Corded and hyalinized endometrioid carcinoma: a rare case and review of the literature

Corded and hyalinized endometrioid carcinoma: a rare case and review of the literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Corded and hyalinized endometrioid carcinoma: a rare case and review of the literature Yan Li, Yuejiao Lang, Kaitao Yuan, Ying Tuo, Pei Xiang, Donghua Zheng, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-71402/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Corded and hyalinized endometrioid carcinoma(CHEC) is a rare morphological variation of endometrioid carcinoma(EC) in the endometrium. Reports of CHEC were very limited. We represent the clinical and pathological findings of this rare endometrioid carcinoma in a 26-year-old woman and reviews the literatures updated on CHEC. Case presentation: A 26-year-old woman presented with abnormal vaginal bleeding for 3 months and the initial cervical biopsy revealed a mullerian mixed tumor in another clinic. Abdominopelvic computed tomography revealed a mass in the uterine cavity and cervix, suggesting a malignant tumor. Histologically, the tumor showed a biphasic pattern characterized by an appearance of 2 components, the conventional endometrioid carcinoma component and sex cord-like component with hyalinization. In the areas of sex cord-like elements, the epithelioid and spindle cells were usually seen around the glands, and mostly arranged in cords or trabeculaes, sometimes embedded within a richly hyalinized collagenous or sometimes myxoid matrix. Tumor cells in the sex cord-like region show a different immunohistochemical expression pattern from conventional adenocarcinoma. Cytokeratin(CK) and vimentin are positive in both components, and vimentin shows more diffuse positivity while CK is more restricted and focally expressed in tumor cells in the sex cord-like region. Complete loss of expression of E-cadherin and epithelial membrane antigen(EMA) was seen in tumor cells in the sex cord-like region whereas it was well preserved in the area of conventional adenocarcinoma. Nuclear expression of β-catenin was noted in tumor cells in the sex cord-like region. P53 was focally positive in both components. Based on histological and immunochemical examinations, the patient was diagnosed with CHEC. Conclusions CHEC is not uncommonly mistaken for a wide variety of diseases. It’s of great significance to raise the awareness of CHEC to avoid over-treatment caused by over-diagnosis, especially in young patients and in curettage. We report one case of CHEC in a 26-year-old woman which was misdiagnosed as a mullerian mixed tumor in the initial curettage specimen. The clinicopathologic, light microscopic, immunohistochemical features of this tumor are described and the differential diagnosis is discussed. Pathology Endometrioid carcinoma corded and hyalinized endometrioid carcinoma sex cord-like formations Figures Figure 1 Figure 2 Figure 3 Background Endometrioid carcinoma (EC) accounts for 70 ~ 80% of newly diagnosed uterine corpus cancer worldwide in recent years[ 1 ]. The recognition of its typical morphology and clinical significance are usually straightforward; however, EC may have a variety of unusual appearances that can pose a diagnostic challenge and be associated with unique clinicopathological findings[ 2 ]. EC with sex cord-like formations and hyalinization is a rare morphological variation of EC in the endometrium which was first described in a review article in 2002[ 3 ]. In 2005, Murray et al. described the clinical and pathologic features of this distinct variant and referred to this subtype as “corded and hyalinized endometrioid carcinoma(CHEC)”[ 4 ]. Histologically, CHEC is characterized by the presence of cords, nests, or clusters of bland epithelioid and spindled cells, which merge with a conventional component of low-grade typical EC. Typically in between the cords and clusters, there is abundant hyalinized to myxoid stroma which compresses the neoplastic cells and imparts a sex-cord like appearance. Clinically, CHECs tend to arise in younger patients compared with typical ECs and are usually low stage with a generally favorable prognosis, so it is important to distinguish CHECs from other endometrial tumors[ 5 ]. However, CHEC is not uncommonly mistaken for a wide variety of diseases, in particular carcinosarcoma, which is often high grade and clinically aggressive. Therefore, increased awareness of this rare morphological variation is essential for both clinicians and pathologists to avoid misdiagnosis and over-treatment. To our knowledge, reports of CHEC were very limited[ 4 , 6 ]. In this study, we represent the clinical and pathological findings of this rare endometrioid carcinoma in a 26-year-old woman and reviews the literatures updated on the clinical, morphologic and immunohistochemical features of CHEC. Materials And Methods The tissue obtained via hysterectomy was processed using routine histological methods: 10% formalin fixed, paraffin embedded and haematoxylin-eosin stained. Immunohistochemical studies were carried out on formalin-fixed paraffin-embedded tissue. Appropriate positive and negative controls were applied simultaneously. The primary antibodies used for the immunohistochemical studies are listed in Table 1 . Table 1 Proteins explored in the present study Targeted proteins Clone Dilution Expression in typical endometrioid carcinoma component Expression in the epithelial cells in the sex cord-like component CK a AE1 + AE3 Ready-to-use Diffuse + Focally + Vimentin a V9 Ready-to-use Focally + Diffuse + E-cadherin a Nch-38 Ready-to-use Diffuse + - EMA a E29 Ready-to-use Diffuse + - CK7 a OV-TL Ready-to-use Diffuse + Focally + ER b SP1 Ready-to-use Diffuse + Focally + PR b 1E2 Ready-to-use Diffuse + Focally + Pax-8uhe c EP298 Ready-to-use Diffuse + Focally + P53 a DO-7 Ready-to-use Focally + Focally + β-catenin c CAT-5H10 1;200 Nuclear - Nuclear + Actin a 1A4 Ready-to-use - Focally + MLH1 a ES05 Ready-to-use Diffuse + Diffuse + PMS2 a EP51 Ready-to-use Diffuse + Diffuse + MSH2 a FE11 Ready-to-use Diffuse + Diffuse + MSH6 a EP49 Ready-to-use Diffuse + Diffuse + CD10 a 56C6 Ready-to-use - - Desmin a D33 Ready-to-use - - Inhibin-a a R1 Ready-to-use - - Melan-A a A103 Ready-to-use - - a : DAKO; b : ROCHE; c : MAI XIN BIOTECHNOLOGY CO.,LTD. Case Presentation Clinical history A 26-year-old woman visited another clinic because of abnormal vaginal bleeding for 3 months. The initial cervical biopsy revealed a mullerian mixed tumor, following which she was referred to our hospital for evaluation and treatment. Her familial history and past history was uneventful. Her body mass index was 28.6 kg/m 2 . Abdominopelvic computed tomography revealed a mass in the uterine cavity and cervix, suggesting a malignant tumor (Fig. 1 a- 1 b). Serum levels of the tumor