Junctional areas in squamous cell carcinoma of the cervix

Junctional

areas in squamous cell

carcinoma of the cervix JEAN

DE

BRUX,

JACQUELINE Paris,

M.D. DUPRE-FROMENT,

M.D.

France

T H E A I M s of this study of the junctional area between the invading squamous cell carcinomas and the normal epithelium of the cervix are to study the superficial growth of the cervical cancer and to determine the morphology of the carcinoma in situ so frequently met in this region; to determine the nature of the so-called “dysplasias” so frequently situated at the border of the carcinoma; and to determine whether or not the in situ carcinoma is an essential stage in the development of invasive carcinoma. Material

and

We shall discuss successively: ( 1) the morphological classification of the 100 invading “epidermoid” carcinomas, as observed chiefly at the junctional areas; i 2) the manner of extension of the cancer along the endocervical, exocervical and vaginal epithelium; and (3) the manner of its extension at a distance from the junctional zones.

MorphoIogical classification of the invasive epidermoid carcinomas and of their junctional areas. Special attention in this study was devoted to the relationships of the morphology of invading carcinoma and that of its junctional areas.“, *‘p I5 This was of particular interest when the carcinoma took the form of a carcinoma in situ which was in its functional area the case in 31 of the 75 complete specimens. There has always been recognized a sharp distinction between the adenocarcinomas and the epidermoid carcinomas of the uterine cervix, but this distinction does not correspond to all the facts. Following Hamper1 and Hellweg,Q Glucksmann,‘, R and others,16 we reported a study3 of so-called “double” cervical carcinomas, noting adjacent to the adenocarcinomatous areas, bands of undifferentiated carcinoma, sometimes showing modifications of the nucleus and staining affinities resembling those of squamous cell carcinoma. Two of these previously reported cases showed a complete succession of structural changes which, starting with the carcinomatous columnar cell, passed through all the phases of epidermoid differentiation and ended as a differentiated epidermoid carcinoma on the exocervix.

methods

The present work is based on material obtained from 100 hysterectomies performed for invading squamous cell carcinomas, without previous radium therapy, studied with numerous slides, often in semiserial sections. Of these 100 specimens only 75 provided the entire exocervix and the vaginal vault to permit the study of the epithelium at a distance from the site of invasion. Hematoxylin and eosin stains and for many sections, in order to determine the epidermoid differentiation, the Barrnett and Seligmar? technique for histochemical demonstration of sulfhydryl and disulfide groups of proteins were employed.

From the Department of Pathology, HBpitaZ Boucicaut, and the Colpocytotogy Laboratory, Clinique Cynkcologique, HBpital Broca. Supported National

by a grant from the Institut de la Santk et de la Recherche Me’dicate and from the Cake Primaire de Securite Sociale de la Region Parisienne.

181

182

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Dupre-Froment

On the basis of this previous work, we have classified” the 100 “epidermoid” carcinomas as follows: “Cylindroid” carcinomas (14 cases). Here the architectural and cellular morphology recalls that of adenocarcinoma rather than that of the “epidermoid” variety. There is a tendency to glandular arrangement (Fig. 1) with occasional evidence of mucus secretion in the cytoplasm. Undifferentiated carcinomas (51 cases).

Fig. 1. “Cylindroid” carcinoma of the matous cells in glanduliform arrangement;

There is a crowding of narrow, elongated cells lacking the characteristics of epidcrmoid differentiation (i.e., without intercellular spaces or bridges and without progressive enlargement of the cytoplasm) (Fig. 2). In certain zones, modification in the eosinophilic staining is present, with nuclear pyknosis, giving the appearance of squamous pearls as in the eosinophilic metaplasia often met in the variety of endometrial carcinoma called “adenoacanthoma” (Fig. 3). Tests for

cervix, made up of round a few are mucus-secreting

Fig. 2. Undifferentiated carcinoma, made and without any epidermoid characters.

up of elongated

and

carcinocells.

piled

cells,

Squamous

Fig. 3. Undifferentiated (negative Barrnett and No intercellular bridges;

Fig. spaces

carcinoma, but the eosinophilic Seligmann staining) makes them no prickle-cells.

4. “Epidermoid” and bridges;

positive

carcinoma, Barrnett

with differentiational and Seligmann stain).

