Adenoid basal lesions of the uterine cervix: evolving terminology and clinicopathological concepts

Cervical Adenoid Basal Carcinoma With High-grade Squamous Component: True Mixed Carcinoma or Colonization of Adenoid Basal Carcinoma by High-grade Squamous Intraepithelial Lesion?

Adenoid basal carcinoma (ABC) is a rare clinically indolent human papillomavirus-associated cervical neoplasm with uniformly bland morphology which in pure form does not metastasize. Many cases co-exist with a human papillomavirus-associated high-grade squamous intraepithelial lesion (HSIL) or squamous cell carcinoma (SCC). The ABC and high-grade squamous components may be clearly separate, albeit intermingled, and when the high-grade squamous component is invasive, the tumor is designated a mixed carcinoma, with clinical behavior determined by the non-ABC component. In other cases, discrete nests of high-grade atypical squamous cells are intimately admixed and incorporated within the ABC. These are more difficult to classify but are also usually reported as mixed carcinomas. Herein, we report a series of 9 cases of ABC in patients aged 33 to 89 years (mean age: 63 y) with a high-grade squamous component. In 7 cases, the high-grade squamous cells partly replaced and expanded the nests of ABC, sometimes with a residual cuff of ABC cells, while in the other 2 cases the ABC and SCC were clearly separate. We propose that the aforementioned 7 cases represent colonization of ABC by HSIL rather than mixed carcinomas; as far as we are aware, this concept has not been proposed before. In all cases which we feel represent colonization of ABC by HSIL, the tumors were confined to the cervix (stages IA1 [3 tumors], IA2 [2 tumors], IB1 [2 tumors]) and follow-up was unremarkable with no evidence of metastasis. One case with separate components of ABC and SCC was stage IVA at diagnosis and the patient died of disease. The other was stage IB1 at diagnosis and the patient died of unrelated causes at 13 months. We discuss the clinical implications of distinguishing true mixed carcinomas from colonization of ABC by HSIL and provide an approach to diagnosis. We also report a unique case of colonization of so-called cervical ectopic prostatic tissue by HSIL.

Adenoid Basal Carcinoma with Adenoid Cystic Carcinoma Component of the Uterine Cervix: A Case Report and Literature Review

Adenoid basal carcinoma (ABC) is rare cancer with a favorable prognosis. However, some ABCs are associated with other histological types, such as squamous cell carcinoma. Here, we present a case of a mixed tumor of ABC and adenoid cystic carcinoma (ACC) of the cervix, with a detailed immunohistochemical study and literature review. We describe a case of a 66-year-old woman who underwent cervical cancer screening that led to the detection of a 0.7 cm nodular lesion. Cervical punch biopsies revealed a high-grade squamous intraepithelial lesion. Cervical conization revealed a mixed carcinoma composed of ABC and ACC, showing stromal invasion, lymphovascular invasion, and positive resection margins. Immunohistochemically, the ACC components were positive for KIT and αSMA and negative for NKX3.1. The tumor presented with proficient mismatch repair (MMR) and was negative for HER2, PD-L1, and TRKA (NTRK1). Subsequent radical hysterectomy with pelvic lymph node dissection revealed the presence of residual tumor cells in the cervix. Our literature review identified six similar cases, including one patient who died of disease recurrence. We report a rare tumor comprising both ABC and ACC. Prognostic data on mixed tumors are scarce; however, given the aggressive nature of ACC, attention should be paid to the detection of mixed tumors. Since ABC and ACC histology may overlap, adequate sampling and IHC for detecting ACC would be helpful.

Skene's Gland Derivatives in the Female Genital Tract and Cervical Adenoid Basal Carcinoma are Consistently Positive With Prostatic Marker NKX3.1