markers carcinoembryonic antigen, cancer antigen 125 and carbohydrate antigen 19 − 9 were 0.66 ug/L, 10.6 U/mL, and 3.85 U/mL respectively. The patient received total hysterectomy with bilateral salpingo-oophorectomy, omentectomy, intra-pelvic, para-aortic and presacral lymphadenectomy. Pathological findings Gross examination in the hysterectomy specimen revealed a 60 × 33 × 10 mm papillary mass with a grey-whitish cut surface in the uterine cavity that appeared to invade into the superficial myometrium and the surface of cervix (Fig. 1 c). Histologically, low-power magnification revealed the tumor invaded the superficial layer of myometrium and extended to the surface of cevix but did not invade the cervical stroma (FIGO stage IA), showing a biphasic pattern characterized by an appearance of 2 components, the conventional endometrioid carcinoma component and sex cord-like component with hyalinization (Fig. 2 a). Sections of the tumor showed typical low-grade endometrioid carcinoma (FIGO grade 1) in a background of endometrial hyperplasia (Fig. 2 b). In 60% of areas of the tumor, sex cord-like elements were found to blend with the conventional endometrioid carcinoma. This distinct component of sex cord-like formations was restricted to the superficial aspects (Fig. 2 c). In the areas of sex cord-like elements, the epithelioid and spindle cells were usually seen around the glands, and mostly arranged in cords or trabeculaes (Fig. 2 d). In some areas, the epithelioid and spindle cells were embedded within a richly hyalinized collagenous or sometimes myxoid matrix, and the cells may formed small clusters or were individually disposed (Fig. 2 e); but in some areas, a hyalinized matrix was absent and the cells were arranged in solid sheets (Fig. 2 f). Squamous differentiation exhibiting keratinization was common (Fig. 2 g). Cytologic atypia of the epithelioid and spindle cells was uniformly low grade. The cells had scant eosinophilic cytoplasm. Compared with the tumor cells within the glands of the typical EC component, the nuclei of the epithelioid, spindle and fusiform cells showed less atypia and only rare mitotic figures(Fig. 2 h). Lymphovascular invasion was not identified. The right and left ovaries and fallopian tubes were negative for tumor. A panel of immunohistochemical stains was performed. In the typical endometrioid carcinoma component, CK, E-cadherin, EMA, CK7, estrogen receptor(ER), progesterone receptor(PR) and Pax-8 was diffusely positive; Vimentin was focally positive; actin was negative. In the epithelial cells in the sex cord-like component, Vimentin was diffusely positive; CK, CK7, ER, PR, Pax-8, actin was focally weakly positive; E-cadherin, EMA was negative. Nuclear expression of β-catenin was noted in tumor cells in the sex cord-like region. P53 was focally positive in both components. MLH1, PMS2, MSH2 and MSH6 was postive in both components. CD10, desmin, inhibin-α, melan-A was negative in both components (Table 1 , Fig. 3 ). Based on histological and immunochemical examinations, the patient was diagnosed with CHEC. Follow up The patient had a disease-free follow-up 8 months after the surgery. Discussion And Conclusions EC may have a variety of unusual appearances which can cause difficulty in making correct diagnosis[ 2 ]. CHEC is a rare morphological variant of EC developing in the endometrium[ 4 ]. Lack of awareness of this entity may lead to misdiagnosis and unnecessary treatment. Reports of CHEC are limited; updating to now, only 37 cases are described by two articles (written in English) retrieved from PubMed[ 4 , 6 ]. From these studies, patient age ranged from 25 to 83 years, with a mean of 51 years. Among 27 patients with clinical staging data, 20 patients (74%) were at FIGO stage Ⅰ. Among 18 patients with follow-up information, 15 patients were alive with no evidence of disease, 1 patient was alive with disease, 1 patient died as a result of tumor, and 1 patient died of other causes. In the present case, the patient was only 26-year-old, at FIGO stage Ⅰand was alive with no evidence of disease for 8 months. We can conclude that CHEC tends to arise in younger patients compared with conventional endometrial EC, and usually develops at a lower stage with more favorable prognosis than conventional endometrial EC[ 7 , 8 ]. However, CHEC is not uncommonly mistaken for a wide variety of diseases. In the present case, the patient was misdiagnosed as a mullerian mixed tumor in the curettage specimen. Accordingly, it’s of great significance to raise the awareness of CHEC to avoid over-treatment caused by over-diagnosis, especially in young patients and in curettage. Histologically, all cases that have been reported consist of a component of conventional grade Ⅰ or Ⅱ conventional EC that accounts for 10–90%. Endometrial hyperplasia can be identified in most cases. The definition of CHEC is the presence of cords of epithelioid cells, spindled cells, or fusiform cells with or without hyalinized stroma. This component is generally restricted to the superficial aspects and often embedded within a striking hyalinized collagenous matrix which in some cases formed osteid. Increased squamous differentiation is often found. As for immunohistochemical staining, tumor cells in the sex cord-like region show a different expression pattern from conventional adenocarcinoma. CK and vimentin are positive in both components in most cases, and vimentin shows more diffuse positivity while CK is more restricted and focally expressed in tumor cells in the sex cord-like region. Complete loss of expression of E-cadherin and EMA was seen in tumor cells in the sex cord-like region whereas it was well preserved in the area of conventional adenocarcinoma. Nuclear expression of β-catenin was noted in tumor cells in the sex cord-like region. Both components show a positive immunoreactive for ER in about half of the cases and p53 overexpression was rarely observed. Desmin, inhibin and CD10 are negative in both components. Molecularly, sequence analysis showed mutations in the exon 3 of β-catenin gene in tumor cells in the corded and hylinized region. The main pathological differential diagnoses of the present case include carcinosarcoma, dedifferentiated EC, sertoliform EC, low-grade endometrial stromal sarcomas (LGESS), i.e. CHEC tends to be easily misdiagnosed as carcinosarcoma, because of its striking biphasic appearance exhibiting both epithelioid and mesenchymal elements, especially in the setting of biopsy or curretage. Unlike CHEC, carcinosarcoma often occurs in elderly women and has a high-stage clinical presentation and more aggressive clinical behavior[ 9 ]. Moreover, pathologically carcinosarcoma is mostly composed of high-grade adenocarcinomatous and sarcomatous components with increased nuclear atypia and mitosis[ 10 ]. Also, p53 is diffusely and