186:180–183
6. Athavale RD, Chia KV: Psammoma bodies on postmenopausal cervical
smear: A rare sinister finding. J Obstet Gynaecol 2002;22:328–329
7. Cameron RI, McCluggage WG: Extensive psammomatous calcification of
the uterus and cervix associated with a uterine serous carcinoma. J Clin
Pathol 2004;57:888–890
Figure 3 Histology showing the extrusion of psammoma bodies through
the ovarian serosal surface and the acquisition of a mesothelial cell mantle 8. Luzzatto R, Brucker N: Benign inclusion cysts of the ovary associated with
(hematoxylin-eosin, × 200). psammoma bodies in vaginal smears. Acta Cytol 1981;25:282–284

Volume 51 Number 4 July–August 2007 ACTA CYTOLOGICA 577