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Year : 2009  |  Volume : 52  |  Issue : 2  |  Page : 282-283
Clear cell adenocarcinoma cervix: A diagnostic dilemma


1 Department of Pathology, J. N. Medical College, A.M.U., Aligarh - 202 002, India
2 Department of Obstetrics and Gynaecology, J. N. Medical College, A.M.U., Aligarh - 202 002, India

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How to cite this article:
Maheshwari V, Sharma R, Mehdi G, Prasad S, Hakim S. Clear cell adenocarcinoma cervix: A diagnostic dilemma. Indian J Pathol Microbiol 2009;52:282-3

How to cite this URL:
Maheshwari V, Sharma R, Mehdi G, Prasad S, Hakim S. Clear cell adenocarcinoma cervix: A diagnostic dilemma. Indian J Pathol Microbiol [serial online] 2009 [cited 2020 Mar 30];52:282-3. Available from: http://www.ijpmonline.org/text.asp?2009/52/2/282/48951


Sir,

Adenocarcinoma of the cervix constitutes 10% to 20% of cervical cancers. [1] They are rare in younger patients and about two thirds are associated with exposure to diethyl stilbestrol (DES) therapy in utero. Clear cell adenocarcinoma can histologically mimic Arias-Stella reaction; thus creating a diagnostic dilemma after childbirth. We report a case of clear cell adenocarcinoma cervix in a young patient, with a negative maternal history of DES exposure in utero.

A 25-year-old female presented with complaints of irregular bleeding per vaginum 6 months after a Caesarian section. Ectocervix was normal looking and the uterus was bulky and mobile, per vaginum (P/V) examination. Histopathological examination of uterine curettage material revealed papillary fragments of tissue consisting of large cells with vacuolated cytoplasm and centrally placed nuclei with areas of hobnail appearance. A diagnosis of Arias-Stella reaction was considered keeping the history of pregnancy in mind.

Due to persistent bleeding, a repeat P/V examination was done which revealed a hard, barrel shaped cervix and bulky uterus. Ultrasonography revealed a 50 30mm hypoechoic mass was visualized in the endocervical region extending up to the internal os and pushing the posterior wall of urinary bladder forward. A repeat curettage (slightly difficult due to the resistance in the endocervical canal) yielded pale looking bulky tissue, which was diagnosed as clear cell adenocarcinoma of the cervix. The patient underwent a radical hysterectomy with lymphadenectomy. Grossly, the uterus and cervix measured 10 5cm. The barrel-shaped endocervix contained a cauliflower-like growth measuring 5cm in diameter, obliterating the endocervical canal, with no extension to the uterine cavity [Figure 1].

Microscopically, papillary and solid clusters of large polygonal cells with voluminous eosinophilic or clear cytoplasm and irregular nuclei with peripherally clumped chromatin and prominent nucleoli were present [Figure 2]. Hobnail cells were also seen. Periodic Acid Schiff (PAS) positive, diastase labile material was present in cells with clear cytoplasm suggesting the presence of glycogen. There was no extension of tumor to the endometrium, myometrium or ectocervix. A final diagnosis of well differentiated papillary clear cell adenocarcinoma limited to endocervix was rendered. No metastasis was seen in the obturator and internal iliac lymph nodes. Abdominal ultrasound, computed tomography and X-ray chest were normal. The tumor was placed in FIGO stage 1 category.

Tumors occurring after in utero exposure to DES present at a median age of 19 years, whereas those developing in the absence of DES exposure occur mostly in postmenopausal women. [2],[3] Three main histologic patterns are seen: tubulocystic, solid and papillary, an admixture of patterns may lead to difficulties in histologic grading. This case exhibited both solid and papillary patterns. The tubulocystic pattern is associated with better prognosis. [4] The differential diagnosis of clear cell adenocarcinoma includes various benign conditions such as Arias-Stella reaction, microglandular hyperplasia, and the rare carcinoma arising in mesonephric remnants of the cervix. Interpretation of small biopsies may be difficult, leading to errors in diagnosis as in this case.

Arias-Stella reaction is differentiated by a striking decidualized stroma and lack of cellular mitosis. The clear cytoplasm represents an increase in cytoplasmic matrix rather than an accumulation of glycogen. [4] Microglandular hyperplasia is recognized by a lack of nuclear atypia and papillary structures. Small tubular glands are seen lined by columnar cells with subnuclear mucin containing vacuoles in contrast to clear cell adenocarcinoma cells, which contain glycogen. [4] Mesonephric carcinoma consists of closely packed tubules lined by cuboidal to columnar cells with negligible intracytoplasmic glycogen and prominent basement membrane as in benign remnants, the endocervical mucosa being spared. [5]

This case highlights the fact that clear cell adenocarcinoma of the cervix may present in younger patients without exposure to DES in utero. A high index of suspicion and scrupulous attention to histological detail will avoid erroneous diagnosis.


   Acknowledgement Top


The authors are grateful to Dr. Saubhada Kane, Prof. of Pathology, Tata Memorial Hospital, Mumbai, for reviewing the case and rendering her valuable opinion.

 
   References Top

1.Tamini HK, Figge DC. Adenocarcinoma of the uterine cervix. Gynecol Oncol 1982;13:335-8.  Back to cited text no. 1    
2.Herbst AL, Cole P, Colton T, Robboy SJ, Scully RE. Age incidence and risk of diethylstilbesterol related clear cell adenocarcinoma of the vagina and cervix. Am J Obstet Gynecol 1977;128:43-50.  Back to cited text no. 2  [PUBMED]  
3.Kaminski PF, Maier RE. Clear cell adenocarcinoma of the cervix ­unrelated to diethylstilbesterol exposure. Obstet Gynecol 1983;62:720-7.  Back to cited text no. 3    
4.Robboy SJ, Young RH, Herbst AL. Female genital tract changes related to prenatal diethylstilbesterol exposure. In: Kurman RJ, editor. Blaustein's pathology of the female genital tract. 2 nd ed. New York: Springer-Verlag; 1982. p. 99-118.  Back to cited text no. 4    
5.Hart WR, Norris HJ. Mesonephric adeno-carcinoma of the cervix. Cancer 1972;29:106.  Back to cited text no. 5  [PUBMED]  

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Correspondence Address:
Veena Maheshwari
2/82, Arya Nagar Avantika Part-II, Ramghat Road, Aligarh - 202 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.48951

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