strongly expressed in adenocarcinoma while it is scattered positive in CHEC[ 11 ]. Dedifferentiated EC contains a component of either FIGO grade 1 or 2 EC and a second component of undifferentiated carcinoma. The undifferentiated carcinoma is composed of dyshesive cells of uniform size arranged in sheets without any corded or trabecular architecture which is seen in CHEC. The nuclear chromatin is usually condensed and most cases have > 25 mitotic figure per 10 HPF while the nuclei of the epithelioid and spindle cells showed less atypia and only rare mitotic figures in CHEC[ 12 , 13 ]. The undifferentiated component grows beneath the differentiated endometrioid component while the epithelioid and spindle cells are restricted to the superficial aspects in CHEC. The undifferentiated components display evidence of epithelial differentiation in only occasional tumor cells, with intense EMA and CK18 expression in the absence of staining with pan-cytokeratins[ 14 ]. Also, a proportion of dedifferentiated EC appear to be associated with microsatellite instability[ 15 ]. In sertoliform EC, tumor cells are arranged as small hollow tubules in the areas resembling Sertoli and Sertoli-Leydig cell tumors, but sometimes they can arranged as cord and trabeculaes, which can be confused with CHEC. However, prominent stromal hyalinization and spindle cells are not a feature of the sertoliform EC of the endometrium and the sertoliform elements are always positive for EMA and CK, which helps us distinguish sertoliform EC with CHEC[ 16 , 17 ]. LGESS can also show sex cord-like features and the tumor cells in this element are small and uniform without prominent nuclear atypia and mitotic activity[ 18 ]. However, typical EC is absent in LGESS. Immunohistochemically, the sex cord elements in LGESS show positive staining of endometrial stromal, smooth muscle markers. Sex cord markers including inhibin, CD99, calretinin and CD56 could also be positive[ 19 , 20 ]. PHF1 rearrangement has been found to be predominant in the sex cord variant of LGESS[ 21 ]. Corded and hyalinized mesonephric-like adenocarcinoma can also mimick CHEC. Differentiating the tumor from CHEC is its heterogeneous architecture resembling mesonephric growth patterns, segments of attenuated epithelium, lack of squamous differentiation, essentially negative hormone receptor expression, considerable positivity for TTF1 and GATA3[ 22 ]. In summary, CHEC is not uncommonly mistaken for a wide variety of diseases. We report one case of CHEC in a 26-year-old woman. The clinicopathologic, light microscopic, immunohistochemical fetaures of this tumor are described and the differential diagnosis is discussed. We hope that this report help to raise the awareness of CHEC and avoid misdiagnosis and mistreatment. Abbreviations CHEC: Corded and hyalinized endometrioid carcinoma; EC:Endometrioid carcinoma; Cytokeratin(CK); EMA:Epithelial membrane antigen; FIGO:International Federation of Gynecology and Obstetrics; ER:estrogen receptor; PR:progesterone receptor. Declarations Ethics approval and consent to participate The patient provided informed consent. The study was approved by the Ethics Committee of Clinical Research and Experimental Animal of the First Affiliated Hospital, Sun Yat-sen University. Consent for publication Written informed consents for publication of clinical details and clinical images were obtained from the patient. A copy of the consent form is available for review by the Editor of this journal. Availability of data and materials Please contact author for data requests. Competing interests The authors declare that they have no competing interests. Funding None. Authors' contributions Y Li, DZ and DL analysed and interpreted histological and immunohistochemistry examination. Y Li and Y Lang made major contributions in writing the manuscript. DL revised the manuscript. KY collected the patient’s clinical history. YT performed the immunohistochemical examination. PX performed the abdominopelvic computed tomography examination and wrote the coincident part of the report. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010;127(12):2893–917. Malpica A. How to approach the many faces of endometrioid carcinoma. Mod Pathol. 2016;29(Suppl 1):29–44. Clement PB, Young RH. Endometrioid carcinoma of the uterine corpus: a review of its pathology with emphasis on recent advances and problematic aspects. Adv Anat Pathol. 2002;9(3):145–84. Murray SK, Clement PB, Young RH. Endometrioid carcinomas of the uterine corpus with sex cord-like formations, hyalinization, and other unusual morphologic features: a report of 31 cases of a neoplasm that may be confused with carcinosarcoma and other uterine neoplasms. Am J Surg Pathol. 2005;29(2):157–66. Jia M, Sun PL, Gao H. Uterine lesions with sex cord-like architectures: a systematic review. Diagn Pathol. 2019;14(1):129. Wani Y, Saegusa M, Notohara K. Aberrant nuclear beta-catenin expression in the spindle or corded cells in so-called corded and hyalinized endometrioid carcinomas. Another critical role of the unique morphological feature. Histol Histopathol. 2009;24(2):149–55. Creasman WT, Odicino F, Maisonneuve P, Quinn MA, Beller U, Benedet JL, Heintz AP, Ngan HY, Pecorelli S. Carcinoma of the corpus uteri. FIGO 26th Annual Report on the Results of Treatment in Gynecological Cancer. Int J Gynaecol Obstet 2006;95 Suppl 1:S105-43. Zaino RJ, Kurman RJ, Diana KL, Morrow CP. Pathologic models to predict outcome for women with endometrial adenocarcinoma: the importance of the distinction between surgical stage and clinical stage–a Gynecologic Oncology Group study. Cancer. 1996;77(6):1115–21. Singh R. Review literature on uterine carcinosarcoma. J Cancer Res Ther. 2014;10(3):461–8. Denschlag D, Ulrich UA. Uterine Carcinosarcomas - Diagnosis and Management. Oncol Res Treat. 2018;41(11):675–9. Keeling L, Taraporewalla D, Perunovic B, Smith JH. Uterine carcinosarcoma with p53-positive intraepithelial component. Histopathology. 2011;59(6):1277–8. Tafe LJ, Garg K, Chew I, Tornos C, Soslow RA. Endometrial and ovarian carcinomas with undifferentiated components: clinically aggressive and frequently underrecognized neoplasms. Mod Pathol. 2010;23(6):781–9. Silva EG, Deavers MT, Bodurka DC, Malpica A. Association of low-grade endometrioid carcinoma of the uterus and ovary with undifferentiated carcinoma: a new type of dedifferentiated carcinoma? Int J Gynecol Pathol. 2006;25(1):52–8. Altrabulsi B, Malpica A, Deavers MT, Bodurka DC, Broaddus R, Silva EG. Undifferentiated carcinoma of the endometrium. Am J Surg Pathol. 2005;29(10):1316–21. Garg K, Leitao MJ, Kauff ND, Hansen J, Kosarin K, Shia J, Soslow RA. Selection of endometrial carcinomas for DNA mismatch repair protein immunohistochemistry using patient age and tumor morphology enhances detection of mismatch repair abnormalities. Am J Surg Pathol. 