Cervical ectopic prostatic tissue and vaginal tubulosquamous polyp are rare lesions which exhibit variable, and often focal, immunohistochemical expression with traditional prostatic markers [prostate-specific antigen and prostatic acid phosphatase (PSAP)]. These lesions are thought to arise from periurethral Skene's glands, the female equivalent of prostatic glands in the male. Adenoid basal carcinoma is a rare and indolent cervical neoplasm. Expression of the prostatic marker NKX3.1 in ectopic prostatic tissue and tubulosquamous polyp has been reported but no studies have examined immunoreactivity with this marker in adenoid basal carcinoma. We stained 19 cases [adenoid basal carcinoma (n=6), cervical ectopic prostatic tissue (n=11), and vaginal tubulosquamous polyp (n=3); 1 case contained both adenoid basal carcinoma and ectopic prostatic tissue] with NKX3.1. In all cases, the glandular component of these lesions exhibited diffuse nuclear immunoreactivity while normal endocervical glands were negative. Prostate-specific antigen was positive in 4 of 9 and 0 of 3 cases of ectopic prostatic tissue and tubulosquamous polyp, respectively, while PSAP was positive in 3 of 4 and 2 of 2 cases of ectopic prostatic tissue and tubulosquamous polyp respectively; 3 of 5 cases of adenoid basal carcinoma tested were focally positive with PSAP and all 5 were negative with prostate-specific antigen. While the specificity of NKX3.1 should be investigated in future studies, positivity with this marker may be useful in diagnosing these uncommon lesions. NKX3.1 appears a more sensitive marker of ectopic prostatic tissue and tubulosquamous polyp than traditional prostatic markers and positive staining provides further support that these lesions exhibit "prostatic" differentiation and are of Skene's gland origin. NKX3.1 and PSAP positivity in adenoid basal carcinoma raises the possibility of an association with benign glandular lesions exhibiting prostatic differentiation and we critically discuss the possible association.

Carcinomas of the Uterine Cervix: Comprehensive Review With An Update on Pathogenesis, Nomenclature of Precursor and Invasive Lesions, and Differential Diagnostic Considerations

Most cervical carcinomas and their related lesions are attributed to an infection by human papillomavirus (HPV). The infection usually starts in the basal cells at the squamocolumnar junction. It causes cell proliferation and maturation abnormalities along with nuclear abnormalities resulting in low-grade squamous intraepithelial lesions. An overwhelming majority of these lesions spontaneously disappear, and the infection is cleared. In a small subset of high-risk HPV infection cases, the lesions may persist and progress to high-grade squamous intraepithelial lesions. These are associated with the incorporation of the viral genome into the human genome. Some of the high-grade squamous intraepithelial lesions, over several years, progress to invasive carcinoma. Carcinomas of the cervix are usually squamous cell carcinomas (SCCs), but 20% to 25% of the cases may manifest as adenocarcinomas. Similar to SCC, adenocarcinomas may initially manifest as adenocarcinomas in situ and may progress to invasive carcinomas after a variable period of time. In the recently published World Health Organization classification of female genital tumors, SCCs, and adenocarcinomas of the cervix are divided into HPV-associated and HPV-independent tumors. This review draws on the latest terminology and the several morphologic subtypes recognized for each category.

NKX3.1 expression in cervical 'adenoid basal cell carcinoma': another gynaecological lesion with prostatic differentiation?

Adenoid basal cell carcinoma (ABC) is considered a rare cervical neoplasm which when present in 'pure' form, uniquely amongst apparently malignant cervical tumours, has never been reported to metastasise or lead to fatal patient outcome. We recently encountered a case of ABC that was morphologically reminiscent of prostatic differentiation, more specifically basal cell hyperplasia of the prostate. Immunohistochemistry was strongly positive for the prostate related marker NKX3.1 in the glandular cells, but there was no expression of prostate specific antigen (PSA) or prostatic acid phosphatase (PAP). However, subsequent review of five additional cervical ABCs demonstrated focal PAP expression in two of four tested cases, and all were NKX3.1 positive. NKX3.1 expression was also demonstrated in the glandular epithelium of 10 additional gynaecological lesions considered to show prostatic differentiation including five cases of cervical ectopic prostatic tissue, three ovarian teratomas with prostatic differentiation, and two vaginal tubulosquamous polyps. We suggest that some lesions traditionally classified as ABC may in fact represent a variant of prostatic differentiation within the cervix, possibly analogous to basal cell hyperplasia of the prostate.

Adenoid basal carcinoma combined with invasive squamous cell carcinoma of uterine cervix: A case report of a 37-year-old woman and literature review

Adenoid basal carcinoma (ABC) is uncommon malignancy of the uterine cervix and it can be pure or combined with cervical intraepithelial lesions. There were less than 20 cases of ABC combined with invasive squamous carcinoma (mixed type) in English literature. These cases had similar properties as seen at postmenopausal women and diagnosed with abnormal cervical smear findings. Here we present a case of 37-year-old woman who suffered from spotting and received endocervical curettage. The pathological report revealed squamous cell carcinoma (SCC) of the cervix. The patient underwent type 3 radical hysterectomy and bilateral pelvic and para-aortic lymph node dissection. The final pathological report revealed SCC coexisting with ABC. Human papillomavirus (HPV) 16,18 and others (11 types) were negative in both components of the mixed tumor by in situ hybridization detection. Our case was cytokeratin 7 negative, cytokeratin 8 positive and p63 positive which supports the hypothesis that mixed type cervical carcinoma originates from endocervical reserve cells.

