Intestinal metaplasia with argentaffin cells in the uterine cervix

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.

Intestinal-type cervical adenocarcinoma in situ and adenocarcinoma exhibit a partial enteric immunophenotype with consistent expression of CDX2

Most cases of cervical adenocarcinoma in situ (AIS) and adenocarcinoma are of the usual or endocervical type. However, intestinal types of AIS and adenocarcinoma exist. With an intestinal-type adenocarcinoma in the cervix, the question may arise as to whether one is dealing with a primary cervical neoplasm or direct or secondary spread from an intestinal adenocarcinoma. In organs such as the ovary, urinary bladder, esophagus, and gallbladder, intestinal-type glandular epithelium often expresses enteric markers, but this has hardly been studied in the cervix. The purpose of this study was to investigate whether intestinal-type AIS and adenocarcinoma in the cervix express enteric markers and to ascertain whether these antibodies are of value in the distinction from a metastatic intestinal adenocarcinoma. We compared the immunophenotype of these lesions with that of usual-type AIS and adenocarcinomain the cervix. Cases included were AIS of usual type (n = 6), primary cervical adenocarcinoma of usual type (n = 6), AIS of intestinal type (n = 21), primary cervical adenocarcinoma of intestinal type (n = 3), primary cervical adenocarcinoma with signet ring cells (n = 2), and colorectal adenocarcinoma involving the cervix (n = 5). All cases were stained with cytokeratin (CK) 7, CK20, monoclonal carcinoembryonic antigen (CEA), p16, and CDX2. Staining was categorized as negative, focally positive (<50% cells), or diffusely positive (50% or more cells). Usual-type AIS was always diffusely CK7 positive, typically diffusely CEA and p16 positive, and always CK20 negative. CDX2 was positive in 1 case. All usual cervical adenocarcinomas were diffusely CK7 and p16 positive, and all were immunoreactive with CEA. Five and 2 cases were CK20 and CDX2 positive, respectively. Intestinal-type AIS was diffusely CK7 positive (all cases) and typically CK20 negative and diffusely CEA and p16 positive. All but 1 case exhibited diffuse nuclear positivity with CDX2. In addition, usual-type AIS adjacent to intestinal type was CDX2 positive in 13 of 21 cases. The 3 cases of primary cervical intestinal-type adenocarcinoma were diffusely CK7 positive, focally or diffusely positive with CK20 and CDX2, and focally positive with CEA. One case was diffusely p16 positive, 1 focal and 1 negative. The foci of signet ring cells in the 2 primary cervical adenocarcinomas were diffusely CK7 and p16 positive and negative with CK20 and CDX2. Colorectal adenocarcinomas involving the cervix were typically diffusely positive with CK20, CEA, and CDX2; negative with CK7; and negative or focally positive with p16. Intestinal types of cervical AIS and adenocarcinoma exhibit a partial enteric immunophenotype, usually with diffuse expression of CDX2 and, in some cases, staining with CK20. They maintain their CK7 immunoreactivity and are usually p16 positive. Although there is immunophenotypic overlap, focal staining with CK20 together with diffuse CK7 and sometimes p16 positivity helps to distinguish intestinal types of cervical adenocarcinoma from involvement by a colorectal adenocarcinoma; CEA and CDX2 are of no value in this regard. CDX2 positivity in usual-type AIS adjacent to intestinal type and in occasional cases of pure usual-type AIS may be a reflection of early intestinal differentiation before this is morphologically apparent. Using a set of cases of AIS diagnosed in a single institution over a 7-year period (77 usual type; 13 intestinal type), intestinal type was more likely to be associated with early invasive adenocarcinoma than usual type (31% vs 17%), suggesting that intestinal differentiation may be a risk factor for invasion in premalignant cervical glandular lesions.

Primary Cervical Adenocarcinoma With Intestinal Differentiation and Colonic Carcinoma Metastatic to Cervix: An Investigation Using Cdx-2 and a Limited Immunohistochemical Panel

Context.—Cdx-2 is expressed in normal colonic epithelia and in most colorectal adenocarcinomas. No data exist on Cdx-2 expression in primary cervical adenocarcinoma with colonic differentiation.