2009;33(6):925–33. Eichhorn JH, Young RH, Clement PB. Sertoliform endometrial adenocarcinoma: a study of four cases. Int J Gynecol Pathol. 1996;15(2):119–26. Liang SX, Patel K, Pearl M, Liu J, Zheng W, Tornos C. Sertoliform endometrioid carcinoma of the endometrium with dual immunophenotypes for epithelial membrane antigen and inhibin alpha: case report and literature review. Int J Gynecol Pathol. 2007;26(3):291–7. Ohta Y, Suzuki T, Kojima M, Shiokawa A, Mitsuya T. Low-grade endometrial stromal sarcoma with an extensive epithelial-like element. Pathol Int. 2003;53(4):246–51. Richmond AM, Rohrer AJ, Davidson SA, Post MD. Low-grade endometrial stromal sarcoma with extensive sex cord differentiation, heterologous elements, and complex atypical hyperplasia: Case report and review of literature. Gynecol Oncol Rep. 2017;19:34–8. Baker RJ, Hildebrandt RH, Rouse RV, Hendrickson MR, Longacre TA. Inhibin and CD99 (MIC2) expression in uterine stromal neoplasms with sex-cord-like elements. Hum Pathol. 1999;30(6):671–9. D'Angelo E, Ali RH, Espinosa I, Lee CH, Huntsman DG, Gilks B, Prat J. Endometrial stromal sarcomas with sex cord differentiation are associated with PHF1 rearrangement. Am J Surg Pathol. 2013;37(4):514–21. Patel V, Kipp B, Schoolmeester JK. Corded and hyalinized mesonephric-like adenocarcinoma of the uterine corpus: report of a case mimicking endometrioid carcinoma. Hum Pathol. 2019;86:243–8. 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Reconstructed sagittal pre-contrast CT image: the presence of endometrial thickening (arrow) and cervical mass (star) is obscured in the pre-contrast CT image. b. Reconstructed sagittal post-contrast CT image：endometrial thickening (arrow), enhancing mass (less enhanced than the myometrium) in the uterus cervix (star). c. Gross examination in the hysterectomy specimen revealed a 60 x 33 x 10 mm papillary mass with a grey-whitish cut surface in the uterine cavity that appeared to invade into the superficial myometrium and the surface of cervix.\n","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-71402/v1/Figure1.jpg"},{"id":2539036,"identity":"83021e25-8ace-42e2-af36-9dac1342a632","added_by":"auto","created_at":"2020-09-22 16:44:41","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13020770,"visible":true,"origin":"","legend":"Histological findings of the tumor. a. Low-power magnification showed a biphasic pattern due to neoplastic endometrioid glands separated by a focally hyalinized stroma containing cords. Haematoxylin-eosin staining, 20x magnification. b. Typical endometrioid carcinoma (grade 1) in a background of endometrial hyperplasia. Haematoxylin-eosin staining, 40x magnification. c. The sex cord-like elements blended with the conventional endometrioid carcinoma. Haematoxylin-eosin staining, 20x magnification. d. In the areas of sex cord-like elements, the epithelioid and spindle cells were around the glands, and mostly arranged in cords or trabeculaes. Haematoxylin-eosin staining, 100x magnification. e. In some areas, the epithelioid and spindle cells were embedded within a richly hyalinized collagenous or sometimes myxoid matrix, and the cells may formed small clusters or were individually disposed. Haematoxylin-eosin staining, 40x magnification. f. A hyalinized matrix was absent and the cells were arranged in solid sheets. Haematoxylin-eosin staining, 200x magnification. g. Squamous differentiation exhibiting keratinization was common. Haematoxylin-eosin staining, 100x magnification. h. The neoplastic cells display low-grade cytologic features. Haematoxylin-eosin staining, 200x magnification.","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-71402/v1/Figure2.jpg"},{"id":2539037,"identity":"29824537-1ae2-42c0-a234-ebcf373d1971","added_by":"auto","created_at":"2020-09-22 16:44:41","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":9077291,"visible":true,"origin":"","legend":"Immunohistochemical findings of the tumor. \na. CK was diffusely positive in the typical endometrioid carcinoma component and was focally weakly positive in tumor cells in the sex cord-like region. b. Vimentin was focally positive in the typical endometrioid carcinoma component and was diffusely positive in tumor cells in the sex cord-like region. c. E-cadherin was diffusely positive in the typical endometrioid carcinoma component and was negative in tumor cells in the sex cord-like region. d. EMA was diffusely positive in the typical endometrioid carcinoma component and was negative in tumor cells in the sex cord-like region. e. Nuclear expression of β-catenin was noted in tumor cells in the sex cord-like region. f. P53 was focally positive in both components. \n","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-71402/v1/Figure3.jpg"},{"id":13594645,"identity":"2ea3a344-cfbc-40fe-9196-6dd4cd593409","added_by":"auto","created_at":"2021-09-17 05:21:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1166905,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-71402/v1/ebe7d066-4818-4c17-932b-7083950cd9a2.pdf"},{"id":2539039,"identity":"48de9774-e36c-460d-968e-c711c88e06e0","added_by":"auto","created_at":"2020-09-22 16:44:42","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1750227,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklisnew.pdf","url":"https://assets-eu.researchsquare.com/files/rs-71402/v1/CAREchecklisnew.pdf"}],"financialInterests":"","formattedTitle":"Corded and hyalinized endometrioid carcinoma: a rare case and review of the literature","fulltext":[{"header":"Background","content":"\u003cp\u003eEndometrioid carcinoma (EC) accounts for 70\u0026thinsp;~\u0026thinsp;80% of newly diagnosed uterine corpus cancer worldwide in recent years[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The recognition of its typical morphology and clinical significance are usually straightforward; however, EC may have a variety of unusual appearances that can pose a diagnostic challenge and be associated with unique clinicopathological findings[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. EC with sex cord-like formations and hyalinization is a rare morphological variation of EC in the endometrium which was first described in a review article in 2002[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In 2005, Murray et al. described the clinical and pathologic features of this distinct variant and referred to this subtype as \u0026ldquo;corded and hyalinized endometrioid carcinoma(CHEC)\u0026rdquo;[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Histologically, CHEC is characterized by the presence of cords, nests, or clusters of bland epithelioid and spindled cells, which merge with a conventional component of low-grade typical EC. Typically in between the cords and clusters, there is abundant hyalinized to myxoid stroma which compresses the neoplastic cells and imparts a sex-cord like appearance. Clinically, CHECs tend to arise in younger patients compared with typical ECs and are usually low stage with a generally favorable prognosis, so it is important to distinguish CHECs from other endometrial tumors[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, CHEC is not uncommonly mistaken for a wide variety of diseases, in particular carcinosarcoma, which is often high grade and clinically aggressive. Therefore, increased awareness of this rare morphological variation is essential for both clinicians and pathologists to avoid misdiagnosis and over-treatment.