Adenoid cystic carcinoma of the uterine cervix. Cytologic features

A case of primary cervical adenoid cystic carcinoma in a 75-year-old woman is reported. Two cervical smears taken at the time of initial presentation for vaginal spotting were negative; a third smear, taken a year later prior to laparotomy, was diagnosed as positive. The cytologic findings in the positive cervical smear are described and illustrated. The differential diagnosis of the cytologic findings is discussed, and the literature on this lesion is briefly reviewed. The results in this case and others suggest that the diagnosis of cervical adenoid cystic carcinoma in an asymptomatic patient may be missed by routine smear examination.     

Review of cervical smears from 76 women with invasive cervical cancer: cytological findings and medicolegal implications

OBJECTIVE: To review cervical smears from 76 women which were taken prior to the diagnosis of invasive cervical cancer and to determine the appropriateness of the cytology reports issued on the smears. METHODS: Cervical smears, clinical records, cervical smear history and cytology reports from 76 women with invasive cervical cancer were reviewed. After microscopic review of the cervical smears, the cases were divided into two groups: Group 1 comprised 50 women who were found to have had at least one false-negative (F/N) smear report prior to the diagnosis of invasive cervical cancer. Group 2 comprised 26 women for whom no evidence of F/N reporting was found. RESULTS: A total of 209 cervical smears from the 50 women in group 1 were available for review (range 2-12 smears per woman); 100 of the 209 smears were considered to have been reported appropriately. Ninety-seven smears which had been reported originally as negative or inadequate were found, on review, to contain numerous severely dyskaryotic cells and were reclassified as F/N smears. All of the 50 women had at least one F/N smear and 29 had two or more. Twelve smears from eight women contained only a few (<200 severely dyskaryotic cells). Forty women developed invasive squamous carcinoma and 10 developed invasive adenocarcinoma. The stage at diagnosis ranged from 1A to stage 4. Seventy-one smears from the 24 women in group 2 were available for review (range 1-15 smears per woman). In two cases included in group 2, no smears were provided for review as the smears had been lost or mislaid. Review of the 71 smears confirmed the accuracy of the original cytological classification of the smear. Nineteen women were diagnosed with squamous cancer, two microinvasive cancer, one glassy cell, two adenocarcinomas, and one with adenosquamous carcinoma. One women was found to have an embryonal rhabdomyosarcoma of the corpus uteri involving the cervix. DISCUSSION/CONCLUSION: The medicolegal implications are discussed in the light of the above findings. Evidence of breach of duty of care was presented in all 50 cases in group I although causation was not established in every case. There was no evidence of failure of duty of care in terms of the standard of the cervical cytology reports issued or standard of clinical management in 17 of the 26 cases in group 2. However, in seven of the 26 cases in group 2, clinical management of the case was substandard due to failure to investigate symptoms of irregular bleeding regardless of a negative cytology report (two cases), failure to act upon a suspicious smear report or consecutive inadequate smear reports (two cases), failure of follow-up after treatment of CIN3 (two cases) and histological misdiagnosis (one case).     

Serum zinc and copper levels in southeastern Turkish children with giardiasis or amebiasis

Alterations of serum zinc (Zn) and copper (Cu) concentrations are commonly found in patients suffering from gastrointestinal infections and with hepatic, renal, cardiovascular, and malignant diseases. In this study, the serum Zn and Cu levels in 20 children with giardiasis and in 40 children with amebiasis were evaluated. The serum Zn levels showed a significant decrease when compared to controls (p<0.001). After metronidazole therapy, a significant increase in Zn levels was observed (p<0.001). There was no significant difference in serum Cu levels between patients and controls before therapy. Before therapy, the serum Cu/Zn ratio in children with either giardiasis or amebiasis was significantly higher than that of the control group. After therapy, the Cu/Zn ratio was found to be back to normal. There were no significant differences in serum Zn levels and Cu/Zn ratios between children with and without diarrhea and there was no significant difference in children with or without failure to thrive. We concluded that Zn deficiency and elevated Cu/Zn ratio could be acute-phase responses to parasitic infections in children with giardiasis or amebiasis and that a successful treatment of the primary disorder will lead to complete recovery. Further studies are in progress to confirm the benefit of Zn supplementation during the acute phase of the disease, particularly in zinc-deficient regions of the world, such as in the case of Turkey.     

