Arias-Stella reaction of the endocervix: a report of 18 cases with emphasis on its varied histology and differential diagnosis

Screening for Cervical Cancer in Pregnancy

Cervical cancer remains a leading cause of cancer related morbidity and mortality in low/low-middle income countries. Lack of screening is the leading cause of cases being diagnosed in advanced stages and screening is still opportunistic in a majority of these countries. Hospital visits during pregnancy provides a window of opportunity to screen these susceptible women and reduce the burden of disease. Screening women during pregnancy is not practiced widely due to concerns of pregnancy loss, bleeding and a lack of clear information among patients as well as healthcare professionals.

Navigating through perplex morphologic changes after exogenous hormone usage

Clinical application of exogenous hormone as a method of contraception and/or treatment of various gynecologic disorders is exceedingly common. Unfortunately, the concurrent use of these agents also complicates the interpretation of pathology specimens. Various studies have shown that morphologic changes induced by hormonal therapies are present in both non-neoplastic and neoplastic tissues within the women's reproductive tract. It is important to understand the exogenous hormone induced morphologic changes, as it helps the pathologists make the accurate diagnosis, and in turn, guide clinicians to make optimal clinical decisions. In this review, we summarize the morphologic changes in both neoplastic and non-neoplastic endometrial, cervical, and myometrial surgical specimens after hormonal therapies, particularly after progestin treatment. In the endometrium, particularly in the scenario of progestin-treated atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia (AEH/EIN), there is notoriously poor interobserver agreement and difficulty in assessing for the residual disease. We summarize current literature and propose our recommended approach in assessing these challenging endometrial biopsies, including a diagnostic algorism, the use of PAX-2, PTEN, beta-catenin immunohistochemistry panel, as well as consistency in diagnostic wording of the report. In the cervix, progestin makes dysplastic lesions appear metaplastic, thus high-grade squamous dysplastic lesions may be easily missed. Within the myometrium, lesions such as adenomyosis may show various degree of decidualization, while smooth muscle neoplasms may show apoplectic changes, and stromal lesions including endometrial stromal sarcoma may show more eosinophilic cytoplasm. All such changes may pose more or less diagnostic challenges in our daily practice. However, most are readily recognizable when we understand particular hormone related scenarios.

Recent advances in invasive adenocarcinoma of the cervix

Endocervical adenocarcinomas (ECAs) are currently classified according to the 2014 World Health Organization (WHO) system, which is predominantly based on descriptive morphologic characteristics, considers factors bearing minimal etiological, clinical, or therapeutic relevance, and lacks sufficient reproducibility. The 2017 International Endocervical Adenocarcinoma Criteria and Classification (IECC) system was developed by a group of international collaborators to address these limitations. The IECC system separates ECAs into two major groups-those that are human papillomavirus-associated (HPVA) and those that are non-HPV-associated (NHPVA)-based on morphology (linked to etiology) alone, precluding the need for an expensive panel of immunohistochemical markers for most cases. The major types of HPVA ECA include the usual (with villoglandular and micropapillary architectural variants) and mucinous types (not otherwise specified [NOS], intestinal, signet-ring, and invasive stratified mucin-producing carcinoma). Invasive adenocarcinoma NOS is morphologically uninformative, yet considered part of this group when HPV positive. NHPVA ECAs include gastric, clear cell, endometrioid, and mesonephric types. The IECC system is supported by demographic and clinical features (HPVA ECAs develop in younger patients, are smaller, and are diagnosed at an earlier stage), p16/HPV status (almost all HPVA ECAs are p16 and/or HPV positive), prognostic parameters (NHPVA ECAs more often have lymphovascular invasion, lymph node metastases, and are Silva pattern C), and survival data (NHPVA ECAs are associated with worse survival). A move from the morphology-based WHO system to the IECC system will likely provide clinicians with an improved means to diagnose and classify ECAs, and ultimately, to better personalize treatment for these patients.