\u003c/p\u003e\u003cp\u003eTo our knowledge, reports of CHEC were very limited[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In this study, we represent the clinical and pathological findings of this rare endometrioid carcinoma in a 26-year-old woman and reviews the literatures updated on the clinical, morphologic and immunohistochemical features of CHEC.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eThe tissue obtained via hysterectomy was processed using routine histological methods: 10% formalin fixed, paraffin embedded and haematoxylin-eosin stained. Immunohistochemical studies were carried out on formalin-fixed paraffin-embedded tissue. Appropriate positive and negative controls were applied simultaneously. The primary antibodies used for the immunohistochemical studies are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eProteins explored in the present study\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTargeted proteins\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClone\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDilution\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eExpression in typical endometrioid carcinoma component\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eExpression in the epithelial cells in the sex cord-like component\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCK\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAE1\u0026thinsp;+\u0026thinsp;AE3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFocally +\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVimentin\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eV9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFocally +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eE-cadherin\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNch-38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEMA\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eE29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCK7\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOV-TL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFocally +\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eER\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSP1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFocally +\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePR\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1E2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFocally +\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePax-8uhe\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEP298\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFocally +\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP53\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDO-7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFocally +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFocally +\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eβ-catenin\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCAT-5H10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1;200\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNuclear -\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNuclear +\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eActin\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1A4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFocally +\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMLH1\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eES05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePMS2\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEP51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMSH2\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFE11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMSH6\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEP49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eDiffuse +\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCD10\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56C6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDesmin\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eD33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInhibin-a\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMelan-A\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReady-to-use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e: DAKO; \u003csup\u003eb\u003c/sup\u003e: ROCHE; \u003csup\u003ec\u003c/sup\u003e: MAI XIN BIOTECHNOLOGY CO.,LTD.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eClinical history\u003c/h2\u003e\u003cp\u003eA 26-year-old woman visited another clinic because of abnormal vaginal bleeding for 3\u0026nbsp;months. The initial cervical biopsy revealed a mullerian mixed tumor, following which she was referred to our hospital for evaluation and treatment. Her familial history and past history was uneventful. Her body mass index was 28.6\u0026nbsp;kg/m\u003csup\u003e2\u003c/sup\u003e. Abdominopelvic computed tomography revealed a mass in the uterine cavity and cervix, suggesting a malignant tumor (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea-\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). Serum levels of the tumor markers carcinoembryonic antigen, cancer antigen 125 and carbohydrate antigen 19\u0026thinsp;\u0026minus;\u0026thinsp;9 were 0.66 ug/L, 10.6 U/mL, and 3.85 U/mL respectively. The patient received total hysterectomy with bilateral salpingo-oophorectomy, omentectomy, intra-pelvic, para-aortic and presacral lymphadenectomy.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003ePathological findings\u003c/h2\u003e\u003cp\u003eGross examination in the hysterectomy specimen revealed a 60\u0026thinsp;\u0026times;\u0026thinsp;33\u0026thinsp;\u0026times;\u0026thinsp;10\u0026nbsp;mm papillary mass with a grey-whitish cut surface in the uterine cavity that appeared to invade into the superficial myometrium and the surface of cervix (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec).