Case 9

View the images and select the correct diagnosis from the list below.

It's a fine line

Pap smear taken from a 35-year-old woman, day 17, wearing an IUD:

Select the correct diagnosis:

A) NILM: reactive cellular changes associated with an IUD

You answered: NILM: reactive cellular changes associated with an IUD

Sorry, that is INCORRECT

The correct diagnosis is: Endocervical adenocarcinoma in situ, intestinal type

CYTOPATHOLOGY:

The smear contains abnormal clusters of slightly enlarged gland cells with nuclear hyperchromasia, elongation, crowding and stratification. There is a suggestion of nuclear protruding beyond the epithelial cluster margins ('feathering"). Some of the cells have distended mucin vacuoles and resemble intestinal cells.
These features are suspicious of endocervical adenocarcinoma in situ.

DISCUSSION:

The cone biopsy reveals endocervical adenocarcinoma in situ, intestinal type.
Based on cytoplasmic characteristics, various subtypes of AIS have been described, including endocervical, intestinal, endometrioid, and mixed adenosquamous.
Intestinal type AIS is characterized by mucin-containing cytoplasm and resembles intestinal goblet cells.
It is important to pay attention to nuclear features such as hyperchromasia, elongation, stratification and crowding in order to avoid mistaking these cells for reactive cellular changes such as those seen with an IUD or with metaplasia.
The mucin content gives these cells a lower N:C ratio than a typical endocervical AIS, and could be a potential pitfall if the nuclear features are not appreciated.
Separation of intestinal type mucinous adenocarcinoma of the cervix from metastatic colonic carcinoma may be difficult and should be considered in the differential diagnosis. History and immunohistochemical stains may be helpful.

BACK TO IMAGES

HISTOLOGY

REFERENCES:

Modem RR, Otis CN, Florence RR, Pantanowitz L. Intestinal type adenocarcinoma in situ of the cervix. Diagn Cytopathol. 2007 Sep; 35(9):584-5.

Nguyen G-K, Daya DE. Cervical Adenocarcinoma and Related Lesions: Cytodiagnostic Criteria and Pitfalls. Pathol Annu (Pt 2) 1993; 28:53-75.

B) Atypical endocervical cells, favour metaplasia

You answered: Atypical endocervical cells, favour metaplasia
Sorry, that is INCORRECT

The correct diagnosis is: Endocervical adenocarcinoma in situ, intestinal type

CYTOPATHOLOGY:

The smear contains abnormal clusters of slightly enlarged gland cells with nuclear hyperchromasia, elongation, crowding and stratification. There is a suggestion of nuclear protruding beyond the epithelial cluster margins ('feathering"). Some of the cells have distended mucin vacuoles and resemble intestinal cells.
These features are suspicious of endocervical adenocarcinoma in situ.

DISCUSSION:

The cone biopsy reveals endocervical adenocarcinoma in situ, intestinal type.
Based on cytoplasmic characteristics, various subtypes of AIS have been described, including endocervical, intestinal, endometrioid, and mixed adenosquamous.
Intestinal type AIS is characterized by mucin-containing cytoplasm and resembles intestinal goblet cells.
It is important to pay attention to nuclear features such as hyperchromasia, elongation, stratification and crowding in order to avoid mistaking these cells for reactive cellular changes such as those seen with an IUD or with metaplasia.
The mucin content gives these cells a lower N:C ratio than a typical endocervical AIS, and could be a potential pitfall if the nuclear features are not appreciated.
Separation of intestinal type mucinous adenocarcinoma of the cervix from metastatic colonic carcinoma may be difficult and should be considered in the differential diagnosis. History and immunohistochemical stains may be helpful.

BACK TO IMAGES

HISTOLOGY

REFERENCES:

Modem RR, Otis CN, Florence RR, Pantanowitz L. Intestinal type adenocarcinoma in situ of the cervix. Diagn Cytopathol. 2007 Sep; 35(9):584-5.

Nguyen G-K, Daya DE. Cervical Adenocarcinoma and Related Lesions: Cytodiagnostic Criteria and Pitfalls. Pathol Annu (Pt 2) 1993; 28:53-75.

C) Endocervical Adenocarcinoma in situ

You answered: Endocervical Adenocarcinoma in situ
That is CORRECT !!

CYTOPATHOLOGY:

The smear contains abnormal clusters of slightly enlarged gland cells with nuclear hyperchromasia, elongation, crowding and stratification. There is a suggestion of nuclear protruding beyond the epithelial cluster margins ('feathering"). Some of the cells have distended mucin vacuoles and resemble intestinal cells.
These features are suspicious of endocervical adenocarcinoma in situ.

DISCUSSION:

The cone biopsy reveals endocervical adenocarcinoma in situ, intestinal type.
Based on cytoplasmic characteristics, various subtypes of AIS have been described, including endocervical, intestinal, endometrioid, and mixed adenosquamous.
Intestinal type AIS is characterized by mucin-containing cytoplasm and resembles intestinal goblet cells.
It is important to pay attention to nuclear features such as hyperchromasia, elongation, stratification and crowding in order to avoid mistaking these cells for reactive cellular changes such as those seen with an IUD or with metaplasia.
The mucin content gives these cells a lower N:C ratio than a typical endocervical AIS, and could be a potential pitfall if the nuclear features are not appreciated.
Separation of intestinal type mucinous adenocarcinoma of the cervix from metastatic colonic carcinoma may be difficult and should be considered in the differential diagnosis. History and immunohistochemical stains may be helpful.

BACK TO IMAGES

D) Atypical endometrial cells, NOS

You answered: Atypical endometrial cells, NOS
Sorry, that is INCORRECT

The correct diagnosis is: Endocervical adenocarcinoma in situ, intestinal type

CYTOPATHOLOGY:

The smear contains abnormal clusters of slightly enlarged gland cells with nuclear hyperchromasia, elongation, crowding and stratification. There is a suggestion of nuclear protruding beyond the epithelial cluster margins ('feathering"). Some of the cells have distended mucin vacuoles and resemble intestinal cells.
These features are suspicious of endocervical adenocarcinoma in situ.

DISCUSSION:

The cone biopsy reveals endocervical adenocarcinoma in situ, intestinal type.
Based on cytoplasmic characteristics, various subtypes of AIS have been described, including endocervical, intestinal, endometrioid, and mixed adenosquamous.
Intestinal type AIS is characterized by mucin-containing cytoplasm and resembles intestinal goblet cells.
It is important to pay attention to nuclear features such as hyperchromasia, elongation, stratification and crowding in order to avoid mistaking these cells for reactive cellular changes such as those seen with an IUD or with metaplasia.
The mucin content gives these cells a lower N:C ratio than a typical endocervical AIS, and could be a potential pitfall if the nuclear features are not appreciated.
Separation of intestinal type mucinous adenocarcinoma of the cervix from metastatic colonic carcinoma may be difficult and should be considered in the differential diagnosis. History and immunohistochemical stains may be helpful.

BACK TO IMAGES

Histology

From the Cytopathology files of BC Cancer
Submitted by: Brenda Smith, BSc and Tom Thomson, MD