Rare endocervical tumour may be a diagnostic dilemma on Papanicolaou smear
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Transcript of Rare endocervical tumour may be a diagnostic dilemma on Papanicolaou smear
IMAGES IN CYTOLOGYSection Editor: Shahla Masood, M.D.
Rare Endocervical Tumour maybe a Diagnostic Dilemma onPapanicolaou SmearYashwant Kumar, M.D., D.N.B.,1* Anjali Bhutani, M.D.,1
and Seema Sharma, M.S.2
Cervical cancers with glandular component remain a
major challenge in gynaecologic cytopathology.1 This is
due to difficulty in interpreting the morphological abnor-
malities of glandular cells in Papanicolaou (Pap) stained
smears or because of sampling error of a neoplasm pri-
marily located in the endocervical canal. The glandular
component sometimes may be overlooked because of the
predominance of abnormal squamous cells as seen in ade-
nosquamous carcinoma.2 It is important to recognise these
glandular cells as they are associated with poorer progno-
sis than a tumour comprising purely of squamous cells.3
Here, we describe cytological features in a rare case of
endocervical carcinoma, which was a diagnostic problem
for the reporting cytopathologists.
A 48-year-old lady from North India presented with
complains of bleeding per vaginum and backache during
menstrual period for the duration of 2 weeks. On exami-
nation, an infiltrating endocervical growth was seen oblit-
erating the fornices. Clinically a malignancy was sus-
pected and a Pap smear was taken followed by cervical
biopsy. The air-dried Pap smear was examined independ-
ently by two cytopathologists. There were large number
of atypical epithelial cells arranged in clusters and few
lying discretely. The cells were of variable size with sig-
nificant atypia. Tumour diathesis was noted in the back-
ground. Therefore Pap smear was unanimously reported
as ‘‘positive for epithelial cell abnormality consistent with
carcinoma’’ by both the cytopathologists. Subtyping how-
ever was kept pending due to lack of consensus among
the two. One of them strongly believed it to be a squa-
mous cell carcinoma while other was in favor of reporting
it as an endocervical adenocarcinoma. When the biopsy
was examined it showed a tumour in the form of glands
with back to back arrangement. No squamous element
could be seen. The cervical biopsy therefore was signed
out as ‘‘endocervical adenocarcinoma.’’ Subsequently, a
radical hysterectomy with bilateral pelvic lymphadenec-
tomy was performed. On gross examination, the uterus
measured 9.5 3 5.0 3 3.2 cm with 3.5 cm length of cer-
vix. Right and left ovaries were 3.0 3 2.5 3 1.0 cm and
4.0 3 2.0 3 2.0 cm, respectively. Each fallopian tube
was 4.5 cm long. Serosal surface of the uterus was
smooth. On slicing, a growth measuring 3.0 3 3.0 3 2.0
cm was identified in the endocervical region. The growth
was located 1.3 cm proximal to cervical os and extending
up to the body-isthmus junction. The cut surface of the
growth was solid yellowish-white with infiltrative margins
(Fig. C-1). Maximum invasion was noted in the endocer-
vical region where it was just 3.0 mm from the peripheral
resection limit. The endomyometrial thickness was 1.7 cm
with no gross abnormality.
Microscopically, the tumour predominantly exhibited a
glandular configuration with back to back arrangement of
the glands and little intervening stroma (Fig. C-2a). In addi-
tion to these, the other areas showed sheets of malignant
cells typical of a squamous cell carcinoma. At places, the
above two components were noted in close proximity to
each other. Few tumour glands with both squamous and
adeno components within the same gland were also present
(Figs. C-2b and c). The squamous areas comprised nearly
20% of the tumour tissue. The pelvic lymph nodes did not
1Department of Pathology, Grecian Super speciality Hospital, Mohali,Punjab, India
2Department of Gynaecology and Obstetrics, Grecian Super specialityHospital, Mohali, Punjab, India
*Correspondence to: Yashwant Kumar, M.D., D.N.B., The Pine, nearAshiana Regency, Chhota Shimla, Shimla 171002, India.E-mail: [email protected]
Received 16 February 2010; Accepted 4 May 2010DOI 10.1002/dc.21465Published online 14 October 2010 in Wiley Online Library
(wileyonlinelibrary.com).