\u003c/p\u003e\u003cp\u003eHistologically, low-power magnification revealed the tumor invaded the superficial layer of myometrium and extended to the surface of cevix but did not invade the cervical stroma (FIGO stage IA), showing a biphasic pattern characterized by an appearance of 2 components, the conventional endometrioid carcinoma component and sex cord-like component with hyalinization (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). Sections of the tumor showed typical low-grade endometrioid carcinoma (FIGO grade 1) in a background of endometrial hyperplasia (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). In 60% of areas of the tumor, sex cord-like elements were found to blend with the conventional endometrioid carcinoma. This distinct component of sex cord-like formations was restricted to the superficial aspects (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec). In the areas of sex cord-like elements, the epithelioid and spindle cells were usually seen around the glands, and mostly arranged in cords or trabeculaes (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ed). In some areas, the epithelioid and spindle cells were embedded within a richly hyalinized collagenous or sometimes myxoid matrix, and the cells may formed small clusters or were individually disposed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ee); but in some areas, a hyalinized matrix was absent and the cells were arranged in solid sheets (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ef). Squamous differentiation exhibiting keratinization was common (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eg). Cytologic atypia of the epithelioid and spindle cells was uniformly low grade. The cells had scant eosinophilic cytoplasm. Compared with the tumor cells within the glands of the typical EC component, the nuclei of the epithelioid, spindle and fusiform cells showed less atypia and only rare mitotic figures(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eh). Lymphovascular invasion was not identified. The right and left ovaries and fallopian tubes were negative for tumor.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eA panel of immunohistochemical stains was performed. In the typical endometrioid carcinoma component, CK, E-cadherin, EMA, CK7, estrogen receptor(ER), progesterone receptor(PR) and Pax-8 was diffusely positive; Vimentin was focally positive; actin was negative. In the epithelial cells in the sex cord-like component, Vimentin was diffusely positive; CK, CK7, ER, PR, Pax-8, actin was focally weakly positive; E-cadherin, EMA was negative. Nuclear expression of β-catenin was noted in tumor cells in the sex cord-like region. P53 was focally positive in both components. MLH1, PMS2, MSH2 and MSH6 was postive in both components. CD10, desmin, inhibin-α, melan-A was negative in both components (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eBased on histological and immunochemical examinations, the patient was diagnosed with CHEC.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eFollow up\u003c/h2\u003e\u003cp\u003eThe patient had a disease-free follow-up 8 months after the surgery.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion And Conclusions","content":"\u003cp\u003eEC may have a variety of unusual appearances which can cause difficulty in making correct diagnosis[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. CHEC is a rare morphological variant of EC developing in the endometrium[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Lack of awareness of this entity may lead to misdiagnosis and unnecessary treatment.\u003c/p\u003e\u003cp\u003eReports of CHEC are limited; updating to now, only 37 cases are described by two articles (written in English) retrieved from PubMed[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. From these studies, patient age ranged from 25 to 83 years, with a mean of 51\u0026nbsp;years. Among 27 patients with clinical staging data, 20 patients (74%) were at FIGO stage Ⅰ. Among 18 patients with follow-up information, 15 patients were alive with no evidence of disease, 1 patient was alive with disease, 1 patient died as a result of tumor, and 1 patient died of other causes. In the present case, the patient was only 26-year-old, at FIGO stage Ⅰand was alive with no evidence of disease for 8\u0026nbsp;months. We can conclude that CHEC tends to arise in younger patients compared with conventional endometrial EC, and usually develops at a lower stage with more favorable prognosis than conventional endometrial EC[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, CHEC is not uncommonly mistaken for a wide variety of diseases. In the present case, the patient was misdiagnosed as a mullerian mixed tumor in the curettage specimen. Accordingly, it\u0026rsquo;s of great significance to raise the awareness of CHEC to avoid over-treatment caused by over-diagnosis, especially in young patients and in curettage.\u003c/p\u003e\u003cp\u003eHistologically, all cases that have been reported consist of a component of conventional grade Ⅰ or Ⅱ conventional EC that accounts for 10\u0026ndash;90%. Endometrial hyperplasia can be identified in most cases. The definition of CHEC is the presence of cords of epithelioid cells, spindled cells, or fusiform cells with or without hyalinized stroma. This component is generally restricted to the superficial aspects and often embedded within a striking hyalinized collagenous matrix which in some cases formed osteid. Increased squamous differentiation is often found.\u003c/p\u003e\u003cp\u003eAs for immunohistochemical staining, tumor cells in the sex cord-like region show a different expression pattern from conventional adenocarcinoma. CK and vimentin are positive in both components in most cases, and vimentin shows more diffuse positivity while CK is more restricted and focally expressed in tumor cells in the sex cord-like region. Complete loss of expression of E-cadherin and EMA was seen in tumor cells in the sex cord-like region whereas it was well preserved in the area of conventional adenocarcinoma. Nuclear expression of β-catenin was noted in tumor cells in the sex cord-like region. Both components show a positive immunoreactive for ER in about half of the cases and p53 overexpression was rarely observed. Desmin, inhibin and CD10 are negative in both components. Molecularly, sequence analysis showed mutations in the exon 3 of β-catenin gene in tumor cells in the corded and hylinized region.\u003c/p\u003e\u003cp\u003eThe main pathological differential diagnoses of the present case include carcinosarcoma, dedifferentiated EC, sertoliform EC, low-grade endometrial stromal sarcomas (LGESS), i.e.