A carcinoma in situ of the cervix are widely published

Transcription

1 denocarcinoma in Situ of the ervix: n Underdiagnosed Lesion MTHILDE E. BOON, MD, J. P.. BK, MD, P. J. H. KURVER, MSc,* S. H. OVERDIEP, MD, ND G. W. VERDONK, MDt lthough invasive adenocarcinoma of the cervix constitutes 5-15% of all cervical cancers, the in situ counterpart is underrepresented in the published series of percursor lesions of cervical cancer. Moreover, no cases are known to have been published in which in situ adenocarcinoma preceded invasive cancer. Partly, this can be explained by the fact that in situ adenocarcinoma is an underdiagnosed lesion. In a series of 52 cases of adenocarcinoma of the uterine cervix, 18 negative endocervical biopsies, taken 3-7 years prior to the clinical presentation of cancer, were available for study. In five of these cases, areas of adenocarcinoma in situ were found. The quantitative parameters of these missed adenocarcinomas in situ and adenocarcinomas in situ adjacent to invasive cancer were the same. The in situ lesions differed significantly from benign endocervical epithelium. This study strongly suggests that these lesions may progress to invasive cancer. With the acquired information on the quantitative features of adenocarcinoma in situ cells, the most significant criteria for routine diagnostic practice can be identified. ancer 48: LTHOUGH THE histologic criteria of epidermoid carcinoma in situ of the cervix are widely published and discussed, this is not true for the other precursor of cervical carcinoma: adenocarcinoma in situ. uthors writing about adenocarcinoma in situ stress the fact that these lesions are easily overlo~ked,~-~ and may often only be found while reviewing cases of epidermoid carcinoma in situ. This may explain why these cases are underrepresented in series of precursor lesions of cervical cancer. In a series of 52 invasive adenocarcinomas of the cervix, adenocarcinoma in situ was found in areas adjacent to the invasive carcinoma in all cases in which ample histologic materials was available for study (46 of 52); 18 cases had had previous negative biopsies, taken 3-7 years prior to the clinical presentation of cancer. On review, highly abnormal endocervical epithelium was found in five of these cases. These cases were classified as missed adenocarcinoma in situ. *From the Department of Pathology, S.S.D.Z., Reynier de Graefweg 7, Delft, The Netherlands. t Department of Pathology, Bergweg Ziekenhuis, Bergselaan 62, Rotterdam, The Netherlands. ddress for reprints: Mathilde E. Boon, M.D., Department of Pathology, S.S.D.Z., Reynier de Graefweg 7, 2625 D Delft, The Netherlands. The authors gratefully acknowledge the skillful assistance of Marian Brandhorst and Trudv.M.. Kock. ccepted for publication July 23, Since we were unable to find any reports in the literature of adenocarcinoma in situ preceding invasive cancer, we report herewith these five cases. Because the characteristics of these intraepithelial abnormalities are not always appreciated, we measured various cell features of these five lesions and of adenocarcinomas in situ adjacent to invasive cancer, using black-andwhite photographs of sections from routine paraffinembedded histologic material. The measurements were made with a plainimeter (SM, Leitz). With the aid of the established quantitative parameters, histologic diagnosis in future cases should be facilitated. Material and Methods Of a series of 52 adenocarcinomas of the cervix, 18 negative endocervical biopsies, taken 3-7 years prior to the clinical presentation of cancer, were available for study; in five of these cases, highly abnormal endocervical epithelium was present, but originally not identified as such (Fig. 1). The histologic material of the later operation specimen of these five patients was reviewed. ll had well-differentiated endocervical adenocarcinoma with extensive areas of adenocarcinoma in situ, and none had areas of squamous cell carcinoma. s control groups, five cases were selected with well-differentiated adenocarcinoma, and for the provision of benign endocervical epithelium, 15 cases X/81/0801/0768 $ merican ancer Society 768

