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: yashwantk74@yahoo.com

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