Objective.—To ascertain the utility of Cdx-2 and a limited immunohistochemical panel in differentiating between primary cervical adenocarcinoma with intestinal differentiation and secondary (colonic) cervical adenocarcinoma, which call for different surgical and chemotherapeutic treatment protocols.

Design.—We examined cervical tract adenocarcinomas in women with previously negative medical histories for neoplastic disease and in women with colonic carcinoma. An immunohistochemical panel consisting of cytokeratin 7, cytokeratin 20, carcinoembryonic antigen, and a new marker, Cdx-2, was evaluated in all cases. The clinical data, the morphologic features, and the immunohistochemical staining patterns were compared.

Results.—Of the tumors diagnosed as metastatic intestinal adenocarcinoma of the cervix, based on clinical data and hematoxylin-eosin–stained sections, all were Cdx-2 positive, whereas Cdx-2 was not expressed in any of our cases of primary cervical adenocarcinoma with colonic differentiation. Carcinoembryonic antigen was expressed both in primary cervical tumor and in secondary (intestinal) cervical adenocarcinoma. Cytokeratin 20 was not expressed in our cases of cervical adenocarcinoma, and it was not expressed in 7.15% of cervical metastases from intestinal carcinoma. Immunostaining with cytokeratin 7 was positive in cervical adenocarcinoma, but was negative in secondary (intestinal) cervical adenocarcinoma.

Conclusions.—Our immunohistochemical analysis shows that Cdx-2 has good specificity and would be a good marker to use in a limited panel of immunohistochemical markers, such as cytokeratin 7, cytokeratin 20, and carcinoembryonic antigen, to distinguish primary cervical adenocarcinoma from intestinal metastases to the cervix.

Endocervical glandular lesions: controversial aspects and ancillary techniques

The incidence of malignant and premalignant endocervical glandular lesions is increasing. This review covers controversial and difficult aspects regarding the categorisation and diagnosis of these lesions. The terminology of premalignant endocervical glandular lesions is discussed because of the differences between the UK terminology and the widely used World Health Organisation classification. The morphology and histological subtypes of premalignant endocervical glandular lesions are described. Early invasive adenocarcinoma and difficulties in the diagnosis and recognition of this entity are covered, as is the measurement of early invasion within cervical adenocarcinoma. Several benign endocervical glandular lesions can mimic malignant and premalignant endocervical glandular lesions, and the distinction of these benign mimics from premalignant and malignant lesions using ancillary immunohistochemical studies is also covered. Antibodies used to distinguish between endometrial and endocervical adenocarcinoma, in the diagnosis of cervical minimal deviation adenocarcinoma of mucinous type (adenoma malignum), and in the diagnosis of cervical mesonephric lesions are also reviewed.

[In situ adenocarcinoma of the uterus cervix: difficulties of its cytohistological diagnosis]

In situ adenocarcinoma is regarded as the precursor of invasive adenocarcinoma. It is asymptomatic and early diagnosis relies solely on cytopathologist. It is usually discovered on a cone for squamous CIN. When diagnosis is made by biopsy, conisation is required to exclude invasive adenocarcinoma. Lesion is histologically characterised by epitheliomatous transformation of endocervical glands without invasion of the chorion. By the appearance of glandular cells, different histological varieties are described. They have no influence on the prognosis. Several benign lesions may mimic adenocarcinoma: tubal metaplasia, glandular atypia due to inflammation or irradiation, mesonephric remnants and microglandular hyperplasia. Precursor lesions (atypical hyperplasia, glandular dysplasia, CIGNI and II) are badly morphologically defined. Preferential location of in situ adenocarcinoma is the transformation zone. Because of this topography, if the surgical margins are disease free, conisation alone may be adequate therapy. HPV infection (mainly HPV 18) are incriminated in its pathogenesis.

Primary vaginal adenocarcinoma of intestinal type arising from an adenoma: case report and review of the literature

A 1 cm polypoid lesion was encountered on the posterior vaginal wall in a 56-year-old woman with no history of diethylstilbestrol exposure that on microscopic examination was a moderately differentiated adenocarcinoma of intestinal type. The tumor was cytokeratin 20 and carcinoembryonic antigen positive and negative for cytokeratin 7. Mucin histochemistry demonstrated the presence of o-acetylated sialomucin, a specific marker of large intestinal differentiation. The initial interpretation favored a metastasis from a colonic adenocarcinoma, but clinical investigations showed no evidence of a primary gastrointestinal lesion. The morphology, histochemical, and differential cytokeratin profile led to the lesion being reinterpreted as a primary intestinal-type adenocarcinoma of the vagina arising from a tubular adenoma. Although a very rare tumor, awareness of this lesion is important as it must be distinguished from metastatic adenocarcinomas from other sites.