Distinctive clinicopathological features and disease‑specific survival of adenoid cystic carcinoma and adenoid basal carcinoma in the lower female genital tract

Adenoid cystic carcinomas (ACCs) and adenoid basal carcinomas (ABCs) in the lower female genital tract are very rare. Data on the clinicopathologic features and survival outcomes of ACCs and ABCs in the lower female genital tract are limited to case reports and small case series studies. The present study systemically analyzed 233 cases, including 84 cervical ACCs, 78 cervical ABCs and 71 vulvar ACCs, to identify clinicopathologic features and survival factors in a population‑based Surveillance, Epidemiology and End Results (SEER) study. Whereas cervical ACCs and ABCs tend to occur in the elderly (median, 72 and 69 years, respectively), vulvar ACCs commonly occurred in patients a decade younger (median, 59 years). The majority of patients with cervical ABC had localized disease and almost all received surgery. In contrast, cervical and vulvar ACC patients tended to have higher stage disease, and a significant proportion of these patients received radiotherapy, with or without surgery. The 5‑year cause‑specific survival (CSS) rates for patients with cervical ACC were 69.3%, vulvar ACC 87.7% and cervical ABC 96.6%. The 5‑year overall survival (OS) rate for patients with cervical ACC was 59.2%, significantly worse than that of cervical ABC (88.3%; P=0.002) and vulvar ACC (81.2%; P=0.01). Increased age and high stage were significantly associated with a worse prognosis in patients with cervical and vulvar ACCs by univariate and multivariate analysis (P<0.05). Tumor stage was the only significant factor associated with 5‑year overall survival in patients with cervical ABC (P<0.05). The present data demonstrated that the distinctive clinicopathologic features and survival outcomes differed significantly among ACCs and ABCs in the lower female genital tract, thus providing a rationale for location/pathologic type‑based treatment modalities.

Cervical Adenoid Basal Carcinoma: Clinicopathologic Features of 9 Cases With Reference to CK17 and Ki-67 Expression

OBJECTIVE

The aims of this study were to clarify the histological features of adenoid basal carcinoma (ABC) and determine whether cytokeratin 17 (CK17) and Ki-67 can facilitate the differential diagnosis of ABC from squamous cell carcinoma (SCC).

MATERIALS AND METHODS

Nine cases of pure ABC were collected from the files of the Division of Pathology at the Zhejiang University Hospital Women's School of Medicine. For comparison, 20 cases of moderately to poorly differentiated cervical SCC, including 2 of basaloid SCC, were also retrieved from the same period. Blocks were recut, reread, and immunostained for CK17 and Ki-67.

RESULTS

Morphologically, ABCs were mainly composed of small basaloid cell nests and variable squamous differentiation foci. For immunohistochemical staining, 1 of 9 cases showed diffuse CK17 staining, 5 of 9 showed focal positive staining, and 3 of 9 showed negative staining in the basaloid cell area of ABC, whereas no CK17 expression was found in ABC squamous foci. Eighteen of the 20 invasive SCCs showed diffuse CK17 staining, and 2 showed focal staining. The Ki-67 proliferative index varied in different ABC areas, with a relatively high index in squamous differentiation foci and a low index in basaloid cell areas. In contrast, Ki-67 staining was unevenly intense in SCC.

CONCLUSIONS

Adenoid basal carcinoma had characteristic morphological features, and the differential diagnosis of ABC from SCC is usually simple, based on morphology. In select cases, when histological findings are equivocal, the loss of CK17 expression in the squamous differentiation area, and a lower Ki-67 index in basal cell foci support ABC diagnosis.

