A Study of significance of mucin histochemistry in histopathological diagnosis of cervical carcinoma

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1 Original article: A Study of significance of mucin histochemistry in histopathological diagnosis of cervical carcinoma 1Dr. Rajesh Chaurasia, 2 Dr Puja Sharma, 3 Dr Pankaj Gharde 1Assistant Professor, Department of Pathology, Peoples College of Medical sciences, Bhopal, Madhyapradesh, India, Associate Professor, Department of Pathology, SHKM Govt Medical College, Nalhar, Haryana, India, Associate Professor, Department of surgery, J. N Medical College,DMIMS(DU), Sawangi, Wardha,Maharashtra, India Corresponding Author: Dr. Rajesh Chaurasia ; drrrajesh_72@rediffmail.com Abstract: Introduction: Squamous cell carcinoma accounts for around 80% of cases followed by adenocarcinoma which is 15% of cases of cervical cancer. Adenosquamous and neuroendocrine carcinomas are other variety comprising of 5% of cases. Mucicarmine stain demonstrates the presence of cytoplasmic mucin in a minority of cases having morphologic features of squamous cell carcinoma in routinely stained sections. Methodology: Sections from cervical biopsies of 305 patients were studied. Out of these, 109 showed chronic cervicitis, 2 were endocervical polyps, 80 were cervical dysplasia, 3 were adenocarcinoma out of which 2 were clear cell type and 111 epidermoid squamous cell carcinoma. Out of these, 114 cases of carcinoma cervix were selected for present study. Observations: Out of 114 cases, 111 (97.3%) showed features of Squamous cell carcinoma and 3 (2.6%)) of adenocarcinoma on routine H & E staining. Out of 111 squamous cell carcinoma, thirty nine (35.1%) showed PAS positivity and 7(2.7%) were positive for mucicarmine. Six (5.4%) cases of squamous cell carcinoma were positive for both PAS & mucicarmine. All the 3 cases of adenocarcinoma were positive for both PAS and mucicarmine. The cases were reclassified after mucin histochemistry & result showed squamous cell carcinomas to be 92.11%, adenocarcinoma 2.63% and adenosquamous carcinoma 5.26%. Conclusion: Mucin staining should be done in all cases of carcinoma cervix to detect poorly differentiated mixed (adenosquamous) carcinomas, which may escape detection on Haematoxylin and Eosin staining alone for proper management and assessment of prognosis. Key Words: Carcinoma Cervix, Cervical biopsy Introduction Cervical cancer is a worldwide problem and its incidence varies with continents. This is 2 nd most common cancer among females. 1 In Indian women it accounts for 20-25% of all the Cancers. 2 The age adjusted incidence rate is highest in Madras which is 30.7 per 100,000, in Delhi it is 26.6 per 100,000, in Barshi it is 29.3 per 100,000 in Bhopal it is 21.7 per 100,000 and at Mumbai it is 17.2 per 100,000 according to population based National Cancer Registry data. 3 Adenosquamous and neuroendocrine carcinomas are other variety comprises of 5% of cases. 5 The incidence of adenocarcinoma and adenosquamous carcinoma is higher in young women. In 178

