Sabato 27 ottobre 2012 - Pacini Editore

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an omental lymph node. To the best of our knowledge, this is the
first case of LPD containing foci of lymph nodal ectopic decidua
in a pregnant woman with a past history of miomectomy and use
of oral contraception for three years.
Methods and results. A 36 year old pregnant woman, at 38 weeks
of gestation, was admitted to Garbagnate Milanese Hospital for a
cesarian section. She had previously undergone miomectomy and
now presented two irregular masses localized in the posterior wall
of the uterus and identified during pelvic ultrasound for the monitoring
of the pregnancy. The masses appeared to narrow the uterine
cavity and to determine a reduced fetal growth. Past medical
history of the woman revealed a miomectomy in 2007. She was
using oral contraceptions for 3 years. At the time of the admission
the patient was in a good condition with stable vital signs.
Physical examination was unremarkable. Laboratory data were
within normal limits. During the cesarian section an intraoperative
biopsy at explorative laparotomy showed multiple peritoneal
proliferative processes of uncertain significance. Tumors masses
measured up to 6x5,5x5,5 cm and were disseminated in the majus
and minus omentum. Due to the difficulties of a complete resection
the surgeon decided to perform an omentectomy, preserving
the uterus, to reduce the dimension of the lesions and to obtain
representative tissue for histopathological examination. On gross
examination, the omentum measured 21x8x12, consisted of a
lobulated yellow-whitish tissue and showed multiple, firm and
well circumscribed nodules. On cut section, the nodules showed
white, whorled trabeculation. In the omentum a lymph node of
0,5 cm in greatest diamenter was found. The histologic features of
the nodules were those of typical benign uterine myomas. There
was neither necrosis nor cell atypia. Mitoses were not observed.
The proliferative cell index as determined by Ki-67 was about
20% of the neoplastic cells. Collagen fibers were intermingled
with muscle cells as well as with decidual cells scattered throughout
the tumors and their periphery. Tumor cells were positive for
vimentin, desmin, smooth muscle actin and muscle specific actin
and strongly expressed progesterone receptors and oestrogen receptors.
The omental lymph node showed foci of decidual cells,
localized in the subcapsular sinus, which were loosely cohesive,
with abundant eosinophilic cytoplasm, well defined prominent
cytoplasmic borders and round to oval nuclei with dispersed chromatin
and single conspicuous nucleoli. Immunohistochemical
stains (Progesterone +, Oestrogen +, CK AE1-AE3-, CAM 5.2-,
CD117-) ruled out a metastatic epithelial lesion or GIST lesions.
The final diagnosis was consistent with benign tumors classified
as leiomyomatosis with foci of ectopic deciduas which was also
localized, peculiarly, in one of the omental lymph nodes.
Discussion. We describe the case of an incidentally detected LPD
with decidual foci in the tumors and in an omental lymph node in
a woman with multiple risk factors for this condition: prolonged
use of oral contraceptives, miomectomy and pregnancy. Several
studies have illustrated the characteristics of LPD and decidual
areas, their behavior and their association with other diseases but,
to our knowledge, only Hsu et al have reported the association
between LPD and decidua in a lymph node. LPD is difficult to
diagnose due to its rarity and the possibility of mimicking malignant
lesions, which are excluded in our cases in the absence
of mitoses, necrosis and atypia. However, histopathological and
immunohistochemical findings are diagnostic. On the other hand,
the exact incidence of ectopic decidua cannot be easily estimated,
because it is usually an incidental microscopic findings (in 100%
of omentum biopsies taken during cesarian section and in tubal
pregnancies and in 30,8% of uteri removed during pregnancy).
LPD is now interpreted as an hormone-dependent lesion which
can regress when hormonal stimulation has been removed. Decidual
areas are frequent in LPD as well as in lymph node during
pregnancy and can be related to endometriosis. It has been shown
that decidua in these ectopic areas may be replaced by fibrosis.
Fibroblasts may become activated as myofibroblasts and smooth
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
muscle cells. The use of oral contraceptives and pregnancy can
favor this metaplastic process. A metaplastic process which also
involves the subperitoneal mesenchymal stem cells to smooth
muscle cells, fibroblasts, myofibroblasts and decidual cells.
However, in our case there were also a uterine myomectomy
in the anamnesis and this does not allow to exclude a iatrogen
muscle cells dissemination in the peritoneal cavity. The presence
of decidual cells in the subcapsular sinus of an omental lymph
node might let us hypothesize a migration of decidual cells by
lymphatic vessels from the omentum to the lymph node. Post
partum the patient underwent a pharmacological treatment with
GnRh agonists for three months aimed at inducing a menopausal
condition and reducing the residual LPD. One year post surgery
the patient was well. Sonographically and in the follow-up CTscan
there were no signs of persistent leiomyomatosis.
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Primary ovarian lymphoma: an incidental finding
in two cases
G. Petracco, P. Uboldi, M. Onorati, A. Del Gobbo * , S. Romagnoli
* , M. Albertoni, I. Talamo, F. Di Nuovo
Pathology Unit, Garbagnate Milanese, AO “G. Salvini” Garbagnate Milanese,
Italy; * Department of Health Sciences, AO S. Paolo, University of
Milan, Medical School, Italy
Introduction. Primary ovarian lymphoma is an uncommon
disease and often pose a diagnostic challenge if his existent is
not suspected, because most cases of ovarian involvement by
lymphomas represent secondary involvement. Most are non-
Hodgkin lymphomas and constitute only the 1,5% of ovarian
tumors with a prevalence ranging from 0.2% to 1.1%. It affects
patients over a wide age. The peak of incidence is in the fourth or
fifth decade for large B-cell lymphoma, whereas follicular lymphoma
are more often found in older women. The main symptom
is abdominal pain, with pelvic mass and ascites, which are also
common in ovarian cancer. A minority of patients have weight
loss, fatigue, fever or abdominal vaginal bleeding. Most ovarian
lymphomas are large B-cell lymphomas followed by primary
ovarian Burkitt’s lymphoma and follicular lymphomas. Ovarian
lymphoma traditionally has been considered an aggressive tumor
with a poor outcome; however in more recent reports with com-