Application of p16 Immunohistochemistry and RNA In Situ Hybridization in the Classification of Adenoid Basal Tumors of the Cervix

Our understanding of adenoid basal tumors of the cervix has evolved over time. Most of the proliferations referred to as adenoid basal carcinoma have a clinically benign course--leading some to suggest the term "adenoid basal epithelioma." However, rarely, these may be associated with invasive carcinomas. These tumors have been etiologically linked with high-risk human papillomavirus (HR-HPV) infection. Here, we investigate the use of p16 immunohistochemistry and HR-HPV RNA in situ hybridization (ISH) in the classification of adenoid basal tumors of the cervix. Seventeen cases of adenoid basal tumors of the cervix were included. The patients' age ranged from 19 to 79 yr (average, 59 yr). p16 immunostain was performed on all cases and RNA ISH was performed in 4 cases with available formalin-fixed paraffin-embedded tissue. There were 11 low-grade tumors, 5 frankly invasive carcinomas, and 1 with histologic features that were intermediate between the former 2 categories. p16 immunostain was negative or showed patchy cytoplasmic staining in the low-grade tumors and was strongly and diffusely positive in the invasive carcinomas. HR-HPV RNA ISH was negative in the 3 low-grade tumors and was positive in 1 case of invasive carcinoma including the adenoid basal component. Distinct p16 immunostaining and HR-HPV RNA ISH patterns exist between low-grade adenoid basal tumors and invasive adenoid basal carcinomas. Our study indicates that p16 immunostaining and HR-HPV RNA ISH can be employed as useful ancillary tools in differentiating between noninvasive and invasive adenoid basal tumors along with careful histopathologic evaluation.

Comparison of Cytologic Characteristics between Adenoid Cystic Carcinoma and Adenoid Basal Carcinoma in the Uterine Cervix

BACKGROUND

Adenoid cystic carcinoma (ACC) and adenoid basal carcinoma (ABC) are rare in the uterine cervix. ACC is more aggressive than ABC, thus accurate differential diagnosis is important. In this study, we identified cytologic features useful in distinguishing these two tumors for diagnosis.

METHODS

Three cases of ACC and five cases of ABC were selected for this study. Cervicovaginal smear slides were reviewed retrospectively, and the area, circumference, major axis, and minor axis of nuclei were measured using an image analyzer.

RESULTS

ACC displayed three-dimensional clusters with a small acini pattern. ABC displayed peripheral palisading without an acini pattern. The nuclei of ACC were more irregular and angulated than those of ABC, and the former showed a coarsely granular chromatin pattern. The nucleic area, circumference, major axis, and minor axis were 18.556±8.665 µm(2), 23.320±11.412 µm, 5.664±1.537 µm, and 4.127±1.107 µm in ACC and 11.017±4.440 µm(2), 15.920±5.664 µm, 4.612±1.025 µm, and 3.088±0.762 µm in the cases of ABC. All measured values showed statistically significant difference (p < .001).

CONCLUSIONS

Although the nuclei of both of these tumor types were oval shaped, inferred from the ratio of minor axis to major axis (0.728 in ACC and 0.669 in ABC), the area of nuclei was approximately 1.7 times larger in ACC than in ABC. Distinguishing nucleic features, including area, morphology, and chromatin pattern, may be helpful in making a correct diagnosis.

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.

Cervical adenoid Basal carcinoma: a case report

Adenoid basal carcinoma (ABC) is a rare epithelial tumor of the cervix. It makes up approximately 1% of all cervical adenocarcinomas. Rare cases have been associated with common cervical epithelial tumors. We present a case of ABC associated with typical squamous cell carcinoma. A 54-year-old post-menopausal woman underwent D&C for vaginal bleeding. Histologically, the tumor was characterized by small cells with a narrow cytoplasm, making up islands and cords. Peripheral palissading in the cells surrounding the cystic areas that contained central cellular debris and keratin was noted. The patient underwent total hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy and omentectomy. Large cell keratinized type squamous cell carcinoma areas in the cervix were noted besides the limited ABC areas. After surgery, the patient was treated with radiation therapy. A retroperitoneal metastasis was found on the first year and chemotherapy was administered. The patient has no evidence of disease 27 months after the first diagnosis. ABC makes up quite a rare group of cervical cancers and should be kept in mind during the evaluation so that a differentiation can be made with tumors with similar morphology as it can show various histological patterns, and can be seen together with more aggressive cancers.

