{"id":47596,"date":"2026-08-26T14:52:20","date_gmt":"2026-08-26T06:52:20","guid":{"rendered":"https:\/\/medicine.nus.edu.sg\/pathweb\/?page_id=47596"},"modified":"2026-08-28T22:02:18","modified_gmt":"2026-08-28T14:02:18","slug":"fgtuc-1","status":"publish","type":"page","link":"https:\/\/medicine.nus.edu.sg\/pathweb\/short-cases\/fgtuc-1\/","title":{"rendered":"Short cases &#8211; FGT case 1 (Uterus)"},"content":{"rendered":"\n<h2>\n\t\t\tFGT Case 1 (Uterus) \t<\/h2>\n\t<p><em>Case writer: Dr Gideon Tan<\/em><\/p>\n\t<p><strong>Clinical history:<\/strong><\/p>\n<ul>\n<li>55F, with no significant past medical history, presents with repeated post-menopausal per-vaginal bleed.<\/li>\n<li>A CT (computer tomography) scan of the abdomen and pelvis showed a large uterine mass, measuring 16 cm in maximum dimension.<\/li>\n<li>A hysterectomy was performed.<\/li>\n<li>Gross examination of the hysterectomy specimen showed a 15.0 cm mass centred within the myometrium. Cut sections show a pale tan appearance, with areas of haemorrhage and necrosis.<\/li>\n<li>What are the histologic findings?<\/li>\n<li>What are your differential diagnoses?<\/li>\n<li>What ancillary tests would you do?<\/li>\n<\/ul>\n\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/FGTU.1-1024x514.png\" alt=\"FGTU.1\" height=\"321\" width=\"640\" title=\"FGTU.1\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t\t\t\t\t\t\t<\/a>\n\t<\/figure>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/FGTU.2-scaled.png\" alt=\"FGTU.2\" height=\"1727\" width=\"2560\" title=\"FGTU.2\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t\t\t\t\t\t\t<\/a>\n\t<\/figure>\n<figure itemscope itemtype=\"https:\/\/schema.org\/ImageObject\">\n\t\t\t\t<a target=\"_self\" itemprop=\"url\">\n\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/FGTU.3-scaled.png\" alt=\"FGTU.3\" height=\"1721\" width=\"2560\" title=\"FGTU.3\" onerror=\"this.style.display='none'\" loading=\"lazy\" \/>\n\t\t\t\t\t\t\t<\/a>\n\t<\/figure>\n\t<p>Click picture to enlarge<\/p>\n\t<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-0\" aria-controls=\"fl-accordion--content-0\" aria-expanded=\"true\" type=\"button\">Histologic Findings <i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Collapse<\/i><\/button><\/a>\n<p>&nbsp;<\/p>\n<table>\n<tbody>\n<tr>\n<td><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/FGTU.4-scaled.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/FGTU.4-scaled.png\" alt=\"\" width=\"2560\" height=\"1489\" \/>(opens in new tab)<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table>\n<tbody>\n<tr>\n<td>\n<ul>\n<li>Fascicles of ovoid to spindled cells with atypical, pleomorphic nuclei<\/li>\n<\/ul>\n<\/td>\n<td>\n<ul>\n<li>\nMarkedly atypical, bizarre tumour cells. Some cells are more epithelioid (arrows)\n<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n<p>&nbsp;<\/p>\n<table>\n<tbody>\n<tr>\n<td><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/FGTU.5-scaled.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/FGTU.5-scaled.png\" alt=\"\" width=\"2560\" height=\"1468\" \/>(opens in new tab)<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table>\n<tbody>\n<tr>\n<td>\n<ul>\n<li>Tumour cell necrosis (circled area)<\/li>\n<\/ul>\n<\/td>\n<td>\n<ul>\n<li>Mitotic activity is prominent, including atypical mitoses (red arrow)<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-1\" aria-controls=\"fl-accordion--content-1\" aria-expanded=\"false\" type=\"button\">Differential Diagnoses<i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Expand<\/i><\/button><\/a><p>&nbsp;<\/p>\n\n<p>In a myometrial-based nodule with atypical, pleomorphic spindled and epithelioid, tumour cell necrosis, and prominent mitotic activity, the differential diagnoses are:<\/p>\n<ul>\n<li>Leiomyosarcoma<\/li>\n<li>Symplastic leiomyoma<\/li>\n<li>Malignant PEComa (perivascular epithelioid cell tumour)<\/li>\n<li>Sarcomatous portion of a carcinosarcoma (only if additional sampling reveals a carcinomatous element to the tumour)<\/li>\n<\/ul>\n<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-2\" aria-controls=\"fl-accordion--content-2\" aria-expanded=\"false\" type=\"button\">Ancillary Tests <i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Expand<\/i><\/button><\/a><p>&nbsp;<\/p>\n\n<table>\n<tbody>\n<tr>\n<td><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/FGTU.6.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/FGTU.6.png\" alt=\"\" width=\"2132\" height=\"1434\" \/>(opens in new tab)<\/a><\/td>\n<td><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/FGTU.7.