Hyaline adenoma of the cervix

ELTON

:

IITALINE

ADENOMA

OF

121

CERVIX

REFERENCES

(1) Dodds, E. C., Goldberg, L., Lawson, W., and Robinson, R.: Nature 141: 247, 1938. (2) Englehart, E.: Wien. klin. Wchnschr. 51: 1356. 1938. (3) Bishov. P. a. F., Boycott, Me., and Zuckerman, 8.: Lancet 1: 5, 1939. (4) Wintkrton, W.-R., and -MacGregor, T. N. : Brit. M. J. 1: 7, 1939. (5) Eellar, R. J., and Szltherland, J. X.: J. Obst. & Gynaec. Brit. Emp. 46: 1, 1939. (6) Dodds, E. C., Lawson, W., an,d Noble, R. L.: Lancet 1: 1389, 1938. (7) Noble, R. L.: Lancet 2: 192, 1938. (X) Pa&es, it. S., Do&s, E. C., and Noble, R. L,: Brit. M. J. 2: 557, 1938. (9) Winthrop Chemical Co. : Communication. (10) Loeser, d. d.: Brit. M. J. 1: 13, 1939.

HYALINE

W.

NORMAN

(From

the Dicisio,n

ADENOMA

of

&hrgical

OF THE

CERVlX

ELTON, M.D., BUFFALO, N. Pathology, Clinical Laboratory Fillmore Ilospital)

Y. of

the Millard

EVERAL months ago a specimen of cervical tissue was examined which pres According to the history, a sented a puzzling and unique histologic pattern. diagnosis of adenocarcinoma of the cervix had been made two years before, and a Upon examination of the uterus after its supracervical hysterectomy performed. removal, no tumor could be found, but a deep longitudinal groove was noted in the lower segment, which was regarded as the probable source of the material obtained for biopsy, and it was assumed that t.he tumor had been completely removed by the curette. During the interval of two years nothing unusual had been observed in t,he cervical stump, until the development of a soft, diffuse, polypoid formation, extending about an inch up into the cervical canal, had prompted the removal of the specimen just mentioned for further examination. Thp specimen was compared with that examined two years before, and the pxtterns of the two were found to be essentially -alike. Since the bi,ology of this tumor and the unusual histologic pattern made it inadvisable to diagnose the tissue as malignant, the descriptive term “hyaline adenoma” was adopted. A search of the files back to 1938 disclosed two other tumors of a similar character, but lacking the hyaline stroma, both of which had been The clinical records of, and meticulous classified as adenocarcinoma of the uterus. histologic study of, the tissue removed from the three patients clearly show that these tumors are not cancer. The first patient was a 27-year-old woman, married for two years, obese, always regular in her menses, and who had had a cervical discharge for ten years. When she finally consulted a regular physician after years of osteopathic treatment for back pain, a polypoid formation extending high in the cervical canal prompted the biopsy, which resulted in the diagnosis of adenocarcinoma and the supracervical hysterectomy just described. Fig. 1 shows the pattern of the cervical tumor found in the initial biopsy. The hysterectomy without removal of the cervix afforded an excellent opportunity to study the biology and subsequent progress of this tumor. Two years later, a.s described in the first paragraph, the second biopsy was made; six months later, the third, which is shown in Fig. 2, and after another interval of ten months, a fourth biopsy. Ko evidence of malignancy ever developed from a clinical point of view. The second biopsy specimen is not presented because of poor rontrast for microphotographic work, but in it the glandular elements had almost disappeared, and between the hpaline islands vascular granulation tissue and pale both intracgtoplasmie and intranuclear hydropic squamous epithelial cells, showing edema, were the essential features. It is to be noted that in the third biopsy the epithelial islands were quite healthy and distinct. The latest biopsy has shown no significant change during the past ten months, an? the squamous epithelium is less prominent. The second patient, a ?&year-old woman, obese, married three years, and never pregnant, was also subject to back pain. Her periods had always been profuse,

-1 r~uti~li),nel~ation of cervical glands, showing variable Fig. I.-Initial bionss-. slegrees of hynernlasiw, .squ;,n>,,u.? metanla.%r, ~~rtttor’y activity and disorganization, are supported by a stroma <.onsistinx almost txntirely of hynlinized connective tissue. About 50 per cent of the tissnc i:: h>-alin<~, \vlii<~b stirins char‘itctr:risticallS by the Van Gieson technique. ;\Iucus :rnfl nf,lJtr4rJhill~s ,v(‘,,*,y the glanri lumens.

Fig. EL-Hyaline adenoma of cervix (hematoxylin and eosinl. Third biopsy. (Two and one-half years after initial biopsy. Magniflcation twice that of Recurrence of the original cervical tumor. No glandular elements Fig. 1.1 Small islands of somewhat hyperplastic squamous epithelium could be found. are imbedded in hyalinized connective tissue, and are derived from glandular epithelium which has undergone squamous metaplasia. This recurrence occurred one inch above the external OS in the cervical canal. A biopsy six months before this had shown a marked increase in the hyalinc areas of vascular granulation tissue stroma, disintegration of glandular structures. surrounded by hyaline, and surface sloughing. Squamous epithelium at that time was scant and hydropic, showing both intracytoplasmic and intranuclear edema. The most recent biopsy, ten months after the third. has shown little change other than further increase in the hyaline reaction with less squamous epitheliUm.