Cervical adenoid basal carcinoma associated with invasive squamous cell carcinoma: a report of rare co-existence and review of literature

Cervical adenoid basal carcinoma (ABC) rarely can harbor associated malignancies like adenoid cystic carcinoma or squamous cell carcinoma (SCC), which express markedly different prognosis from a pure ABC, making an appropriate biopsy essential to provide a clear diagnosis and therapeutic plan. We report a 64-year-old asymptomatic lady with an abnormal cervical cytology, who underwent a conization to reveal an ABC with overlying microinvasive SCC. Doubtful resection margins led us to perform radical hysterectomy with lymph node dissection. Subsequent pathological examination showed a true invasive SCC co-existing with ABC, with invasion of the parametrium. Unlike the indolent course of many pure ABC patients, the prognosis of 11 previously reported co-existing invasive SCC with ABC patients appears to depend on the SCC component. Our case reiterates the importance of adequate biopsy with careful interpretation to cover the possibility of a co-existent malignancy. Besides, it presents an argument in favor of radical surgery for the primary treatment of suspicious associated malignancy, and supports adjuvant treatment according to the unfavorable extent of the co-existent invasive carcinoma.

Outcomes of patients undergoing radical hysterectomy for cervical cancer of high-risk histological subtypes

BACKGROUND

The most common types of cervical cancer are squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma, referred to here collectively as SA cervical cancer. Other types of cervical cancer, referred to here collectively as nonsquamous/nonadenocarcinoma (NSNA) cervical cancer, include neuroendocrine, small cell, clear cell, sarcomatoid, and serous tumors. Anecdotally, NSNA tumors seem to have a worse prognosis than their SA counterparts. We sought to determine whether patients with early-stage NSNA have a worse prognosis than those with early-stage SA cervical cancer.

METHODS

We retrospectively reviewed charts of women with stage IA1-IB2 NSNA cervical cancer treated by radical hysterectomy and lymph node staging at M. D. Anderson Cancer Center from 1990 to 2006. The NSNA patients were matched 1:2 to patients with grade 3 SA lesions on the basis of stage, age at diagnosis, tumor size, and date of diagnosis.

RESULTS

Eighteen patients with NSNA primary cervical cancer subtypes (neuroendocrine [n = 7], small cell [n = 5], clear cell [n = 4], papillary serous [n = 1], and sarcomatoid [n = 1]) were matched to 36 patients with grade 3 SA lesions. There were no differences between the 2 groups in age, body mass index, clinical stage, or lesion size. The 2 groups also did not differ with respect to number of nodes resected, lymphovascular space invasion, margin status, lymph node metastasis, or adjuvant radiation therapy or chemotherapy. At a median follow-up of 44 months, median progression-free and overall survivals had not been reached; however, both progression-free survival (P = 0.018) and overall survival (P = 0.028) were worse for the NSNA group. The 5-year progression-free and overall survival rates were 61.2% and 67.6%, respectively, for the NSNA group, compared with 90.1% and 88.3%, respectively, for the SA group.

CONCLUSIONS

Patients with early-stage NSNA cervical cancer undergoing radical hysterectomy and pelvic lymphadenectomy have a worse prognosis than patients with grade 3 SA lesions. Patients with NSNA tumors may require a multimodality approach to their cancer care.

Neoplastic Lesions of the Cervix

This review presents a discussion of the gross and microscopic features, diagnosis, differential diagnosis, and prognosis of neoplastic lesions of the cervix. Biomarkers are discussed for each entity presented - cervical intraepithelial neoplasia, squamous carcinoma, glandular neoplasms, adenocarcinoma in situ, adenosquamous carcinoma, and others.

Pilomatrix carcinoma presenting as an extra axial mass: clinicopathological features

Pilomatrix carcinoma is the rare malignant counterpart of pilomatrixoma, a skin adnexal tumour originating from hair matrix cells. Pilomatrix carcinoma can arise as a solitary lesion de novo, or through transformation of a pilomatrixoma. Pilomatrixoma was first described erroneously as being of sebaceous gland origin but was later discovered to be derived from hair matrix cells. They are rare, slow growing tumours of the skin found in the lower dermis and subcutaneous fat and are predominantly found in the neck and the scalp. While known to be locally aggressive, no malignant form was thought to exist until it was described relatively recently. Since then, approximately ninety cases of pilomatrix carcinoma have been reported.We report the case of a 41 year old mentally retarded male who had a longstanding lesion in the left neck for approximately fifteen years previously diagnosed as a pilomatrixoma. He presented with severe headache, falls and visual disturbance and a biopsy showed pilomatrix carcinoma of the occipital region which, on computed tomography ( CT ) invaded the occipital bone, the cerebellum and the left temporal lobe. At his initial presentation he had a craniotomy and subtotal excision of the lesion but received no adjuvant therapy. After an early intracranial recurrence he had further debulking and adjuvant external beam radiotherapy. He has had no further intracranial recurrence after three and a half years of follow-up. Here we present the pathological features of this uncommon tumour.