2 No. 3 ERVIL DENORINOM SITU - Boon et al. 769 with endometrial bleeding were used. Thus, the cases studied quantitatively included 15 benign lesions (BEE), 5 missed adenocarcinomas in situ (MIS), 10 proven adenocarcinomas in situ (PIS), and 10 foci of invasive cancer (FI). Quantitative Studies Black-and-white photographs were taken with a 1000 x magnification of the endocervical epithelium in the benign group (BEE) (Fig. 1); of misdiagnosed adenocarcinoma in situ (MIS) (Fig. 2); of the areas of adenocarcinoma in situ adjacent to invasive carcinoma in the subsequent operation specimen of these five patients and, in addition, of the adenocarcinoma control group (proven IS or PIS); and of foci of invasive cancer (FI) in the two latter groups (Fig. 3). In the benign epithelium and in situ lesions, only those areas were photographed in which it was evident that the cells were cut vertically and in which the vertical axis of the cell was perpendicular to the basement membrane. Mechanically disformed cells were not taken. Three or four photographs were made of each slide. The cell images of the photographs were measured with a graphic tablet (SM, Leitz W. Germany). Subcylindrical cells were not included in the measure- FIG. 1. Benign endocervical epithelium. The measured cells are indicated; subcylindrical cells were not measured (X 1000). ments (Fig. 1). The nuclei and cytoplasm of the cylindrical cell were outlined with a digitizing cursor coupled to the graphic tablet. The photograph was placed in such a way on the graphic tablet that the vertical axis of the cell was parallel to the Y coordinate of the tablet. The computer calculated from the two de- FIG. 2. Missed adenocarcinomain situ of the endocervix. Note enlarged nuclei, long nuclear vertical axis, and unfavorable NI size ratio (original magnification X 1000-see Fig. 1 for original magnification). FIG. 3. Foci of invasive cancer (original magnification X1000-see Fig. 1 for original magnification).

3 770 NER ugust I 1981 Vol I I inhii II I 1- Ic* 1 -I ch FIG. 4. Schematic drawing of cylindrical cells: nh = nuclear horizontal axis; ch = cell horizontal axis; nv = nuclear vertical axis; cv = cell vertical axis. Features are as follows. Nuclear area: cell = 72 pm2; cell B = 80 pm2. ell area: cell = 308 pm2; cell B = 280 pm2. Nuclear horizontal axis: cell = 1 pm; cell B = 0.5 pm. ell horizontal axis: cell = 1.1 pm; cell B = 1.2 pm; Nuclear vertical axis: cell = 1.3 pm; cell B = 2.4 pm. ell vertical axis: cell = 3.8 pm; cell B = 4.0 pm. lineated areas the following features (Fig. 4): nuclear perimeter, cell perimeter, nuclear area, cell area, nuclear horizontal axis, cell horizontal axis, nuclear vertical axis, cell vertical axis, ratio nuclear axes, ratio cell axes, and nuclear cytoplasmic (N/) size ratio. The size of the objects was computed as follows: 2 \/area?r From each slide the mean and the standard deviation of the measured features were calculated: this resulted in 22 parameters per case being the mean and the standard deviation of the 11 features shown in Figure 4. Statistical nalysis Statistical analysis was carried out on an 11 DE computer with a part of the program statistical package (STP) developed by P.H.J.K. The descriptive statistics of the measurements were computed for each group. Wilcoxon's test was used to establish significant differences between the four groups. s a level of significance, P L 0.05 (two sides) was adopted. With a discriminant analysis6 the best discriminating parameters for distinguishing benign epithelium, proven adenocarcinoma in situ, and invasive foci were assessed. Results From Table 1 it is evident that the quantitative data of the missed carcinoma in situ (MIS) and proven carcinoma in situ (PIS) were very similar. This table lists the mean values and standard deviations of the four groups. Twelve of these 22 parameters proved to be of importance in the differentiation of benign lesions (BEE) from proven carcinoma in situ (PIS) on the one hand, and of PIS from FI on the other (Table 2). The most potent parameters in discriminating BEE from PIS proved to be: mean cellular horizontal axis; mean nuclear vertical axis; and mean ratio of the two nuclear axes (P L 0.001), although the mean N/ size ratio and mean nuclear perimeters were also significant (P L 0.01). In the discrimination between BEE and FI, the nuclear horizontal axis, mean horizontal cellular axis, standard deviations of cellular horizontal axis, ratio nuclear axes, and ratio cell axes proved to be of great importance (P L 0.01). In the discriminant analysis6 the discriminating factors to distinguish BE from PIS from FI were: mean horizontal nuclear axis, mean nuclear area, mean vertical nuclear axis, mean N/ size ratio, and standard deviation of the horizontal axis. Two discriminant factors (factor I and 11) were computed from these five parameters and standardized (unit variance, centered at TBLE 1. Mean Values of Parameters for the Four Groups BEE MlS PIS FI Parameter* (n = 15) (n = 5) (n = 10) (n = 10) Mean nuclear perimeter 27.85t SD nuclear perimeter Mean cell perimeter SD cell perimeter Mean nuclear area SD nuclear area Mean cell area SD cell area Mean nuclear horizontal axis SD nuclear horizontal axis Mean cell horizontal axis SD cell horizontal axis Mean nuclear vertical axis SD nuclear vertical axis Mean cell vertical axis SD cell vertical axis Mean ratio nuclear axes SD ratio nuclear axes Mean ratio cellular axes SD ratio cellular axes Mean N/ size ratio$ SD N/ size ratio BEE = benign endocervical epithelium; MIS = missed adenocarcinomas in situ; PIS = proven adenocarcinoma in situ; FI = foci of invasive cancer. * Parameters used are the means and standard deviations of a given cell feature of the measured cells of one case. The means and standard deviations in this table are the mean values and standard deviations of the given parameters of all cases in one group. t Values expressed in Fm. 2\/area 4 Size was computed as follows:. 7T

