A 67-year-old female, mother of 5 children, complained two months history of post menopausal bleeding and weight loss without evidence of pain or fever. Physical examination findings were normal. Gynecologic examination revealed uterine prolapsus. Laboratory tests showed marked elevation of white blood cells (11800) and low hemoglobin value (9mg/dl). On transvaginal ultrasound, endometrium was measured 2.6 cm thick and marked heterogenic appearance with cystic hypoechoic areas in endometrium was detected. Those findings were supposed to be endometrial malignancy, hyperplasia or pyometra by radiologist. Endometrial culture and biopsy were performed but during biopsy very limited small fragmented tissue was obtained. Histological examination of this small fragmented tissue revealed abundant foamy histiocytes with variable amount of multinucleated giant cells, hemosiderin, and mixed inflammatory reaction. No evidence of normal endometrial glands, endometrial hyperplasia or carcinoma was found. Endometrial culture revealed no specific microorganism.
Total abdominal hysterectomy and bilateral salpingooopherectomy (TAH and BSO) was planned. During operation, intraoperative pathology consultation (frozen section) was performed. Onmacroscopic examination, TAH and BSO specimen was measured 10 × 8 × 5 cm. Endometrium was observed linear in some areas and irregular in other areas. Endometrium was measured 2 mm thick. Myometrial thickness was 12 mm. Both ovaries and uterine tubes were unremarkable. Whole endometrium was sampled for routine histopathological examination.
On histopathological examination of endometrial samples, abundant foamy histiocytes, mixed inflammatory reaction
composed of polymorphonuclear leucocytes, plasma cells and lymphocytes, hemosiderin, calcification, and fibrosis
were detected (see ). Neither of the endometrial samples showed hyperplasia or carcinoma. Additionally, chronic cervicitis and focal mucinous metaplasia of tubal epithelium with minimal chronic inflammation were detected. Special histochemical stains such as periodic acid schiff (PAS), Grocots methenamine silver (GMS), Gram stain, Prussian blue, and Von Cossa were applied on the endometrial samples. PAS, GMS, and Gram stain showed no specific microorganism; neither bacteria nor fungi. Prussian blue revealed intracytoplasmic hemosiderin accumulation in the foamy histiocytes. Von Cossa stain showed no calcium deposition within the endometrial inflammation. Immunohistochemically CD68 (1:40, mousemonoclonal, Neomarkers, Westinghouse, USA), Mac 387 (1:10, clone Mac 387, mouse monoclonal, DAKO, Denmark), CD 20 (for detecting B lymphocytes, 1:100, Clone L26, mouse monoclonal, Neomarkers, Westinghouse, USA), UCHL-1 (for detecting T lymphocytes, 1:100, mousemonoclonal, Neomarkers, Westinghouse, USA), and CD 138 (for detecting plasma cells, ready to use, mouse monoclonal, Neomarkers, Westinghouse, USA) were studied. The foamy cells were stained strongly positive for Mac 387 and CD 68 (see Figures and ). T and B lymphocytes and plasma cells were found within the endometrial inflammation with CD 20, UCHL-1, and CD 138, respectively .
Histopathological features of endometrial samples include
abundant foamy histiocytes and inflammatory cells (H
CD 68 positive histiocytes within the endometrium.
Mac-387 positive histiocytes within the endometrium.
CD 138 positive plasma cells within the endometrial inflammation.