Glutathione level and its relation to radiation therapy in patients with cancer of uterine cervix

Glutathione functions as an important antioxidant in the destruction of hydrogen peroxide and lipid peroxides by providing substrate for the glutathione peroxidase and also promotes the ascorbic acid. Glutathione plays a vital role in detoxification of xenobiotics, carcinogens, free radicals and maintenance of immune functions. The study was aimed to determine plasma glutathione as well as erythrocyte glutathione and glutathione peroxidase in patients with invasive cervical carcinoma (n = 30) before initiation and after completion of radiotherapy and subsequently, at the time of first three monthly follow-up visit. The levels of plasma glutathione, erythrocyte glutathione and glutathione peroxidase activity were found to be lower in all cervical cancer patients as compared to age matched normal control women. The study indicates a change in antioxidant status in relation with the glutathione system among patients with invasive carcinoma of the uterine cervix. This study also demonstrates the effect of radiation therapy on this antioxidant system.     

Squamous cell carcinoma antigen for monitoring cervical cancer

The tumour-associated antigen was determined in the plasma of patients with squamous cell carcinoma (SCC) of the uterine cervix by radioimmunoassay. Setting a limit of 2 ng/ml, levels were abnormal in 13.4% of healthy controls, in 14% of patients with carcinoma in situ and in 62% of patients with invasive cervical SCC. The incidence of elevated SCC antigen levels and the absolute antigen plasma concentration were dependent upon the tumour load, increasing significantly with advanced stage disease. Abnormal SCC antigen values in operable cervical cancer declined to normal within one week after radical hysterectomy with pelvic lymphadenectomy. In cases of radiotherapy antigen values took 4-6 weeks after the start of treatment to return to normal. The success of both treatment modalities was announced by an early rise in the SCC antigen in the initial phase of therapy, followed by normalisation. After successful primary treatment and a complete remission during further follow-up SCC antigen in plasma was only increased in 3.8% of the cases. Retrospective evaluations in ten patients with progressive disease showed the reappearance of abnormal SCC titers and further increase preceeding the clinically detectable relapse or progression, with a median interval of 8 weeks. The present study indicates that SCC antigen determination is not useful for the early diagnosis of cervical cancer, but it is a potential means for monitoring the efficacy of individual anticancer therapy of SCC of the uterine cervix and for detecting recurrent disease.     

Origin of adenocarcinoma cells observed on cervical cytology

OBJECTIVE: To clarify the ratio of diseases suspected when malignant glandular cells are observed on cervical cytology. STUDY DESIGN: Seventy cases of cervical adenocarcinoma/adenosquamous carcinoma, 207 cases of endometrial adenocarcinoma, 7 cases of tubal adenocarcinoma and 83 cases of ovarian adenocarcinoma were reviewed. The positive rate in cervical cytology performed 3 months before surgery was calculated. Based on the positive rate for each entity and the number of cases treated in the previous 10 years, we estimated the incidence of disease responsible for malignant glandular cells on cytology. RESULTS: The positive rate was 93% in cervical adenocarcinoma/adenosquamous carcinoma, 45% in endometrial adenocarcinoma, 14% in tubal adenocarcinoma and 6% in ovarian adenocarcinoma. These positive rates and case numbers at our institute indicated the percentage of suspicious diseases to be 38% for cervical aaenocarcinoma/adenosquamous carcinoma, 53% for endometrial adenocarcinoma, 1% for tubal adenocarcinoma and 8% for ovarian adenocarcinoma. CONCLUSION: When a cytologic specimen suggested the existence of adenocarcinoma, the most probable disease was endometrial adenocarcinoma, and the second was cervical adenocarcinoma/adenosquamous carcinoma. Adnexal malignancies were responsible in 9% of cases. In the case of positive cervical cytology suggesting adenocarcinoma, the ratio of suspicious diseases is as valuable as the cytologic findings for the differential diagnosis.     

Epithélioma anaplasique de la thyro?de 6 ans après irradiation cervicale pour lymphome malin

Carcinoma of the thyroid gland may develop after irradiation of the cervical region. It is well documented in patients who received radiation therapy to the neck in childhood but rarely when the therapy was given in adulthood. A case of an undifferentiated carcinoma of the thyroid gland occurring in an adult 6 years after irradiation of the cervical region for a malignant lymphoma is reported. The role of irradiation and the factors related to the development of carcinoma of the thyroid gland are reviewed.     