4 No. 3 zero). The most important parameter in factor I is the mean nuclear horizontal axis, and, in factor 11, the mean nuclear vertical axis. For the calculation of factors I and 11, the data of MIS were not used. When these results are plotted (Fig. 5), all cases of in situ carcinoma (MIS and PIS) fall into the same group. The rank sign test showed that there were no statistical differences between MIS and PIS. ERVIL DENORINOM SITU Boon et al, 771.,... t _...f...*..._..._ 030E01 PlS 024E.01 B = FI E D MIS OlSEtOl t 012E01 D 0 0 D B B ~ B ~ BEE Discussion The results of this study indicate that adenocarcinoma in situ can precede invasive adenocarcinoma: in one patient, transition time was as long as seven years. Based on studies of mean age for adenocarcinoma in situ and invasive cancer, the change from in situ stage to invasive cancer can even be longer; in our material, mean age of the in situ cases is 39 years; of the patients with invasive cancer, 57 year^.^,^ The same phenomenon is observed in other series: mean age for the discovery of in situ adenocarcinoma in the series of Qizilbash5 is 35 years, whereas average age of patients with clinical invasive adenocarcinoma is in the early part of the sixth de~ade.~. ~ nother argument in favor of the premalignant nature of adenocarcinoma in situ is the presence of in situ lesions adjacent to invasive cancer.2-5,10-12 I n our patients, extensive areas of in situ carcinoma were found next to invasive cancer in all cases with ample histologic material available for study. The histologic characteristics of in situ adenocarcinoma in cervical epithelium have been widely documented in recent year~ 9~ ~- l6 and include elongation of nuclei, prominence of nucleoli, and abnormalities in chromatin pattern. Involvement is often limited to 000E00 Y 060Ei00 * 012Ei01 * 024E01 * 030E*01 * c c c... t,.-./ -0 30Et E*Ol 0 60E Ei E ~*01-024E01 012Ef01 000E Et01 024E*01 FIG. 5. Scattergram of cases with benign endocervical cells (BEE), proven adenocarcinoma in situ (PIS), missed adenocarcinoma in situ (MIS) and foci of invasive cancer (FI). Factor I and Factor I1 were computed from the five parameters: mean horizontal nuclear axis, mean nuclear area, mean vertical nuclear axis, mean NI size ratio, and standard derivation of horizontal axis, and standardized with unit variance and centered at zero. deep glands of the cervix, with a sharp demarcation between the benign mucin-secreting epithelium and the area of adenocarcinoma in situ with less prominent mucin production (Fig. 6). The areas of adenocarcinoma in situ are often alcian-blue negative or contain only few faintly alcian-blue positive cells: this phe- Y TBLE 2. Significant Differences Between Different Groups (Wilcoxon s Two-Sample Test) Parameter* Mean nuclear perimeter Mean nuclear area SD nuclear area Mean cell horizontal axis SD cell horizontal axis Mean nuclear vertical axis Mean ratio nuclear axes SD ratio nuclear axes Mean ratio cellular axes SD mean ratio cellular axes Mean N/ size ratio BEE PIS FI (n = 15) Difference7 (n = 10) Difference (n = 10) 27.85$ BEE = Benign endocervical epithelium; MIS = missed adenocarcinoma in siru; PIS = proven adenocarcinoma in situ; FI = foci of invasive cancer. * Parameters are the means and standard deviations of a given cell feature of the measured cells in one case. The means and standard deviations in this table are the mean values and standard deviations of the given parameters of all cases in one group. t = P < 0.05; = P < 0.01; = P < 0,001. $ Values expressed in fim.

