defined and universally accepted. Several pseudoneoplastic conditions may mimic neoplastic and pre-neoplastic lesions such as microglandular hyperplasia, ...
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including an evaluation of 11 cases with ‘‘pseudomyxoma peritonei.’’ Am J Surg Pathol 2000;24:1447–64. Rodriguez IM, Irving JA, Prat J. Endocervical-like mucinous borderline tumors of the ovary: a clinicopathologic analysis of 31 cases. Am J Surg Pathol 2004;28:1311–8. Lee KR, Nucci MR. Ovarian mucinous and mixed epithelial carcinomas of mullerian (endocervical-like) type: a clinicopathologic analysis of four cases of an uncommon variant associated with endometriosis. Int J Gynecol Pathol 2002;22:42–51. Masafumi yasunaga MD et al. Immunihistochemical characterization of mullerian mucinous borderline tumors: possible histogenetic link with serous borderline tumors and low-grade endometrioid tumors. Human pathology 2009; 40:965-974
Ligneous cervicitis: a rare benign, condition that mimics cervical adenocarcinoma. A report of two cases E. Pacella1, N. Piol1, L. Mastracci1, F. Grillo1, E. Fulcheri1,2, S. Carinelli3, G.F. Zannoni4, VG. Vellone1 1
DISC-Anatomia Patologica, Università di Genova; 2 UOSD Centro di diagnostica e patologia feto-placentare, Istituto Giannina Gaslini, Genova; 3 Divisione di Anatomia Patologica, IEO, Milano; 4 Istituto di Anatomia Patologica, Università Cattolica del S.Cuore, Roma
Introduction. Carcinoma of the cervix is still the second cause of cancer related mortality in women aged 20 to 39 years old in the USA. Tumors with glandular differentiation are steadily rising in incidence and this represents a problem in diagnostic pathology. The putative precursor lesion for cervical adenocarcinoma (ADK) is still debated and a common, widely recognized, nomenclature does not exist. Adenocarcinoma in situ (AIS, corresponding to HG-CGIN of UK authors) is the recognized precursor of invasive ADKand is related to high-risk HPV with usually strongly and diffusely positive immunostain for p16. A lesser degree of certainty exists for earlier lesions variously named as endocervical glandular dysplasia (EGD or LG-CGIN) whose diagnostic criteria, relations with HPV infection and evolution to invasive cancers are not well defined and universally accepted. Several pseudoneoplastic conditions may mimic neoplastic and pre-neoplastic lesions such as microglandular hyperplasia, reactive/reparative atypia, endometriosis, tuboendometrioid metaplasia, endometriosis and mesonephric remnants. Ligneous (wood-like) cervicitis is a chronic non-infectious, pseudomembranous disease characterized by extensive fibrin deposition in various organs. Although the most frequent site is the conjunctiva, the female genital tract may also be affected with reactive epithelial changes that may mimic malignancy. This rare condition seems related to an inherited defect in plasminogen activity and it is known to cause infertility. Case report. We report two cases of ligneous inflammation of the cervix in absence of any preceding conjunctival or systemic symptoms. Case 1: A 31 years old woman, para 1, gravida 2, presented with post-coital bleeding. Colposcopy revealed granulation tissue on the cervix. She had a history of condilomata and HPV infection in 2006 treated with diathermocoagulation; followup Pap smears were all negative. Histological examination of cervical biopsies revealed a proliferation of mostly irregular “back-to-back” glands, lined by a cuboidal or low columnar epithelium with reduced muciparity and hyperchromatic or vesiculated nuclei, occasionally with nucleoli and only rare mitotic figures. These glands were embedded in an amorphous eosinophilic material in which neutrophils and some lymphocytes were dispersed. Immunohistochemistry showed intense but inconstant positivity to p16 and CEA and a proliferation index of 60% (evaluated with Ki67 antibody). All these features were suspicious for cervical adenocarcinoma with rare, clear and microglandular features. The patent underwent cone
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biopsy showing the same, previously described, lesion with no sign of stromal invasion and ambiguous HPV positivity. Concurrent HC2 test were positive for HR-HPV. The case was sent in consultation with the final diagnosis of ligneous cervicitis. Serum levels of plaminogen resulted decreased to 33% (range 80-120%) confirming the diagnosis. Case 2: A 27 years old woman, para 3 gravida 4, suffered a miscarriage and during dilation and curettage the gynaecologist saw a friable and bleeding area of the cervix which was biopsied. Histologically a chronic and active, erosive cervicitis with mature and immature metaplasia was seen. There was a focal area with microglandular pattern with little intervening stroma lined by a cuboidal epithelium with loss of muciparity and slightly hypercromatic but relatively monomorphic nuclei with only occasional mitotic figures. This glands were embedded in an amorphous amyloid-like material. Neutrophils were present both around and inside the glands. Immunostain for p16 and CEA revealed intense but inconstant positivity. Proliferation index was 20% with Ki67 antibody. All these features completely overlapped those of the previously reported case We concluded that the histomorphologic findings were consistent with a diagnosis of atypical (probably reactive) microglandular hyperplasia consistent with ligneous cervicitis. The patients has been advised to test for HPV and plasminogen defect. Discussion. Only a few cases of ligneous inflammation of the female genital tract have been reported to date. Patients are usually premenopausal and infertility is often reported. We present two cases of ligneous cervicitis in young women with a recent miscarriage, both with no ocular or systemic symptoms and uneventful medical or family history. The clinical and histological aspects of ligneous cervicitis are suggestive for an aberrant response to diverse inflammatory stimuli. It is believed that this disease is triggered by injury with hemorrhage and accumulation of fibrinogen and fibronectin. This chronically recidivating inflammation may cause reparative/ reactive changes of the endocervical epithelium to such an extent that it can simulate malignant transformation. P16 positivity and a high proliferative index, as seen in both our cases, may further, erroneously, suggest a carcinogenic mechanism. However the positivity for p16, although strong, was not uniform in all areas of the samples and no clear signs of HPV infection were observed in epitheliamapart from the lesion. These cases show the importance of correlating pathologic, colposcopic (pseudomembranes with granulation tissue) and laboratoristic (serum plasminogen levels) findings in the diagnosis of ligneous cervicitis because of the rarity of the disease and the heterogeneity at presentation. Histologically it represents a diagnostic pitfall that can lead a young patient to an unnecessary, demolitive surgery with possible medico-legal consequences. Abnormalities of glandular cells on first level cytology: what do they really mean? The Genoa experience V.G. Vellone1, E. Cartesegna1, P. Calamaro1, F. Sarocchi1, L. Abete1, L. Mastracci1, F. Grillo1, E. Fulcheri1,3 DISC-Anatomia Patologica, Universitˆ di Genova; 2 UOSD Centro di diagnostica e patologia feto-placentare, Istituto Giannina Gaslini
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Pap test is the leading and most successful procedure for screening and diagnosis of precursor lesions of cervical cancer. For largely unknown reasons, cervical adenocarcinoma and its precursor lesions are steadily increasing in Western Countries, hence the presence of atypical cells with glandular phenotype on first level cytology represents an emerging problem. All patents with a previous, first level diagnosis of atypical glandular cell (AGC), adenocarcinoma in situ (AIS) and invasive adenocarcinoma (ADK) admitted to IRCCS San Martino-IST,