Endocervical metaplasias and their association with glandular and squamous abnormalities

OBJECTIVE

The presence of endocervical metaplasias and their association with cervical squamous and glandular neoplasias were studied.

MATERIALS AND METHODS

Cervical specimens were examined microscopically to identify the presence of glandular metaplasias. The type of cervical neoplastic abnormality, when present, also was recorded. Statistical analyses of the microscopical findings included frequency observation counts and contingency analysis (Fisher's exact test).

RESULTS

One hundred eighty-seven cervices were examined. Diagnoses included adenocarcinoma (8), adenocarcinoma in situ (14), glandular dysplasia (4), squamous carcinoma (2) and cervical intraepithelial neoplasia (78); 4 cervices had combined squamous and glandular abnormalities. Eighty-seven had no evidence of cervical neoplasias. The glandular metaplasias were tubal (79 ciliated cell, 3 eosinophilic cell) and intestinal (22); 14 cases had combined tubal and intestinal metaplastic change. Ninety-seven cervices had no evidence of glandular metaplasia. Intestinal metaplasia was intimately associated (p = .0002) with neoplastic changes, particularly glandular abnormalities. Ciliated cell metaplasia also was associated with glandular or squamous abnormalities (p < .04), but more than one-third of specimens with this metaplasia had no associated abnormality.

CONCLUSIONS

A high degree of association exists between cervical intestinal glandular metaplasia and cervical glandular and squamous neoplasias. Patients with this metaplastic change should be followed up closely if no associated lesion is found initially.

Mucinous adenocarcinoma of the endometrium with intestinal differentiation: a case report

Mucinous differentiation of endocervical type has been well documented in endometrial carcinoma. However, we describe an unusual case of adenocarcinoma of the endometrium showing diffuse histological, immunohistochemical, and ultrastructural evidence of intestinal differentiation. Although intestinal differentiation has been described in mesodermally derived tissues including endocervix, ovary, and urinary tract, it has not been reported in normal endometrium. One previous case has been reported showing this pattern in endometrial carcinoma. Possible histogenetic mechanisms of this pattern are discussed.

Intestinal metaplasia in stilboestrol-induced vaginal adenosis

We present an unusual case of vaginal adenosis with progressive intestinal metaplasia, previously undescribed, in a female patient exposed to stilboestrol in utero. Argentaffin cells were present within these areas, a feature not previously reported in benign vaginal adenosis. The development of the intestinal metaplasia coincided with the onset of a vaginal discharge so severe that, after 7 years, a vaginal resection was performed. Intestinal-type glands have been described in the cervix and ovary, almost invariably associated with malignancy. The possible role of intestinal metaplasia in the development of enteric-type neoplasms of the vagina is discussed.

Unusual endocervical lesions with endocrine cells

Four cases of unusual lesions of endocervix are presented. They were all incidental findings, showing no obvious infiltrative and metastatic properties to attest their malignant nature. Two lesions were entirely confined to the endocervical mucosa. The main characteristics of these proliferative processes thus were an abnormal architecture with branched or small glands, a hypermucinous benign-appearing epithelium of endocervical type, and stromal smooth-muscle. In contrast with normal endocervical mucosa, all lesions contained prominent and variegated endocrine cells. These 4 cases were quite comparable to 3 other observations previously reported. This homogeneous group of endocervical lesions does not correspond to a well-defined type of endocervical neoplasia. It shares morphological analogies with adenoma malignum. The relationship with adenoma malignum as well as with some other gynaecological neoplasms is discussed. The recognition of these small-sized and highly differentiated lesions is largely facilitated by the use of the Grimelius reaction to detect argyrophilic cells.