5 772 NER ugust Vol. 48 FIG. 6. One case of missed adenocarcinoma in situ with involvement of a deep endocervical gland. Note sharp demarcation between benign mucin-secreting epithelium and area of adenocarcinoma in siru with less prominent mucin production. (top): H & E, X 125; B (bottom): H & E, x37.5.

6 No. 3 ERVIL DENORINOM SITU - Boon et a/. 773 nomenon aids in the detection at low-power magnification. Our findings agree with those of Qizilbash5 and hristopherson et af. that adenocarcinoma in situ is an underdiagnosed lesion. The ratio of squamoid carcinoma to adenocarcinoma in hristopherson s series and in our material8 is, respectively, for the in situ lesions, 239: 1 and 25: 1, and for the invasive lesions, 15 : 1 and 13 : 1. These data suggest that there is an underdiagnosis of adenocarcinoma in situ in both laboratories although these differences could also be due to differing biologic behavior of the two tumors. Several factors are responsible for these underdiagnoses: Weisbrot et al. l6 suggested that these lesions are often small in size and confined to a small area of the cervix. hristopherson et al. speculated that the surface columnar cells are often replaced by benign metaplastic cells or dysplastic cells, while the adenocarcinoma in situ frequently involves the deep glands of the cervix and may even be missed in curettage. In our experiences, however, the lesion is not always recognized even when it is present in the histologic material. It can be found when sections of more distinctive and eye-catching squamous carcinoma in situ are re~iewed.~ There exists a real danger of underdiagnosing adenocarcinoma in situ and, when there is no abnormal squamous component, the histologic report will be negative and thus the patient will not receive proper treatment. The five patients described in this paper are examples of the consequences of such undertreatment: all developed invasive adenocarcinoma. With the intention of getting a better insight into the most important diagnostic criteria of this underdiagnosed lesion, we quantified cellular and nuclear features in routine histologic sections of these five cases of benign endocervical epithelium, proven adenocarcinoma in situ, and invasive carcinoma. There were significant statistical differences between benign epithelium and adenocarcinoma in situ for nine parameters, the most important for adenocarcinoma in situ being a large mean vertical axis nucleus, large mean horizontal nuclear axis, a high mean ratio between the vertical and horizontal nuclear axes and a high N/ size ratio (Table 2). Translated into microscopic images, this means that adenocarcinoma in situ cells have elongated nuclei with a large width and a high nuclear cytoplasmic ratio. The missed adenocarcinomas in situ were neither significantly different from the proven cases nor did the rank sign test reveal differences; thus it may be assumed that these were true adenocarcinomas in situ. The foci of active invasive growth consisted of cells with relatively rounder nuclei with a higher N/ size ratio: this may point to a more pronounced immaturity of the cell population with invasive properties. With the acquired information on the quantitative features of adenocarcinoma in situ cells we have been able to appreciate which are the most important diagnostic criteria. The application of quantitative microscopy, which also has proved to be important in the endometrial path~logy, ~ can be of great help in defining precursor lesions of adenocarcinoma of the uterine cervix. REFERENES 1. hristopherson WM, Nealon N, Gray L. Noninvasive precursor lesions of adenocarcinoma and mixed adenosquamous carcinoma of the cervix uteri. ancer 1979; 44: Melnick PJ, Lee LE, Walsh HM. Endocervical and cervical neoplasms adjacent to carcinoma in situ. m J Pathol 1957; 28: Sachs H, Ikeda J, Brachetti KJ. Mikroinvasives denokarzinom und Karzinom der ervix uteri. Med Welt. 1975; 26: Werner R, Waidecker F. denocarcinoma in situ und mikroinvasives denokarzinom der ervix Uteri. Osrerr. Onkol 1972; 2: Qizilbash li H. In situ and microinvasive adenocarcinoma of the uterine cervix. m J lin Pathol 1975; 64: ooley WW, Lohnes, PR. Multivariate data analysis. New York: John Wiley & Sons, Inc., 1971: Beyer-Boon ME, Verdonk GW. The identification of atypical cells in smears of patients with pre-malignant changes in the squamous and glandular epithelium of the uterine-cervix. cta ytol 1978; 22~ Boon ME, Tabbers-Boumeester ML. Gynaecological cytology, Textbook and tlas. London: McMillan Press, lva J, Lauchln S. 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