\u003c/p\u003e\u003cp\u003eCHEC tends to be easily misdiagnosed as carcinosarcoma, because of its striking biphasic appearance exhibiting both epithelioid and mesenchymal elements, especially in the setting of biopsy or curretage. Unlike CHEC, carcinosarcoma often occurs in elderly women and has a high-stage clinical presentation and more aggressive clinical behavior[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Moreover, pathologically carcinosarcoma is mostly composed of high-grade adenocarcinomatous and sarcomatous components with increased nuclear atypia and mitosis[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Also, p53 is diffusely and strongly expressed in adenocarcinoma while it is scattered positive in CHEC[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDedifferentiated EC contains a component of either FIGO grade 1 or 2 EC and a second component of undifferentiated carcinoma. The undifferentiated carcinoma is composed of dyshesive cells of uniform size arranged in sheets without any corded or trabecular architecture which is seen in CHEC. The nuclear chromatin is usually condensed and most cases have \u0026gt;\u0026thinsp;25 mitotic figure per 10 HPF while the nuclei of the epithelioid and spindle cells showed less atypia and only rare mitotic figures in CHEC[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The undifferentiated component grows beneath the differentiated endometrioid component while the epithelioid and spindle cells are restricted to the superficial aspects in CHEC. The undifferentiated components display evidence of epithelial differentiation in only occasional tumor cells, with intense EMA and CK18 expression in the absence of staining with pan-cytokeratins[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Also, a proportion of dedifferentiated EC appear to be associated with microsatellite instability[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn sertoliform EC, tumor cells are arranged as small hollow tubules in the areas resembling Sertoli and Sertoli-Leydig cell tumors, but sometimes they can arranged as cord and trabeculaes, which can be confused with CHEC. However, prominent stromal hyalinization and spindle cells are not a feature of the sertoliform EC of the endometrium and the sertoliform elements are always positive for EMA and CK, which helps us distinguish sertoliform EC with CHEC[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eLGESS can also show sex cord-like features and the tumor cells in this element are small and uniform without prominent nuclear atypia and mitotic activity[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, typical EC is absent in LGESS. Immunohistochemically, the sex cord elements in LGESS show positive staining of endometrial stromal, smooth muscle markers. Sex cord markers including inhibin, CD99, calretinin and CD56 could also be positive[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. PHF1 rearrangement has been found to be predominant in the sex cord variant of LGESS[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCorded and hyalinized mesonephric-like adenocarcinoma can also mimick CHEC. Differentiating the tumor from CHEC is its heterogeneous architecture resembling mesonephric growth patterns, segments of attenuated epithelium, lack of squamous differentiation, essentially negative hormone receptor expression, considerable positivity for TTF1 and GATA3[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn summary, CHEC is not uncommonly mistaken for a wide variety of diseases. We report one case of CHEC in a 26-year-old woman. The\u003c/p\u003e\u003cp\u003eclinicopathologic, light microscopic, immunohistochemical fetaures of this tumor are described and the differential diagnosis is discussed. We hope that this report help to raise the awareness of CHEC and avoid misdiagnosis and mistreatment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCHEC: Corded and hyalinized endometrioid carcinoma; EC:Endometrioid carcinoma; Cytokeratin(CK); EMA:Epithelial membrane antigen; FIGO:International Federation of Gynecology and Obstetrics; ER:estrogen receptor; PR:progesterone receptor.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\u003cp\u003eThe patient provided informed consent. The study was approved by the Ethics Committee of Clinical Research and Experimental Animal of the First Affiliated Hospital, Sun Yat-sen University.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eWritten informed consents for publication of clinical details and clinical images were obtained from the patient. A copy of the consent form is available for review by the Editor of this journal.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\u003cp\u003ePlease contact author for data requests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNone.\u003c/p\u003e\u003ch2\u003eAuthors' contributions\u003c/h2\u003e\u003cp\u003eY Li, DZ and DL analysed and interpreted histological and immunohistochemistry examination. Y Li and Y Lang made major contributions in writing the manuscript. DL revised the manuscript. KY collected the patient\u0026rsquo;s clinical history. YT performed the immunohistochemical examination. PX performed the abdominopelvic computed tomography examination and wrote the coincident part of the report. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFerlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010;127(12):2893\u0026ndash;917.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMalpica A. How to approach the many faces of endometrioid carcinoma. Mod Pathol. 2016;29(Suppl 1):29\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eClement PB, Young RH. Endometrioid carcinoma of the uterine corpus: a review of its pathology with emphasis on recent advances and problematic aspects. Adv Anat Pathol. 2002;9(3):145\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMurray SK, Clement PB, Young RH. Endometrioid carcinomas of the uterine corpus with sex cord-like formations, hyalinization, and other unusual morphologic features: a report of 31 cases of a neoplasm that may be confused with carcinosarcoma and other uterine neoplasms. Am J Surg Pathol. 2005;29(2):157\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJia M, Sun PL, Gao H. Uterine lesions with sex cord-like architectures: a systematic review. Diagn Pathol. 2019;14(1):129.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWani Y, Saegusa M, Notohara K. Aberrant nuclear beta-catenin expression in the spindle or corded cells in so-called corded and hyalinized endometrioid carcinomas. Another critical role of the unique morphological feature. Histol Histopathol. 2009;24(2):149\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCreasman WT, Odicino F, Maisonneuve P, Quinn MA, Beller U, Benedet JL, Heintz AP, Ngan HY, Pecorelli S. Carcinoma of the corpus uteri. FIGO 26th Annual Report on the Results of Treatment in Gynecological Cancer. Int J Gynaecol Obstet 2006;95 Suppl 1:S105-43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZaino RJ, Kurman RJ, Diana KL, Morrow CP. Pathologic models to predict outcome for women with endometrial adenocarcinoma: the importance of the distinction between surgical stage and clinical stage\u0026ndash;a Gynecologic Oncology Group study. Cancer. 