Endocervical Polyp With Florid "Epidermal Metaplasia": Report of a Previously Undescribed Phenomenon

Endocervical polyps are common benign lesions which rarely result in diagnostic problems, although a variety of alterations occasionally complicate histologic interpretation. We report an unusual, and not previously described, finding of florid "epidermal" metaplasia with keratinization and extensive formation of skin appendages structures (sebaceous and sweat glands and hair follicles) within an endocervical polyp. The features closely resembled an epidermal inclusion cyst. We speculate on the possible pathogenesis of this rare phenomenon and review unusual findings in endocervical polyps.

The spectrum of cervical glandular neoplasia and issues in differential diagnosis

CONTEXT

Premalignant and malignant glandular lesions of the cervix are known to often cause diagnostic problems with a variety of benign (more common) as well as other malignant mimics, the latter setting often being represented by secondary involvement by endometrioid endometrial carcinoma especially in small samplings.

OBJECTIVE

To highlight key histologic features and immunohistochemical markers that may be helpful in the distinction of in situ endocervical carcinoma from benign glandular proliferations, and those that separate different subtypes of invasive endocervical carcinoma, as well as invasive carcinoma from other carcinomas secondarily involving the cervix and nonneoplastic proliferations of the cervix.

CONCLUSIONS

Clinical and morphologic features as well as immunohistochemistry results should be used in conjunction in the differential diagnosis of glandular proliferations of the cervix, as correct interpretation has major clinical consequences for the patient in most instances (especially benign versus malignant). Immunohistochemical markers should be used as part of a panel of antibodies, as exceptions may occur to the usual pattern of staining, and if used singly, they may mislead the pathologist to establish a wrong diagnosis.

Conservative Treatment of Stage IA1 Adenocarcinoma of the Uterine Cervix during Pregnancy: Case Report and Review of the Literature

Microinvasive adenocarcinoma (MIAC) of the uterine cervix is rare in pregnancy. Published data on conservative treatment of MIAC both in pregnant and nonpregnant women are scarce. A conservatively treated case of MIAC in a 13-week-pregnant woman after a diagnosis of atypical glandular cells (AGC) on pap smear at the 6th week of pregnancy is presented. The problems of suspected adenocarcinoma in situ (AIS) on biopsy and MIAC on cone biopsy in pregnancy, as well as the risks and benefits of a conservative treatment are discussed. After colposcopic guide laser cervical conization and expression of informed consent the patient underwent followup and vaginal delivery at 40 weeks plus 3 days of gestation. In this case, no obstetric complication has been recorded after the cervical conization, and after a followup of 18 months the patient was alive and free of disease, with negative results as far as pap smear, colposcopy, HPV status, and cervical curettage are concerned. In a stage Ia1 disease of endocervical type, with clear margins and without lymph-vascular space invasion, cervical conization performed during the second trimester may be considered a definitive and safe treatment, at least up to delivery, after expression of informed consent by the woman.

Arias-Stella reaction of the cervix: The enduring diagnostic challenge

Background:

The Arias-Stella reaction is a hormone-related atypical endometrial change characterized by hypertrophy and vacuolization of glandular epithelial cells, associated with marked nuclear pleomorphism, enlargement, and hyperchromasia. When presenting in extra-uterine sites, the differentiation of Arias-Stella changes from other more ominous clear cell lesions may pose significant difficulties.

Case Report:

We report a case of an endocervical clear cell lesion incidentally discovered during a prenatal visit of a young pregnant woman. Interpretation of the pathological findings was complicated by the small size and fragmentation of the specimen.

Conclusions:

Recognition of Arias-Stella reaction in extra-uterine sites, especially in young women, is critical to avoid misdiagnosis of this innocuous lesion as clear cell adenocarcinoma. Attention to cellular and nuclear detail, as well as careful consideration of the clinical scenario, is crucial for establishment of the correct diagnosis.

IGFBP-1 is expressed specifically in ovarian clear cell adenocarcinoma

AIMS

To investigate the specific expression of insulin-like growth factor binding protein-1 (IGFBP-1) in ovarian clear cell adenocarcinoma (CCA).