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/FGTU.7.png\" alt=\"\" width=\"2166\" height=\"1434\" \/>(opens in new tab)<\/a><\/td>\n<td><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/FGTU.8.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/medicine.nus.edu.sg\/pathweb\/wp-content\/uploads\/2026\/08\/FGTU.8.png\" alt=\"\" width=\"2069\" height=\"1391\" \/>(opens in new tab)<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<ul>\n<li>\nThe tumour cells show patchy positivity for desmin (a marker of myogenic differentiation)\n<\/li>\n<li>\nH-caldesmon and SMA (smooth muscle actin) are also positive. H-caldesmon is a smooth muscle marker, while SMA is a smooth muscle and myofibroblastic marker.\n<\/li>\n<\/ul>\nOther ancillary tests performed which were negative:\n<ul>\n<li>HMB-45, Melan-A (this excludes a malignant PEComa)<\/li>\n<\/ul>\n<a role=\"heading\" aria-level=\"2\"><button id=\"fl-accordion--button-3\" aria-controls=\"fl-accordion--content-3\" aria-expanded=\"false\" type=\"button\">Diagnosis and Learning Points <i data-label-icon=\"fas fa-plus\" data-active-icon=\"fas fa-minus\">Expand<\/i><\/button><\/a><p>&nbsp;<\/p>\n\n<p><u><b>Diagnosis<\/b><\/u><\/p>\n<ul>\n<li>Leiomyosarcoma<\/li>\n<\/ul>\n<p><u><b>Learning Points<\/b><\/u><\/p>\n<ul>\n<li>Adequate sampling is essential to diagnosing a leiomyosarcoma\n<ul>\n<li>The characteristic triad of significant cytologic atypia, high mitotic rate, and tumour cell necrosis may only be identified in certain areas of the tumour. The presence of a high mitotic rate, tumour cell necrosis, as well as widespread (rather than focal) cytological atypia distinguishes leiomyosarcoma from a symplastic leiomyoma.<\/li>\n<li>Adequate sampling is also key to excluding any heterogenous tumour elements &#8211; if a malignant epithelial component is found admixed, the diagnosis is carcinosarcoma.<\/li>\n<\/ul>\n<\/li>\n<li>Leiomyosarcomas can exhibit a range of morphologies\n<ul>\n<li>As seen in this case, leiomyosarcomas can have both spindled and epithelioid cells.<\/li>\n<li>While nuclear atypia will be present, it is important to remember that the atypia may not be very marked and may be heterogenous within the tumour (again emphasizing the importance of adequate sampling)<\/li>\n<li>Leiomyosarcomas can also show epithelioid, and myxoid morphologies.<\/li>\n<\/ul>\n<\/li>\n<li>Immunohistochemical stains are supportive but may not always be confirmatory\n<ul>\n<li>PEComas can also demonstrate positivity for smooth muscle markers, and leiomyosarcomas can sometimes be positive for the melanocytic markers which are positive in PEComas.<\/li>\n<li>Some have proposed certain immunohistochemical stains to help differentiate leiomyosarcomas from benign leiomyomas\/symplastic leiomyomas. While supportive, these are often not confirmatory.<\/li>\n<li>It is important to rely on assessment of morphological features, beyond just immunohistochemistry.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\t<a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/pathology-updates-journal-clubs\" target=\"_blank\" rel=\"noopener\">Pathology Updates &#038; Journal Clubs(opens in new tab)<\/a><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/short-cases\/\" target=\"_blank\" rel=\"noopener\">Short Cases(opens in new tab)<\/a><a href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/pg-patho\/\" target=\"_blank\" rel=\"noopener\">Postgrad Pathology Home(opens in new tab)<\/a>\n\n","protected":false},"excerpt":{"rendered":"<p>FGT Case 1 (Uterus) Case writer: Dr Gideon Tan Clinical history: 55F, with no significant past medical history, presents with repeated post-menopausal per-vaginal bleed. A CT (computer tomography) scan of the abdomen and pelvis showed a large uterine mass, measuring 16 cm in maximum dimension. A hysterectomy was performed. Gross examination of the hysterectomy specimen [&hellip;]<\/p>\n","protected":false},"author":828,"featured_media":0,"parent":47288,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-47596","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>NUS Pathweb<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/medicine.nus.edu.sg\/pathweb\/short-cases\/fgtuc-1\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:description\" content=\"FGT Case 1 (Uterus) Case writer: Dr Gideon Tan Clinical history: 55F, with no significant past medical history, presents with repeated post-menopausal per-vaginal bleed. 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