1996;77(6):1115\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSingh R. Review literature on uterine carcinosarcoma. J Cancer Res Ther. 2014;10(3):461\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDenschlag D, Ulrich UA. Uterine Carcinosarcomas - Diagnosis and Management. Oncol Res Treat. 2018;41(11):675\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKeeling L, Taraporewalla D, Perunovic B, Smith JH. Uterine carcinosarcoma with p53-positive intraepithelial component. Histopathology. 2011;59(6):1277\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTafe LJ, Garg K, Chew I, Tornos C, Soslow RA. Endometrial and ovarian carcinomas with undifferentiated components: clinically aggressive and frequently underrecognized neoplasms. Mod Pathol. 2010;23(6):781\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSilva EG, Deavers MT, Bodurka DC, Malpica A. Association of low-grade endometrioid carcinoma of the uterus and ovary with undifferentiated carcinoma: a new type of dedifferentiated carcinoma? Int J Gynecol Pathol. 2006;25(1):52\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAltrabulsi B, Malpica A, Deavers MT, Bodurka DC, Broaddus R, Silva EG. Undifferentiated carcinoma of the endometrium. Am J Surg Pathol. 2005;29(10):1316\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGarg K, Leitao MJ, Kauff ND, Hansen J, Kosarin K, Shia J, Soslow RA. Selection of endometrial carcinomas for DNA mismatch repair protein immunohistochemistry using patient age and tumor morphology enhances detection of mismatch repair abnormalities. Am J Surg Pathol. 2009;33(6):925\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEichhorn JH, Young RH, Clement PB. Sertoliform endometrial adenocarcinoma: a study of four cases. Int J Gynecol Pathol. 1996;15(2):119\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiang SX, Patel K, Pearl M, Liu J, Zheng W, Tornos C. Sertoliform endometrioid carcinoma of the endometrium with dual immunophenotypes for epithelial membrane antigen and inhibin alpha: case report and literature review. Int J Gynecol Pathol. 2007;26(3):291\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOhta Y, Suzuki T, Kojima M, Shiokawa A, Mitsuya T. Low-grade endometrial stromal sarcoma with an extensive epithelial-like element. Pathol Int. 2003;53(4):246\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRichmond AM, Rohrer AJ, Davidson SA, Post MD. Low-grade endometrial stromal sarcoma with extensive sex cord differentiation, heterologous elements, and complex atypical hyperplasia: Case report and review of literature. Gynecol Oncol Rep. 2017;19:34\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBaker RJ, Hildebrandt RH, Rouse RV, Hendrickson MR, Longacre TA. Inhibin and CD99 (MIC2) expression in uterine stromal neoplasms with sex-cord-like elements. Hum Pathol. 1999;30(6):671\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eD'Angelo E, Ali RH, Espinosa I, Lee CH, Huntsman DG, Gilks B, Prat J. Endometrial stromal sarcomas with sex cord differentiation are associated with PHF1 rearrangement. Am J Surg Pathol. 2013;37(4):514\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatel V, Kipp B, Schoolmeester JK. Corded and hyalinized mesonephric-like adenocarcinoma of the uterine corpus: report of a case mimicking endometrioid carcinoma. Hum Pathol. 2019;86:243\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Endometrioid carcinoma, corded and hyalinized endometrioid carcinoma, sex cord-like formations","lastPublishedDoi":"10.21203/rs.3.rs-71402/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-71402/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eCorded and hyalinized endometrioid carcinoma(CHEC) is a rare morphological variation of endometrioid carcinoma(EC) in the endometrium. Reports of CHEC were very limited. We represent the clinical and pathological findings of this rare endometrioid carcinoma in a 26-year-old woman and reviews the literatures updated on CHEC.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e\u003cp\u003eA 26-year-old woman presented with abnormal vaginal bleeding for 3\u0026nbsp;months and the initial cervical biopsy revealed a mullerian mixed tumor in another clinic. Abdominopelvic computed tomography revealed a mass in the uterine cavity and cervix, suggesting a malignant tumor. Histologically, the tumor showed a biphasic pattern characterized by an appearance of 2 components, the conventional endometrioid carcinoma component and sex cord-like component with hyalinization. In the areas of sex cord-like elements, the epithelioid and spindle cells were usually seen around the glands, and mostly arranged in cords or trabeculaes, sometimes embedded within a richly hyalinized collagenous or sometimes myxoid matrix. Tumor cells in the sex cord-like region show a different immunohistochemical expression pattern from conventional adenocarcinoma. Cytokeratin(CK) and vimentin are positive in both components, and vimentin shows more diffuse positivity while CK is more restricted and focally expressed in tumor cells in the sex cord-like region. Complete loss of expression of E-cadherin and epithelial membrane antigen(EMA) was seen in tumor cells in the sex cord-like region whereas it was well preserved in the area of conventional adenocarcinoma. Nuclear expression of β-catenin was noted in tumor cells in the sex cord-like region. P53 was focally positive in both components. Based on histological and immunochemical examinations, the patient was diagnosed with CHEC.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eCHEC is not uncommonly mistaken for a wide variety of diseases. It\u0026rsquo;s of great significance to raise the awareness of CHEC to avoid over-treatment caused by over-diagnosis, especially in young patients and in curettage. We report one case of CHEC in a 26-year-old woman which was misdiagnosed as a mullerian mixed tumor in the initial curettage specimen. The clinicopathologic, light microscopic, immunohistochemical features of this tumor are described and the differential diagnosis is discussed.\u003c/p\u003e","manuscriptTitle":"Corded and hyalinized endometrioid carcinoma: a rare case and review of the literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-09-22 16:44:39","doi":"10.21203/rs.3.rs-71402/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eceef69c-46cf-4c73-9a85-6ad0d59f160e","owner":[],"postedDate":"September 22nd, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":562644,"name":"Pathology"}],"tags":[],"updatedAt":"2020-09-29T11:54:52+00:00","versionOfRecord":[],"versionCreatedAt":"2020-09-22 16:44:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-71402","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-71402","identity":"rs-71402","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}