METHODS AND RESULTS

Immunohistochemistry and in situ hybridization for IGFBP-1 were performed in normal endometrium, placenta, and 100 surgically resected cases of ovarian cancer including 31 CCAs and 69 non-CCAs. Immunohistochemistry for hepatocyte nuclear factor-1 (HNF-1β) was also examined in all cases. Specific expression of IGFBP-1 was confirmed in secretory endometrium, decidua of placenta and Arias-Stella glands of miscarriage material. Among ovarian cancers, almost all cases of CCA showed expression of both IGFBP-1 protein and mRNA, but non-CCA hardly expressed IGFBP-1. There was a significant difference between CCA and non-CCA in the expression of IGFBP-1 protein and mRNA. No correlation was found between the rate of IGFBP-1 expression and pathological T and N factors of the tumour-node-metastasis (TNM) classification. All CCA cases except for one exhibited expression of HNF-1β protein, whereas only 15.9% of non-CCAs did so.

CONCLUSION

The expression of IGFBP-1 in CCA is more specific than that of HNF-1β. IGFBP-1 shows expression by decidual endometrium and Arias-Stella glands, and CCA also exhibits characteristic expression. These results indicate that IGFBP-1 is a immunohistochemical marker for CCA.

Arias-Stella reaction as a diagnostic pitfall in a bladder biopsy with endometriosis: case report and review of the pseudoneoplastic bladder lesions

Arias-Stella reaction is a hormone-induced atypical endometrial change that may involve endometrial, extraendometrial, or endometriotic sites. Establishing a correct diagnosis of Arias-Stella reaction may sometimes be problematic when seen outside of the uterine corpus, particularly in a limited biopsy sample when the pathologist is not aware of the clinical history. We report an Arias-Stella reaction in bladder endometriosis, which presented as a bladder mass in a 25-year-old pregnant woman. Clinical information of intrauterine pregnancy (week 16) was not initially provided when the biopsy was performed. We also discuss endometriosis, endocervicosis, and müllerianosis of the bladder, which are benign glandular lesions that may mimic tumors within the bladder wall.

Minimal uterine serous carcinoma: current concepts in diagnosis and prognosis

Uterine serous carcinoma (USC) is an aggressive type of endometrial cancer with a propensity to have extra-uterine spread at diagnosis, in some cases despite limited involvement of the uterus. Serous endometrial intra-epithelial carcinoma (EIC) is a recently recognised entity with the same cytological features and p53 mutations as USC, but it does not demonstrate stromal or myometrial invasion. In addition to representing the putative precursor to USC, the pure form of serous EIC may also be associated with extra-uterine tumour at the time of diagnosis and with risk for recurrence, spread, and eventual death from tumour. Current evidence indicates that serous EIC is a form of minimal USC with behaviour that is stage dependent, thereby necessitating complete surgical staging despite limited disease in the uterus. We review the diagnostic criteria for minimal USC, pitfalls in the differential diagnosis, and discuss a practical approach to evaluating biopsies, polypectomies, or hysterectomies containing minimal USC.

Arias-Stella reaction in upper genital tract in pregnant and non-pregnant women: a study of 120 randomly selected cases

AIMS

1. To study the diagnostic importance of the Arias-Stella reaction. 2. To study tubal epithelial changes in ectopic pregnancy. 3. To study the occurrence of Arias-Stella reaction in non-pregnant women receiving hormonal treatment.

METHODS

A prospective study was conducted on 120 patients who underwent endometrial curettage and/or salpingectomy. The patients were divided into four groups, each comprising of 30 patients. Groups 1 and 4 included non-pregnant patients who were being evaluated for infertility and dysfunctional uterine bleeding respectively, while pregnant patients were included in Group 2 (intra-uterine abortions) and Group 3 (ectopic tubal gestation). The endometrial curettings and fallopian tube lining epithelial cells were examined for the changes described by Arias-Stella. Cases which showed the presence of the Arias-Stella reaction were further classified.

