Endometrial stromal tumor with limited infiltration and probable extrauterine metastasis: Report of a case

Endometrial stromal nodule (ESN) is a tumor composed of cells closely resembling those of the endometrial stroma with minimal cytologic atypia. The most important criterion for the differential diagnosis from the endometrial stromal sarcoma (ESS) is a well-defined noninfiltrative expansile border. However, the definition of the ESN also includes a tumor with the presence of focal irregularities or fingerlike projections of the margin into the adjacent myometrium, none of which exceeds 2 to 3 mm. In some cases, however, it is difficult to differentiate marginal irregularities of ESN from "true invasion" of ESS. We described a case of extrauterine ESS that was associated with small intramyometrial stromal lesions with limited infiltration. The intramyometrial lesion could be definitionally categorized as ESNs. However, peritumoral fibroblastic band and inflammatory stromal reactions, irregular fingerlike projections, and multiple concurrent extrauterine ESS strongly suggested that these were small primary focus of ESS mimicking ESN. We propose that the patient with endometrial stromal tumor with limited infiltration should be more carefully followed than the usual ESN for possible metastasis and that a hysterectomy with meticulous histological examination of the specimen be performed before a diagnosis of primary extrauterine ESS is made, even in a case showing a grossly or radiologically normal uterus.