Case 3 - GYN. History: 66 year old, routine Pap test. Dr. Stelow

Case 3 - GYN History: 66 year old, routine Pap test Dr. Stelow

Case 3

66 year year old woman Routine Pap Test

Cytologic Features 3 dimensional clusters of cells with small to moderate amount of delicate cytoplasm, focally vacuolated. Somewhat enlarged, somewhat monomorphic nuclei with focal irregular contours. Fine to slightly granular chromatin with small nucleoli.

Questions AGC vs Other What flavor of AGC

AGC vs Other!! Sensitivity for glandular lesions is limited by problems with both sampling and interpretation!!

Other Squamous lesions Cervicitis Endometriosis Polyp Tubal Metaplasia Microglandular Hyperplasia Endometrial Cells, in general and including IUD

Squamous lesions Cervicitis Endometriosis Polyp Tubal Metaplasia Microglandular Hyperplasia Endometrial Cells, in general Are the cells single and squamoid? Rigid? Polygonal? Keratinization?

Squamous lesions Cervicitis Endometriosis Polyp Tubal Metaplasia Microglandular Hyperplasia Endometrial Cells, in general Are the cells sheeting? Obviously columnar? Nucleoli? Regular nuclei?

Squamous lesions Cervicitis Endometriosis Polyp Tubal Metaplasia Microglandular Hyperplasia Endometrial Cells, in general Are they acceptable as normal endometrial cells? Any nuclear atypia? How old is our patient?

Squamous lesions Cervicitis Endometriosis Polyp Tubal Metaplasia Microglandular Hyperplasia Endometrial Cells, in general Any cilia? Yes, they re vacuolated, but those nuclei look atypical

Squamous lesions Cervicitis Endometriosis Polyp Tubal Metaplasia Microglandular Hyperplasia Endometrial Cells, in general

DX: Atypical Glandular Cells OBVIOUS!! Interobserver Variability Results:There was no consensus among observers for both the origin of the cells and the diagnosis. Interobserver agreement for site was poor (kappa < 0.4) especially in the AGC category. Unanimous agreement for site was reached for 7 of 23 smears (30%). Two of five endocervical AIS were classified as endometrial and another two were classified as benign by four observers. Interobserver agreement was poor in all diagnostic categories (kappa < 0.4) and showed slight correlation with level of experience. Unanimous agreement for diagnosis was reached for only 2 smears (9%). Three of 11 (27%) smears demonstrating preneoplastic/neoplastic processes were diagnosed as benign by 3 observers. Three (25%) benign CPS were diagnosed as ACA by 2 observers. Accurate prediction of the final histologic diagnosis by observers varied from 30% to 87% and did not correlate closely with experience. Cancer Cytopathol 2003; 99: 232-30.

AGC, What Flavor Atypical Endocervical Cells, NOS Atypical Endometrial Cells, NOS Atypical Glandular Cells, NOS Atypical Endocervical Cells, Favor Neoplastic Atypical Glandular Cells, Favor Neoplastic Endocervical adenocarcinoma in situ Adenocarcinoma (endocervical,, endometrial, extrauterine,, NOS)

First, some images Dr. Wilbur did not show us

Cytologic Features 3-dimensional clusters of cells with small to moderate amount of delicate cytoplasm, focally vacuolated. Somewhat enlarged, somewhat monomorphic nuclei with focal irregular contours. Fine to slightly granular chromatin with small nucleoli. Also atrophic smear with clean background! Numerous cells (in clusters and single) with large, single vacuoles displacing the nuclei with central condensation (signet ring / targetoid cells)!

AGC, What Flavor Atypical Endocervical Cells, NOS Atypical Endometrial Cells, NOS Atypical Glandular Cells, NOS Atypical Endocervical Cells, Favor Neoplastic Atypical Glandular Cells, Favor Neoplastic Endocervical adenocarcinoma in situ Adenocarcinoma (endocervical,, endometrial, extrauterine,, NOS) Are they obviously endocervical or endometrial? What s up with those single cells? What s up with the background?

AGC, What Flavor Atypical Endocervical Cells, NOS Atypical Endometrial Cells, NOS Atypical Glandular Cells, NOS Atypical Endocervical Cells, Favor Neoplastic Atypical Glandular Cells, Favor Neoplastic Endocervical adenocarcinoma in situ Adenocarcinoma (endocervical,, endometrial, extrauterine,, NOS)

AGC, What Flavor Atypical Glandular Cells, NOS Atypical Glandular Cells, Favor Neoplastic Adenocarcinoma (extrauterine,, NOS)

Real Life Atypical Glandular Cells, NOS

Speculation

BS 2001 Extrauterine Carcinomas Three ways to the Pap: 1: Direct extension from primary, 2: Metastasis, and 3: Peritoneal involvement and passage through the fallopian tubes, etc. Majority of patients have known primary disease! May be recognized because of its unique cytologic features Majority have a clean background

Secondary Tumors to the Cervix Cancer 1986; 57: 2002-5

Extragenital Tumors to the Uterus Cancer 1982; 50: 2163-9

BS, Again Primary Breast Stomach Ovary / FT Colon Kidney Bladder Cytology Signet ring cells Cell in cell Signet ring cells Cell in cell Large Cells Tight papillary clusters Psammoma bodies Tall Cells with mucin Large Cells Large nuclei with nucleoli Abundant delicate cytoplasm Like squamous metaplasia Dense cytoplasm

Out on a Limb Metastatic mammary carcinoma, most likely left breast

GYN Case 3 Diagnosis Audience Vote 1) Negative atrophy 2) Metastatic adenocarcinoma breast 3) Changes associated with Chlamydia 4) Transitional cell metaplasia 5) Endometriosis

Tas Dev

Participants Signout NILM, atrophy AGC, NOS AGC, NOS, atrophy AGC, NOS

Participants Best Diagnosis Metastatic adenocarcinoma? breast Atrophy, inclusions suggestive of Chlamydia Metastatic adenocarcinoma? breast Atrophy

Additional Clinical History Breast Carcinoma

Original Signout & Management AGC, favor met. breast ca Colposcopy EC curetting EM biopsy

ER PR GCDF-15

Final Diagnosis Metastatic breast carcinoma

What Did I Learn Case 3 Atrophy is difficult HCG s in atrophy should prompt a very careful review Parabasal cells don t t wrap Always get the history Pap is a screening test!