Got Path? Issues in Gynecological Pathology-Pagetoid Spread of an Endocervical Adenocarcinoma

Image 1-Endocervical surface mucosa with replacement by adenocarcinoma in situ.

Image 2-Higher power magnification.

Figure 3-Endocervical Adenocarcinoma in situ involving the submucosal glands.

Figure 4-Higher power magnification.

Figure 5-Pagetoid intraepithelial spread of endocervical adenocarcinoma into overlying benign squamous mucosa.

Figure 6-Higher power magnification of pagetoid spread.

Figure 7-Cytokeratin 7 is strongly positive within the pagetoid cells.

Image 1-Endocervical surface mucosa with replacement by adenocarcinoma in situ. Image 2-Higher power magnification. Figure 3-Endocervical Adenocarcinoma in situ involving the submucosal glands. Figure 4-Higher power magnification. Figure 5-Pagetoid intraepithelial spread of endocervical adenocarcinoma into overlying benign squamous mucosa. Figure 6-Higher power magnification of pagetoid spread. Figure 7-Cytokeratin 7 is strongly positive within the pagetoid cells.	Issues in Gynecological Pathology
	Pagetoid Spread of an Endocervical Adenocarcinoma We recently reviewed a complicated and fascinating case, first identified on a routine Pap smear of a 54 year old woman. Initial Pap smears revealed atypical glandular cells of undetermined origin although we suspected an endocervical origin. Subsequent Pap smears revealed atypical glandular cells as well as atypical squamous cells. Finally, colposcopic examination and biopsy yielded several biopsies which contained atypical epithelial cells within the cervical squamous mucosa. The histologic findings were most unusual but at least some of the cells were represented by the cells identified on the Pap smears. An outside consultation agreed that the cells were unusual and a wide range of diagnoses ranging from an unusual squamous cell carcinoma, endocervical adenocarcinoma, and even melanoma were suggested. Additional immunoperoxidase studies were non-contributory due to the small sample size of the biopsy. Additional Pap smears continued to contain the atypical glandular cells. Finally, the patient underwent a total hysterectomy with bilateral salpingo-oophorectomy. The endocervix contained extensive areas of endocervical adenocarcinoma in situ involving all four quadrants of the cervix. In addition, there was prominent pagetoid spread into adjacent squamous epithelium. Immunoperoxidase studies revealed strong immunopositivity for CK7 within the pagetoid cells and rare positivity for p16. The tumor cells were negative for CEA, S100, and p53. The case was forwarded to Dr. Christopher Crum at Brigham and Women's Hospital in Boston, who concurred with the diagnosis. He additionally noted pagetoid extension of an endocervical adenocarcinoma in situ is rare but may occur. Potential primary sources could include a urothelial carcinoma or an upper gential tract serous carcinoma. Although no definite invasion was identified, he recommended careful clinical follow-up with periodic vaginal cytologic examinations.
	Comments: `Great case! The cell type reminds me of serous carcinoma of the endometrium. It must have been a good pick-up on the first Pap smear. Have you got any pictures of these cells on the Pap smears? I would like see those too, for correlation.` Very nice case. I'll pay attention in our future practice V`ery interesting- would like to see the Pap.`