8
Benign Proliferative Reactions, Intraepithelial Neoplasia, and Invasive cancer of the Uterine cervix
Fig. 8.91 Adenocarcinoma
in situ.
Aggregate of cells with a gland-like
structure with partly overlapping nuclei. Variation in size of predominantly
round-to-oval nuclei. Moderate hyperchromasia of predominantly finely
granular and regularly distributed nuclear chromatin. One to multiple
nucleoli are present (Papanicolaou x OI).
the cytological specimens by means of special architectural and
cellular features.
Reevaluation of the cytological specimens revealed that in
some cases, failure to detect the GCL was attributable to the
abundance of abnormal squamous cells in the smear sample,
whereas in other cases, abnormal glandular cells were over-
looked or underestimated in severity at initial diagnosis. It also
is possible for an abundance of abnormal glandular cells to
mask the presence of a squamous cell abnormality.
Cytological interpretation of GCLs as with squamous lesions
is subjective in nature and thus demonstrates considerable inter-
observer variability.
We therefore advocate a thorough evaluation of smears
having been reported with glandular cell abnormalities, by
correlating cytological and histological findings and intra- and
interlaboratory exchange of cases with glandular abnormalities
in different grades of severity in order to achieve consensus upon
the interpretation of cytomorphological characteristics. This will
improve diagnostic accuracy.
Cytological identification of cervical glandular cell abnor-
malities is important for patients with coexisting squamous cell
lesions, because the treatment of these combined lesions differs
from the treatment of pure squamous cell lesions (Figs 8.93 to
8.97). Diagnosis of only a squamous cell abnormality may result
in insufficient surgical treatment. Even circular biopsy (shallow
conization) may not reveal glandular abnormalities, which typi-
cally are located more proximally in the endocervical canal.
Because the prognosis for patients with adenosquamous car-
cinoma or carcinoma with glandular differentiation is said to be
poorer than the prognosis for patients with squamous cell carci-
noma,177-179 every effort must be made to increase the reliability
of cytological diagnosis and the quality of cervical specimens, as
cytological screening is likely to remain for the foreseeable future
the most widely used method for detecting cervical abnormali-
ties (both squamous and glandular).
More accurate identification of intraepithelial GCLs or com-
bined squamoglandular lesions of the cervix may eventually
lead to a decrease in the incidence of cervical adenocarcinoma,
just as increases in diagnostic accuracy have led to decreases in
the incidence of squamous intraepithelial lesions and invasive
squamous carcinoma of the cervix.
For a detailed description of the cytomorphologic character-
istics of adenocarcinoma in situ, see our studies on columnar
cell abnormalities171-174,180 and Chapter 9, Glandular Neoplasms
of the Uterine Cervix.
Dysplasia and Carcinoma in Situ during Pregnancy
In general, the cellular features of dysplastic changes in preg-
nant women are identical to the changes observed in nongravid
women. Dysplastic changes often remain undetected in view of
the significantly larger number of smears of unsatisfactory qual-
ity. Particularly during the first trimester of pregnancy, smears
may contain a large number of relatively small, immature, atypi-
cal cells. In general, dysplastic lesions during the first months of
pregnancy tend to be composed of relatively small cells, thus
suggesting a severe abnormality. These relatively immature dys-
plastic changes may lead to a dilemma: whether the patient
should undergo histologic evaluation. In most instances, with
progression of pregnancy, a reduction of the severity of a dys-
plastic lesion occurs. In a study of 87 women with dysplasia dur-
ing pregnancy, Slate and Merritt found 45% of lesions to regress,
29% to persist, and 25% to progress to a more severe abnormal-
ity after a variable period of time.109
As a general rule, unless clinical symptoms suggest a severe
lesion, routine cytologic diagnosis should be avoided during
the first trimester. Contrary to widespread belief, there is no
evidence that dysplastic lesions and carcinoma in situ behave
differently during pregnancy. The morphologic features of carci-
noma in situ do not differ from those presented for nongravid
patients. The growth rate of preinvasive epithelial changes is not
greater during pregnancy.
Surgical procedures may induce overstimulation or may
damage the cervix and thus may interfere with the pregnancy.
In general, it is fully warranted to monitor the abnormality
carefully during pregnancy, even in cases of carcinoma in situ,
and to postpone treatment of the epithelial change until after
childbirth. It is advocated that surgical treatment be instituted
only after cytologic reconfirmation of the lesion, when normal
menstrual cycling has resumed and epithelial atrophy has been
reversed. In some of the cases, the epithelial abnormality dis-
appears after childbirth, possibly owing to the passage of the
newborn through the cervical canal or because of a change in
hormonal influence on the cervical epithelium, potentially
179
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