' 2010 WILEY-LISS, INC. Diagnostic Cytopathology, Vol 39, No 7 505
Figs. C-1–C2. Fig. C1. Gross photograph of the uterus showing an endocervical growth. Cut surface of the tumour is solid, yellowish-white and fri-able. Note the extension of the tumour into body-isthmus region above and ectocervix below. Fig. C2. A photomicrograph of endocervical tumourshowing features of adenosquamous carcinoma. Histology reveals: (a) A glandular component, (b) Areas with admixture of squamous and glandularpatterns, (c) Merging of both the components in a single focus (Haematoxylin and eosin). Cytological features recapitulating the histology: (d) Cellularsmear with clusters of epithelial cells forming a rosette like structure with central lumina [arrow], (e) Clusters of round to oval glandular cells. Malig-nant squamous cells noted in the vicinity are arranged in a sheet like configuration and show dark pyknotic nuclei [arrow], (f) Both glandular and squa-mous components can be seen merging with each other even in the smear (Pap staining).
KUMAR ET AL.
506 Diagnostic Cytopathology, Vol 39, No 7
Diagnostic Cytopathology DOI 10.1002/dc
show any evidence of tumour metastasis. Myometrium,
bilateral parametria, ovaries, and fallopian tubes were
grossly and microscopically free of tumour. The final report
therefore was given as adenosquamous carcinoma of endo-
cervical region.
The work up of the case would have been incomplete
without a retrospective analysis of cytological features and
their correlation with histopathology findings. The litera-
ture was therefore searched and the Pap smear was
reviewed by both the cytopathologists. On cytology the
majorities of the atypical epithelial cells were of glandular
origin and arranged in clusters with few squamous cells.
The glandular cells were small to medium-sized with a
high-nuclear cytoplasmic ratio, hyperchromatic nuclei,
irregular nuclear membrane and occasional conspicuous
nucleoli. Some of these were forming glandular structures
with central lumina (Fig. C-2d, arrow) while others were
arranged in sheets and showed crowding of nuclei with
overlapping or stratification (Fig. C-2e). Few single atypi-
cal glandular cells were also observed. The malignant
squamous cells were forming either sheets or lying singly.
They had marked anisonucleosis with scanty to moderate
amount of cytoplasm and dark pyknotic nuclei (Fig. C-2e,
arrow). In many areas both the patterns were found to be
merging with each other (Fig. C-2f). Background showed
inflammatory cells, RBCs, and nuclear debris. The other
features for atypical glandular component described in the
literature like feathered edges to endocervical cell groups,
loss of honeycomb pattern, and nuclear polarity were how-
ever not seen in the present case. Mitosis and tumour di-
athesis are generally present. Tight balls, syncytial groups,
papillae, or mucinous goblet cells, if present, may make
the interpretation particularly easy.4
Adenosquamous carcinoma is a rare subtype of cervical
cancer for which Pap smear screening may be less effi-
cient and glandular component may be easily missed.4 In
the present case, both the components were picked up but
by two different cytopathologists. During Histo-cyto cor-
relation it was noted that the Pap smear exactly recapitu-
lated the patterns observed on histopathology. To the best
of our knowledge the cytological features of a cervical
adenosquamous carcinoma have not been well described
in the literature. A greater awareness of the changing epi-
demiology and a careful approach while seeing the Pap
smear may help in recognition of this relatively rare sub-
type of cervical cancer.
References1. Kinney W, Sawaya G, Sung HY, et al. Stage at diagnosis and mor-
tality in patients with adenocarcinoma and adenosquamous carcinomaof the cervix diagnosed as a consequence of cytologic screening.Acta Cytol 2003;47:167–171.
2. Boon ME, Baak JPA, Kurver PJH, et al. Adenocarcinoma-in-situ ofthe cervix: An underdiagnosed lesion. Cancer 1981;48:768–773.
3. Yasuda S, Kojima A, Maeno Y, et al. Poor prognosis of patientswith stage IB1 adenosquamous cell carcinoma of the uterine cervixwith pelvic lymph node metastasis. Kobe J Med Sci 2006;52:9–15.
4. Hayes MMM, Matisic JP, Chen CJ, et al. Cytological aspects of uter-ine cervical adenocarcinoma, adenosquamous carcinoma and com-bined adenocarcinoma-squamous carcinoma: Appraisal of diagnosticcriteria for in situ versus invasive lesions. Cytopathology 1997;8:397–408.
ENDOCERVICAL TUMOUR MAY BE A DIAGNOSTIC DILEMMA
Diagnostic Cytopathology, Vol 39, No 7 507
Diagnostic Cytopathology DOI 10.1002/dc