Pleuropulmonary amebiasis

Pleuropulmonary amebiasis may be manifest without diarrhea or dysentery.In obscure lesions of the right lower lung field, one should always consider pleuropulmonary amebiasis-especially with low grade fever and moderate leukocytosis. Abscess and empyema contents should be examined promptly microscopically or kept warm to preserve the motility of the trophozoites until satisfactory examination is possible. Conservative therapy will successfully manage most cases of pleuropulmonary amebiasis. If a thorough search fails to reveal Entameba histolytica, and the diagnosis is still entertained, a medical therapeutic trial is in order.     

Brushing cytology in biliary tract obstruction

During a period of eight years (1980 to 1987), cytologic samples were obtained by brushing and reverse screw devices from 54 patients undergoing transhepatic cholangiography for evaluation of obstructive jaundice. Eight patients were excluded from this study, seven for inadequate follow-up and one because of unsatisfactory cytologic material. Of the remaining cases, 32 were cytologically diagnosed as adenocarcinomas; all but one patient proved to have malignant disease by histologic examination and/or through clinical follow-up. These included 21 pancreatic carcinomas, 6 bile duct carcinomas, 1 ampullary carcinoma, 1 gallbladder carcinoma and 2 metastatic carcinomas. In one case, the diagnosis of malignancy was found to be in error upon review of the cytologic smears. Of 14 patients with negative cytologic diagnoses, 7 were found to have malignant neoplasms and 7 had benign diseases. These findings indicate that, while a positive cytologic diagnosis is a reliable indicator of a malignant biliary obstruction, a negative result does not exclude malignancy.     

Verrucous carcinoma of the cervix uteri: report of a case

A case of verrucous carcinoma of the cervix uteri is reported. The cytologic findings in a Papanicolaou smear of the cervical area that permitted a diagnosis of verrucous carcinoma as opposed to epidermoid carcinoma or hyperkeratotic severe dysplasia are described. The importance of a proper diagnosis of verrucous carcinoma in order to avoid its treatment by radiation is stressed since verrucous carcinoma can turn into a more aggressive malignancy after such treatment.     

PLEUROPULMONARY AMEBIASIS

Pleuropulmonary amebiasis may be manifest without diarrhea or dysentery.In obscure lesions of the right lower lung field, one should always consider pleuropulmonary amebiasis—especially with low grade fever and moderate leukocytosis.Abscess and empyema contents should be examined promptly microscopically or kept warm to preserve the motility of the trophozoites until satisfactory examination is possible.Conservative therapy will successfully manage most cases of pleuropulmonary amebiasis.If a thorough search fails to reveal Entameba histolytica, and the diagnosis is still entertained, a medical therapeutic trial is in order.     

Fulminating necrotizing amebic colitis with perforation: case report and review.

A seriously ill patient with diffuse abdominal tenderness of unknown cause is described. The diagnosis proved to be fulminating necrotizing amebic colitis with perforation. This case report serves as a reminder that amebiasis may occur in patients who have not been outside Canada, that it may readily be confused with other types of inflammatory bowel disease, and that particular care should be taken in obtaining a history of exposure. Before inflammatory bowel disease is diagnosed not only should the usual diagnostic tests such as stool examination and mucosal biopsy be done, but also serologic testing for amebiasis should be carried out.     

LESS COMMONLY RECOGNIZED CLINICAL FEATURES OF AMEBIASIS

Among the less commonly recognized clinical manifestations of intestinal and hepatic amebiasis are vague abdominal distress in the absence of diarrhea, symptoms like those of peptic ulcer, and symptoms of a kind that may be ascribed to psychoneurosis. Hepatic amebiasis may be confused with other diseases affecting areas above or below the right diaphragm, such as cholecystitis, viral hepatitis, pneumonia or pleurisy.Adequate therapy in every case must include a course of a drug effective against hepatic involvement (chloroquine or emetine) and a drug effective against intestinal involvement (Diodoquin, Milibis, or carbarsone). Even in the absence of positive results of stool examinations, a course of antiamebic therapy is always justified as a diagnostic and therapeutic measure.     