ELTON

:

HYALINE

ADENOMA

OF

133

C:EKVIS

and for the preceding three years irregular and lasting from sixteen to twenty days. Both her mother and sister had menstruated regularly throughout their pregnancies. Three years ago the cervix and uterus were curetted, and a laparotomy performed, although only the appendix and an ovary were removed, because the uterus appeared normal. The curettings were reported as adenocarcinoma of the cervix (Fig. 3) by two pathologists, and irradiation was administered to the uterus and cervix. Another biopsy, made just before irradiation treatment \vas begun, showed only a low grade, chronic inflammatory reaction with no evidence of remnants of the original tumor. Management was based upon the tissue obtained in the original curettage. No further abnormalities developed, and for the past three years she has been regarded as cured.

Fig. 3.-Adenoma of cervix without hyaline stroma. (Hematoxylin :2nd eosin.) The glandular pattern of this tumor so closely resembles that of the hyalin e adenoma, shown in Figs. 1 and 2, that it seems allied to it. Here the stroma is scant, but without any hyalinisation. _Gland septa .have broken down,. and t&e co nfluence of ,. . __ _ ttN2 glands has PrOUUCeU a UlUIlnUtlVe CyStadeUOmatOUS rormatlon. Many glands are cystic, and neutrophiles are present in their lumens. Endometrium present in the curettings showed the pathologic follicular phase, with cystic and dilated glands.

Mucicarmine stains demonstrated of the cervical glands.

an

abundance

of mucus

in

the

cells

and

lumens

The third patient, a 4%year-old woman, underwent a panhysterectomy for fibroids, but died forty-eight hours after the operation. Besides multiple intramural leiomyomas, the uterus presented rough, granular, shaggy tabs involving the mucosa of the lower segment and cervical canal, which on histologic examination invited the diagnosis of low grade adenocarcinoma (Fig. 4). Menorrhagia and metrorrhagia had developed five months before operation, with back pain and low abdominal cramps, prior to which she had experienced no abnormalities. Early menopausal symptoms were also noted. She had been married since the age of 17, and one abortion eighteen years before admission constituted the only pregnancy. Because of the unusual interest of the first of these three lesions, and since all three types are undoubtedly being encountered from time to time, it is felt that the presentation of these three cases will be of interest. I can find in the literature no reference to the pathologic entity which I have described as a hyaline adenoma, but the other two are occasionally mentioned as adenomatoid hyperplasias of the

Since the first patient with f hc hxxline :~I~CIIO~I:L had had :I wrvid dii;cll:lr~t~ i’or ten years, and since the glandular patterns of the lesions of the others aW ~erp similar, but lacking the hyaline stroma, it, is possible that their shorter tluration without prolonged inflamn1ator.y irritation may explain the absence of the hyaline. Neither of these two lent themselves to the follow-up study possible with the first..

Fig. 4.-Adenomatoid hyperplasia of cervical glands. (Hematoxylin and eOSin.) This specimen perhaps represents the youngest form of the process terminating in hyaline adenoma. and is typical of an inflammatory reaction in glandular POlYPOid tissue, with marked multiplication of the glands and a tendency to sCIuamous metaplasia. warranting its inclusion in this series. Neutrophile infiltration is marked in the stroma and gland lumens. Hyalinization is not present. Endometrium aCCompanying the cervical curettinff. P showed the earIy follicular phase. SUMMARY A tumor of the cervix, termed hyaline adenoma, the evolution of which has been observed in situ for over three years, is described. Two other lesions simulating it, but lacking the hyaline stroma, are also presented. The study of the life cycle of the hyaline adenoma has shown that its first stage consists of a proliferation of small, dilated and cystic cervical glands enclosed in a dense hyaline stroma which comprises about 50 per cent of the microscopic fields, and in which the glandular epithelium is disorganized and shows considerable squamous rnetaplasia. Subse. quent biopsies exhibit disintegration and disappearance of the glands and the development of small islands of squamous epithelium with further proliferation of the hyaline stroma in which they are imbedded, but manifesting no evidence of malignancy. The two lesions presented as similar to the hyaline adenoma and tentatively regarded as its possible precursors, would be more properly classified as adenomatoid glandular hyperplasia. These entities are believed to be of inflammatory origin, thus far reported only in the cervix of nulliparous women. KEFEREXCES (1) 1935.

Laffont, A., Mcmtpellier, (2) Oppenheimer, JT.:

J.. Arch.

n?,d Laffargzle, f. GynHk. 150:

P.: 741,

GynBc. 1932.

et obst.

32:

390,