Psammoma bodies are discrete laminated forms of calcifications found in normal tissues and various benign and malignant conditions, and are observed rarely in cervicovaginal smears.1 Malignancies reported with psammoma bodies in cervicovaginal smears include serous carcinomas of the uterus, fallopian tubes, ovaries,2–6 borderline ovarian carcinomas,7 and neuroendocrine carcinomas of the cervix.8 Numerous benign conditions are associated with psammoma bodies, including oral contraceptive (OC) pills,9 benign papillary structures of the ovary,10 intrauterine devices (IUD),11 ruptured ovarian cysts,12 endosalpingiosis,13 tuberculous endometritis,10 and ovarian cystadenofibromas.14 Most of those reports are single-case studies with a review of the literature. The rare finding of psammoma bodies in Papanicolaou smears has caused confusion for clinicians. The purpose of this paper was to determine the prevalence of psammoma bodies in routine cervicovaginal smears and describe clinical diagnoses associated with their identification in pre- and postmenopausal women.
Materials and Methods
From 1994 to 1998, women with psammoma bodies on Papanicolaou smears were identified from the computerized pathology database at Yale-New Haven Medical Center. A gynecologic pathologist reviewed all 18 Papanicolaou smears reported to have psammoma bodies to confirm, qualify, and quantify them.
Clinical information was obtained from retrospective review of women's medical records before and after identification of psammoma bodies. Data collected included age, gravity, parity, menopausal status, interval from last normal Papanicolaou smear, symptoms present at the time of abnormal Papanicolaou smear, appropriate follow-up Papanicolaou smears, smoking history, contraceptive and gynecologic history, and detailed family history of gynecologic cancers. All diagnostic tests and procedures were noted. In those women with a gynecologic malignancy, the neoplasm was reviewed.
Eighteen of 34,816 Papanicolaou smears (0.05%) had psammoma bodies, rare (1–3), occasional (4–8), or numerous (more than 8) bodies present. The median age (Table 1) of women was 49.5 years (range 17–78 years). Ten were premenopausal and eight were postmenopausal.
No malignancy was detected in the ten premenopausal women. Two women presented with adnexal masses, three were taking OCs, and one was receiving a progestational agent. One woman presented with an intrauterine device (IUD) in place, one was pregnant at the time of the abnormal Papanicolaou smear, and two were postpartum. The two who presented with adnexal masses had laparoscopic oophorectomies. One had a cystadenofibroma and the other a hemorrhagic corpus luteum cyst. All ten women had repeat Papanicolaou smears 3 to 6 months after the initial identification of psammoma bodies, and none had persistent psammoma bodies.
Seven of eight postmenopausal women had gynecologic malignancies. As with the premenopausal women, the number of psammoma bodies reported ranged from one to many; however, in all seven malignancies, clusters of atypical glandular or malignant cells also were noted. Five women had uterine serous or clear-cell carcinomas with postmenopausal bleeding. One woman presented with a pelvic mass found to be ovarian serous carcinoma. One presented with only psammoma bodies on a Papanicolaou smear and had a serous adenocarcinoma of the fallopian tube. That woman had a normal physical examination and radiologic studies, but culdocentesis found a serous carcinoma. All the malignancies were high-grade serous or clear-cell carcinomas. The only asymptomatic postmenopausal woman with rare psammoma bodies without clusters of atypical glandular or malignant cells had a benign cervical polyp.
Psammoma bodies are concentrically lamellated concentrations that might be associated with papillary neoplasms of various organs. In the female genital tract, they are most commonly described in association with serous carcinomas of the ovary and less commonly with uterine serous or clear-cell carcinomas. The literature consists mainly of single-case reports or short series. In our population, prevalence of psammoma bodies in consecutively screened Papanicolaou smears was 18 of 34,816, which confirmed that the presence of psammoma bodies is an unusual event. Atypical glandular or malignant cells and not the number of psammoma bodies correlated with gynecologic malignancies. Psammoma bodies have been reported to be associated with numerous benign processes that involve the müllerian tract (Table 2). The median age of those women in the literature is 36 years with a range of 29–55 years. In our series of 11 women with benign findings (Table 1), the median age was 23 years with a range of 17–66 years.
Endometrial changes from OCs and IUDs have been reported.9,11 In our series, three women were on OCs, one had an IUD, and one was receiving a progestational agent. In three women, psammoma bodies were thought to be pregnancy related; one was pregnant and the other two were postpartum. Inflammatory changes of endometrium have been associated with psammoma bodies.6 One woman had uterine fibroids and a cervicalpolyp. Benign ovarian cysts have been associated with psammoma bodies,12 as in our series in which one woman had a benign hemorrhagic cyst and two had cystadenofibromas.
As reported, psammoma bodies associated with malignancy tend to occur in the postmenopausal women2–8 with a median age of 60 years and a range of 21–76 years in the literature (Table 2). In our series of seven women, rare to numerous psammoma bodies were identified associated with malignancy in peri- or postmenopausal women with a median age of 68 years and a range of 50–78 years. The Papanicolaou smears of those women showed clusters of atypical glandular or malignant cells consistent with carcinoma. That finding was consistent with the literature in that atypical or malignant cells are associated with malignancy.2–6 Two women7,8 who had atypical glandular cells had either neuroendocrine carcinoma of the cervix or a borderline ovarian adenocarcinoma. In our series, malignancies were serous or clear-cell adenocarcinomas that involved the uterus, ovaries, or fallopian tubes.
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