Clinical impact of atypical squamous cells of undetermined significance. A cytohistologic comparison

OBJECTIVE: To assess the percentage of squamous intraepithelial lesions (SILs) in the atypical squamous cells of undetermined significance (ASCUS) cytologic diagnosis. STUDY DESIGN: From January 1994 to December 1995, 421 cervical Pap smears with a diagnosis of ASCUS were followed with cervical biopsies within three months. The ASCUS cytologic diagnosis was correlated with the histologic findings and stratified according to age group, previous abnormal history and cell type of ASCUS (squamoid vs. metaplastic). RESULTS: Histologic diagnosis showed that of ASCUS diagnoses, 13% were normal, 34% were reactive, 4.8% were atypical, 43% were low grade SIL, 4% were high grade SIL, 1% were carcinoma in situ, and none were invasive lesions. The patients in the youngest group, up to 25 years, demonstrated the highest percentage of SIL. Patients with a previous abnormal gynecologic history showed a higher percentage of SIL than those without an abnormal history. SILs were observed in 51.5% of squamoid ASCUS and 36.5% of metaplastic ASCUS. CONCLUSION: Forty-eight percent of females having an ASCUS diagnosis on Pap smears had SIL and thus a preneoplastic lesion. The highest percentage of SIL was found in females 25 years and younger. Our findings suggest that an ASCUS diagnosis warrants ongoing follow-up.     

Less commonly recognized clinical features of amebiasis

Among the less commonly recognized clinical manifestations of intestinal and hepatic amebiasis are vague abdominal distress in the absence of diarrhea, symptoms like those of peptic ulcer, and symptoms of a kind that may be ascribed to psychoneurosis. Hepatic amebiasis may be confused with other diseases affecting areas above or below the right diaphragm, such as cholecystitis, viral hepatitis, pneumonia or pleurisy. Adequate therapy in every case must include a course of a drug effective against hepatic involvement (chloroquine or emetine) and a drug effective against intestinal involvement (Diodoquin, Milibis, or carbarsone). Even in the absence of positive results of stool examinations, a course of antiamebic therapy is always justified as a diagnostic and therapeutic measure.     

Cytohistologic correlation between AGUS and biopsy-detected lesions in postmenopausal women

OBJECTIVE: To evaluate histologic findings in patients aged 50 and older whose cervical smears revealed atypical glandular cells of undetermined significance (AGUS). STUDY DESIGN: Computerized records spanning a four-year period were retrospectively analyzed. Thirty patients over age 50 had cervical smears interpreted as AGUS and had follow-up biopsies within 12 months following the abnormal smear. The most important histologic diagnosis from the biopsy specimens was correlated with the subcategory of the cervical smear. RESULTS: Five smears interpreted as AGUS, favor reactive, revealed abnormal histology in four cases: three endometrial polyps and one squamous carcinoma. Two smears interpreted as AGUS, favor dysplasia, revealed squamous intraepithelial lesions on biopsy in both cases. Seventeen smears interpreted as AGUS, favor endometrial cells, revealed abnormal histology in 13 cases: 1 endocervical polyp, 6 endometrial polyps, 3 endometrial hyperplasias and 3 adenomyosis. Six patients with smears interpreted as AGUS, unclassifiable, revealed abnormal histology in five cases: two endocervical polyps, one endometrial polyp, one endometrial carcinoma and one ovarian carcinoma. CONCLUSION: The presence of AGUS in cervical smears from women over 50 was highly predictive of abnormal lesions detected by histologic examination. Although three cancers were detected on histologic follow-up, the most common lesions detected were endometrial polyps.     

Effect of radiotherapy and chemoradiotherapy on circulating antioxidant system of human uterine cervical carcinoma

Circulating lipid peroxide, antioxidant components and the activities of defense enzymes were estimated in uterine cervical carcinoma patients (before and after radiotherapy and radiotherapy combined chemotherapy) and compared with controls. Some of the antioxidant components such as glutathione, vitamin E and selenium are reduced in cervical cancer. The reduced levels of vitamin E and glutathione were normalized after treatment. Erythrocyte lipid peroxide (E-LPx) and erythrocyte membrane lipid peroxide (EM-LPx) levels were found to be increased in all the stages of uterine cervical carcinoma. The important antioxidant enzymes such as erythrocyte superoxide dismutase (E-SOD), catalase (CAT), glutathione peroxidase (GSH-Px), glutathione-S-transferase (GST) and glucose-6-phosphate dehydrogenase (G6PDH) were found to be decreased in uterine cervical carcinoma. These altered biochemical parameters were reversed to normal, of course with varied degree after different mode of therapy. Significant normalization was observed in Type 11 chemoradiotherapy.     

Superficial endometrial involvement by cervical intraepithelial neoplasia detected by intrauterine cytology. A case report

A case of cervical carcinoma in situ with superficial spread to the endometrium is presented. The role of endometrial cytology in the diagnosis of such neoplastic diffusion spread is emphasized.