Nucleolar organizer regions in benign and malignant glandular lesions of the cervix

The argyrophil technique for nucleolar organizer regions was applied to cases of normal cervix (n = 6), microglandular hyperplasia (n = 6), adenocarcinoma in situ (n = 15), and invasive adenocarcinoma of the cervix (n = 19). A rigorous staining technique was employed which facilitated the enumeration of individual AgNORs even when they were aggregated as tight clusters within the nucleolus (AgNUs). Two methods of counting AgNORs were used: a simple enumeration of dispersed AgNORs and AgNUs, and the more time-consuming counting of all individual AgNORs, including those within AgNUs. With both techniques, there was no significant difference in counts between in situ and invasive adenocarcinoma, but cases of microglandular hyperplasia showed significantly fewer AgNORs than either of these. This suggests that AgNORs may be useful in differentiating difficult cases of microglandular hyperplasia from adenocarcinoma and that the simplified counting technique is adequate for this purpose. AgNOR counts are of no use in discriminating between invasive and in situ adenocarcinoma.

Enteric tumours of the lower female genital tract: a report of three cases

Three enteric-type neoplasms of the lower female genital tract are described; an enteric adenocarcinoma of the cervix, an enteric adenocarcinoma of the vagina and a tubulo-villous adenoma of the vagina. The two adenocarcinomas were characterized by the presence of columnar cells with a prominent brush border and an abundance of goblet cells. The tubulovillous adenoma was identical to similar lesions found in the large intestine. The criteria for diagnosis of an enteric adenocarcinoma of the female genital tract are discussed and it is concluded that the histochemical demonstration of o-acetylated sialomucin is the most specific marker of intestinal differentiation. It is suggested that enteric tumours of the cervix arise from foci of gastrointestinal metaplasia. Enteric tumours of the vagina are more likely to develop from cloacal remnants.

Glandular lesions of the uterine cervix: the present state of our knowledge

The assessment of squamous lesions of the uterine cervix is a major preoccupation of diagnostic histopathologists and this can overshadow the recognition of significant abnormalities affecting the adjacent endocervical glands. This review gives an account of recent advances in our knowledge of the histology and histochemistry of endocervical glands. The review of benign lesions concentrates on those that continue to cause diagnostic difficulty. Adenocarcinoma in situ, lesser degrees of possibly pre-malignant cervical glandular atypia and histological subtypes of adenocarcinoma are outlined. The increasing awareness that glandular and squamous lesions often co-exist is emphasized. Finally, adenocarcinoma metastatic to the cervix is discussed.

Cervical glandular atypia associated with squamous intraepithelial neoplasia: a premalignant lesion?

Recent studies have described premalignant changes in the endocervical epithelium, but morphological criteria for the diagnosis of cervical glandular atypia of lesser severity than adenocarcinoma in situ have not been established. Adenocarcinoma in situ is often associated with cervical intraepithelial neoplasia (CIN). The endocervical mucosa in 105 cases of CIN grade III was evaluated and compared with that of 100 controls. Sixteen cases of cervical glandular atypia and one case of adenocarcinoma in situ were identified, and it was possible to discriminate between these and a range of benign glandular lesions. Interestingly, the control series included two patients with cervical glandular atypia, one of whom on review had had a cone biopsy for CIN. The progression of cervical glandular atypia through adenocarcinoma in situ to invasive adenocarcinoma is known, but the natural history of cervical glandular atypia is as yet uncertain.

Unusual endocervical polypoid tumor with endocrine cells: an immunohistochemical and ultrastructural analysis

Light microscopic, immunohistochemical, and ultrastructural features of an unusual polypoid tumor of endocervix are reported. Numerous polypeptide hormone and amine-producing endocrine cells were disclosed. Main conventional characteristics were the architectural growth pattern, with infolding glands giving rise to small secondary glands, the hypermucinous benign-appearing epithelium of endocervical type, and, possibly, the stromal smooth muscle. Ultrastructural analysis showed a highly differentiated tumor. Glandular elements were surrounded by a basal lamina. Mucinous cells, several endocrine cell types, amphicrine cells, nonsecretory ciliated cells, ciliated mucinous cells, and possible reserve cells were observed. This tumor departs appreciably from normal mucosa and common varieties of endocervical polyp, particularly its distinctive endocrine profile. The present case does not correspond to a well-defined type of endocervical neoplasia. It shares morphologic analogies with mucinous tumor of ovary. The malignant potential of this lesion as well as its relationship with minimal deviation adenocarcinoma remain questionable.