2 most studies, the prognosis of adenocarcinoma is found to be poor than for squamous cell carcinoma. On other hand adenosquamous carcinomas have a worse prognosis than squamous cell carcinoma or adenocarcinoma. Mucicarmine stain demonstrates the presence of cytoplasmic mucin in a minority of cases having morphologic features of squamous cell carcinoma in routinely stained sections. These tumours are referred to as mucoepidermoid carcinoma, adenosquamous carcinoma or squamous cell carcinoma with mucin secretion. 6 The present work was with an aim to morphologically retypify the cases of cervical carcinoma with the help of mucin histochemistry. Materials and Method This study was done at Gandhi Medical College Bhopal, after due clearance from institutional committee for Ethics. This study was conducted from January 2001 to December 2002 in Department of pathology after taking consent from the patient. Procedure Sections from cervical biopsies of 305 patients were studied. Out of these, 109 showed chronic cervicitis, 2 were endocervical polyps, 80 were cervical dysplasia, 3 were adenocarcinoma out of which 2 were clear cell type and 111 epidermoid squamous cell carcinoma. Out of these, 114 cases of carcinoma cervix were selected for present study. The biopsies were subjected to routine paraffin sectioning at 4 µm thickness. These sections were subjected to H and E stain, PAS and Mucicarmine staining. Normal endocervical tissue was taken as control for these stains, using one control for each batch of cases. All the cases were classified into various categories as per criteria given by Buckly, Beards and fox. 7 Tumors which showed well defined, squamous pattern of growth and on special stains showed no mucin production or in less than 5% of tumor volume were classified as squamous cell carcinoma. They were further categorized as well, moderately and poorly differentiated tumours. Tumours with no evidence of squamous differentiation but showing either formation of glandular structures or widespread mucin secretion i.e. in at least 75 % of tumour cells were classified as adenocarcinomas. The diagnosis of adenosquamous carcinoma was made only when the neoplasm contained both squamous and adenomatous elements and the minor component comprised at least one third of the total. Mucin secreting cells were either nonspecific or signet ring like. Diagnosis of squamous cell carcinoma with mucin secretion(adenosquamous carcinoma) was made when mucin secretion in these tumours was >5% but <30 % of the tumour volume. Histological classification was done by using Haematoxylin and Eosin (standard method) as Squamous cell carcinoma, as well differentiated, moderately differentiated, poorly differentiated; others were adenocarcinoma and adenosquamous carcinoma. Periodic Acid Schiff, Southgate Mucicarmine techniques were subsequently used for staining. ⁸ Observations A total number of 305 cases of lesions of cervix were studied. Staining was done initially with haematoxylin and Eosin and subsequently with special stains for mucin in cases showing features of carcinoma cervix. International J of Healthcare and Biomedical Research is now with IC Value

3 TABLE I: Histopathological distribution of cervical lesions (n = 305) DIAGNOSIS n Chronic cervicitis with or without nabothian follicle formation 109 Endocervical polyps 02 Cervical dysplasias 80 Squamous cell carcinoma 111 Adenocarcinoma 03 Total 305 Table I shows that total 305 cases were studied in which 114 revealed features of carcinoma cervix. Out of 114 cases of carcinoma cervix, 111 (97.3%) showed features of Squamous cell carcinoma and 3 (2.6%)) of adenocarcinoma on routine H & E staining. TABLE II: Age wise distribution of cases of carcinoma cervix (n=114) Age Squamous cell Carcinoma Adenocarcinoma Total Well differentiated Mod. differentiated Poorly Total differentiated above O2-02 Total Table II shows that maximum cases of carcinoma cervix ( 85%) were in between age group of years.youngest patients were 30 years old while the oldest patient was 81 years old. This also shows that more aggressive or poorly differentiated lesions are more common in older age groups

4 TABLE III : Distribution of carcinoma of cervix cases according to parity (n = 114) PARITY NUMBER OF CASES Nulliparity 02 Para Para Para Para Para Para->5 25 Total 114 Table III reveals that very few cases of carcinoma cervix were observed in females with low parity status whereas 35.9 % of cases were seen in females of parity 05 and 75.4 % of cases were found to be in women having parity 3. TABLE IV: Results of mucin histochemistry in carcinoma cervix (n =114) Types H & E PAS + Mucicarmine + Squamous cell carcinoma Adenocarcinoma Total Out of 111, thirty nine (35.1%) of squamous cell carcinoma showed PAS positivity and 7(2.7%) were positive for mucicarmine.six (5.4%) cases of squamous cell carcinoma were positive for both PAS & mucicarmine. All the 3 cases of adenocarcinoma were positive for both PAS and mucicarmine.(table IV) TABLE V: Reclassification based upon mucin staining Types Initial Diagnosis After mucin stains Sq. Cell Carcinoma 111 (97.37 %) 105 (92.11%) Adenocarcinoma 03(2.63%) 03 (2.63%) Adenosquamous 00(00%) 06(5.26%) Total