RESULTS

The changes of the Arias-Stella reaction in endometrial glands were observed in 80% cases of intra-uterine abortions. Secretory/hypersecretory pattern was the most commonly observed type (36.67%). The reaction was seen in 3.33% each of patients evaluated for infertility and patients on hormonal therapy with oral progestational agents for the management of dysfunctional uterine bleeding. Although uncommon, the Arias-Stella reaction was noted in the epithelium of fallopian tubes (16.67%) from patients with ectopic tubal gestation.

CONCLUSION

The findings of the present study emphasize the diagnostic importance of the Arias-Stella reaction. The changes of the reaction are a histological clue to the presumptive diagnosis of the presence of chorial tissue in cases in which the chorionic material is not found in the endometrial biopsy. The morphological features can be mistaken for malignancy if the pathologist is not aware of the patient's pregnancy or history of hormonal intake.

Pseudoinfiltrative Tubal Metaplasia of the Endocervix: A Potential Form of In Utero Diethylstilbestrol Exposure-Related Adenosis Simulating Minimal Deviation Adenocarcinoma

We report three cases of unusual tubal-type endocervical glandular proliferations simulating minimal deviation adenocarcinoma in women with a history of in utero diethylstilbestrol (DES) exposure. The lesions were characterized by haphazard glandular proliferations extending from 3.4 to 6.1 mm into the endocervical stroma and to the margins of excision in all cases. Most of the glands were small to medium-sized and round; some exhibited a moderate degree of cystic dilatation, and occasional glands had curvilinear profiles. The glandular epithelium displayed extensive tubal-type differentiation in all cases. In two cases, the glands lacked cytologic atypia and mitotic activity, and in one case, there was mild to moderate nuclear atypia with occasional mitotic activity. Immunohistochemical studies showed diffuse expression of estrogen and progesterone receptors and essentially no expression of p16 in two cases tested; there was no expression of CD10 in one case that was tested. The Ki-67 proliferation index was zero in one case and 25% in another. Human papillomavirus DNA was not detected by in situ hybridization in one case that was tested. The proliferations lacked features of mucinous and tubo-endometrioid types of minimal deviation adenocarcinoma. The clinicopathologic findings suggest the lesions are benign, and the association with in utero DES exposure raises the possibility that these could be a form of DES-related adenosis.

Multinucleated epithelial giant cells in colorectal polyps: a potential mimic of viropathic and/or dysplastic changes

Multinucleated epithelial giant cells (MEG) simulating viral cytopathic effect and/or dysplasia have been reported in the esophagus in association with inflammation, but the occurrence of similar cells in the colon has not been documented. Twenty-three colon specimens (22 biopsies and 1 partial colectomy) featuring MEG from 21 patients were evaluated for a variety of histologic features and correlated with clinical, endoscopic, and follow-up data. Patients included 9 males and 12 females (mean age, 64.9 years; range, 45-86 years). Eleven cases were obtained from 10 asymptomatic patients undergoing surveillance biopsies. Presenting symptoms in the remaining patients were dyspepsia, anemia, abdominal pain, and hematochezia. Over half (13 of 23) of the specimens were from descending and rectosigmoid colon, and almost all were visualized as polyps on endoscopy. Microscopically, all but 1 of the cases featured multiple MEG (range, 6 to >50 cells per biopsy) in the base and mid crypt zones of inflamed polyps with serrated architecture. Immunohistochemical stains for CMV, HSV, adenovirus, EBV, and polyoma virus were negative and no viral particles were identified on ultrastructural examination. Nuclear staining for hMLH1 and hMSH2, markers of microsatellite instability, was similar in distribution to adjacent serrated crypts, but reduced staining intensity was noted in occasional multinucleated cells. Expression of Ki-67 and cleaved caspase 3 was consistent with a quiescent or low proliferative state. Clinical follow-up was available for 9 patients (mean duration, 22.7 months). One patient died of heart failure; all others were well at last follow-up. Bizarre MEG may occasionally be seen within the crypts of inflamed polyps with serrated architecture, raising concern for dysplasia or viral infection. Immunohistochemical and ultrastructural studies fail to establish a viral etiology, and follow-up does not indicate clinically aggressive disease. These changes appear to represent a nonspecific, possibly degenerative response to inflammation and injury, and should be distinguished from dysplasia.