5 Reclassification of cervical carcinomatous lesions was done based on mucin histochemistry.(9) It showed that 6 cases initially reported as pure squamous cell carcinoma on routine H & E staining were re-diagnosed to be adenosquamous carcinoma.(table V) DISCUSSION: This study was carried out to morphologically retypify the cases of cervical carcinoma with the help of mucin histochemistry & to reassess the prevalence rate of mucin secreting adenocarcinorma of cervix in different age, and parity in Central India. In the present study,maximum cases of carcinoma cervix ( 85%) were in between age group of years.this is comparable with many studies that indicate that invasive carcinoma showed rise with increasing age. 10,11,12 Evidence suggest that the sexual behavior is strongly associated with the development of cervical cancer. 13 It is assumed that earlier age of marriage increases the susceptibility of cervix to the further 14, 15 action of carcinogens. Epidemiological studies suggest that there is increasing risk of cervical cancer with increasing parity of women. 16,17 High fertility can be considered as important risk factor for carcinoma cervix which is same as our study. 1. A total number of 114 cases of carcinoma cervix were studied and examined for mucin secretion. Two well established staining techniques were used in the study those were PAS and mucicarmine. The study revealed that mucicarmine stain preferable due to greater specificity and intensity of staining. PAS also gives good results, the only drawback is that, keratin also take the same stain and increases the chances of false positivity, though on careful examination it was found that the positivity shown by keratin was granular, it is different from block shown by mucin. In present study a definite change in the amount and quality of mucin was observed from normal endocervical glands to adenocarcinoma or adenosquamous carcinoma. Normal endocervical glands and inflammatory lesions of the cervix uteri are mixture of all the three types of mucin with neutral mucin being predominant. Broadly the categories routinely considered are squamous cell carcinoma, Adenocarcinoma and adenosquamous carcinoma as other lesions are rare. The lesions those are well differentiated usually do not produce diagnostic error, but the lesions those are poorly differentiated squamous cell carcinomas on Haematoxylin and Eosin stain, may turn out to be poorly differentiated adenocarcinomas or mixed(adenosquamous) carcinomas, when stained with mucin, depending upon the quantity of mucin present in sample. This fact emphasizes the importance of including mucin stains as a routine diagnosis. In 114 cases of carcinoma cervix, 111(97.37%) were squamous cell carcinoma and 3(2.63%) were adenocarcinoma. To assess the accuracy of this fact, evaluation on H and E stain alone and then on both H and E and special stains were carried out. Criteria for diagnosis were followed as given by Buckley, Beards and Fox. 7 In our study it has been observed after mucin histochemistry, squamous cell carcinomas formed major proportion of cases studied, number being 105 (92.11%) out of 114 cases. Adenosquamous carcinomas were second in list, cases amounting to 6 in number (5.26%) and adenocarcinoma being only 3 (2.63%) As far as incidence of adenosquamous carcinomas is concerned our result are in accordance with studies which have reported the incidence ranging from 3.6 to 6 %. 18, 19 Some workers reported quite high

6 incidence 16 to 26 % possibly due to inclusion of small number of cases in their studies. 7, 20, 21, 22 The associated squamous cell element in adenosquamous carcinomas in the present study was moderate to poorly differentiated in most of cases, which is in accordance with other studies. Incidence of adenocarcinoma without stains in the present series has been quite low, being 2.63 % as compared to other studies. Table VI : Prevalence of squamous cell carcinoma V/S adenocarcinoma without mucin staining. Name of author Prevalence Squamous Cell Carcinoma Adenocarcinoma Adenosquamous Carcinoma Buckley CH et al (7) 76% 11.4% 12.6% Mishra V et al (9) 91.84% 6.12% 2.04% Mathur et al(23) 94% 2.67% 3.33% Present study 92.11% 2.63% 5.26% In this study emphasis has been laid down on diagnosis of poorly differentiated adenocarcinomas and mixed (adenosquamous) carcinomas. Significance of identifying mixed tumors lies in the fact that these neoplasms run an unusually aggressive course and are associated with a much worse prognosis that their pure squamous and adeno counterparts. 7,24,25,20,26,27 These tumors occur with increased frequency in women aged less than 40 years and account to significant extent of poor prognosis in young patients who present with rapidly metastasizing tumors. 7,24,25,20 Poor prognosis of mixed carcinomas as suggested by various authors is because of high incidence of poor differentiation and high incidence of lymph node metastasis. Considering all these factors, it becomes important to recognize this category of mixed carcinomas. This can help to predict prognosis and to plan management of patient, as some authors have recommended use of adjuvant chemotherapy in addition to radiotherapy for treatment of these malignancies. 26 CONCLUSION Thus concluding, mucin staining should be done in all cases of carcinoma cervix in order to avoid errors in diagnosis and to detect poorly differentiated mixed (adenosquamous) carcinomas, which may escape detection on Haematoxyline and Eosin staining alone, so that proper management of these patients can be done and prognosis may be assessed and predicted. REFERENCES 1. Aras RY, Pai N P. High fertility: Risk factor for carcinoma cervix. The journal of family welfare 1995; 41(3): Luthra UK. Epidemiology and control of cervical cancer. Annals of The National Academy of Medical Science (India)1983;19:

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