SH and SS radicals were negative in all cases. In a total of 51 carcinomas of this 15 were altogether undifferenti9our-h ated, wh ile 36 showed eosinophilic modifications. Truly “epidermoid” carcinomas (22 cases). Intercelh ular spaces and bridges were more or less d istinct and more or less constant in

cell

carcinoma

of

the

cervix

183

modification of the cells resemble squamous pearls.

characters

(intercellular

these cases (Fig. 4). Tests for SH were positive. Well-differentiated and very nlat dermoid carcinomas (13 cases) _ The be termed truly epidermal (Fig. undifferentiated carcinomas, includi those with and without eosinophilic cation, comprised more than 50 per

t ndicals ure epiw could 5:. The .ng both modifi” cent of

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and

Dupre-Fromenf

Fig. 5. “Epidermal” tion,

and with

carcinoma, with “keratinized pearls.”

cancers. They the “epidermoid” cervical appear to arise from the subcylindrical or “reserve” cells of Robert MeyerI which in becoming malignant may remain undifferentiated or may become squamous or columnar cells3, *. lo The site of the junction of the 75 cancers completely studied occurred in the following locations: in 48 cases on the exocervix; in 13 cases in the vaginal vault; and in 18 cases at the endo-exocervical union. The morphology of the cancer in the junctional areas may be of differentiated types on one or the other lip of the cervix in the same case. A study of Table I showing the distribution of these junctional types demonstrates the existence of tze~o topo( 1) those graphic varieties of cancers: bordered by carcinoma in situ which may spread out onto the exocervix. Here the junctional zone may often be situated on the vaginal mucosa; and (2) those without a marginal zone of carcinoma in situ in which the junction is very often situated at the exo-endocervical union with immediate invasion on this site. Study of the type of invading cancer in relation to the type of junctional area, showed that in the 75 removed uteri 44 had a junctional area of undifferentiated type; 19 were of differentiated and mature

complete

differentiation

and

Table I. Distribution cancer

according

matura-

of types of junctional to site of junction

Site of junctron

~Yiyj

cg%j;a

Endo-exocervical Exocervix Vagina

union

Table II. Types

of invading at junctional

type of cancer

16 23 4

2 25 9

cancer, area

and

Type of cancer at junctional zone

No.

T::eg~iEe’

10 14 41

“Epidermal” “Epidermoid” Undifferentiated “Cylindroid”

10

“&{&?;j

?Ji;

L,..

1 5 29

8 4 7

1 5 5

9

0

1

type; and 12 were of mixed type. Zones of differentiated and undifferentiated structure were distributed as shown in Table II. In general there is a correspondence between the general type of the cancer and its aspect at the junctional area. Its variability in a certain number of cases corrob-

Squamous

epithelium:

streams

Fig. 7. Cancerous nar

epithelium.

between the carcinoma of carcinomatous cells

metaplasia

carcinoma

of

the

cervix

carcinoma cells beneath the CIolumnar it, as thelium, progressively raising stream progresses.” I4 The 01Jerlying thelium may be preserved but may on contrary show signs of injur y (oran philia of the cytoplasms, nuclt bar pyknc (Fig. 6) ; and 1,21 true cancer01 1s metrrj)l of the reserve cells, which pr oiiferate pile up, pushing up the columna Lr epitheli which then exfoliates,” resultir 1s~ in an

of the plasticity of the orates the theory original res erve cells. of extension of the cancer into Manner the normal epithelium. Cancer a nd columnar epithelium. Whether the cancer in a given case involves the endothe junction cervix or a n area of ectropion, between th le cancer and the columnar epithelium is formed by one of two processes: “slipping” of streams of f,1) Ry an apparent

Fig. 6. Junction

cell

from

and the columnar under the normal

the reserve

cells

cell cells.

of the colum-

185

epithe epithe $CO4s ) lasia and :um. nn-

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carcinomatous differentiated higher than the surrounding nar epithelium (Fig. 7).

epithelium, normal colum-

Cancer and squamous epithelium. ?‘he junction between the carcinoma and the squamous epithelium may occur in severa abruptly, by zones of ways17 I4 (namely, necrosis and ulceration, and by interposition of a carcinoma in situ). ABRUPT JUNCTION. In 18 of the 75 removed uteri, the junction was clean-cut, and

ran either tangentially or verticaliy. When tangential, the junction is composed of two distinct parts. On the cancer side, the anaplastic cellular elements at first occupy the entire thickness of the epithelium, the germinal layer and the basement membrane being indistinguishable, As the carcinomatous zone becomes narrower, the basement membrane reappears, and the germinal layer again becomes recognizable, though with cellular anomalies and slight anaplasia (Fig. 8).

Fig. 8. Tangential junction between cancer and normal squamous cell epithelium; the place of the regular basal membrane is an edematous line easily torn off; the underlying tissue is infiltrated with inflammatory cells.

Fig. 9. Vertical

junction

between

cancer

and

normal

epithelium.

Squamous

When the junction is vertical, the recognizable layers on the malignant side seem to pass abruptly into those of the normal squamous epithelium (Fig. 9). Serial sections sometimes showed that this aspect simply reflects the overgrowth by the cancer of an ulceration of the exocervical epithelium (Fig. 10). NECROSIS AND ULCERATIONS. Of the 75 uteri removed, 36 showed, at the junction of the cancer with the squamous epithelium, a zone of ulceration which seemed to have

cell

carcinoma

of

the

in successive phases. A necrobiosis. at a middle level of the normal epithelium resulted first in a rapid exfoliation of the upper layers. An edema, separating the stroma from the epithelium, producing a “bubble” aspect, followed with an intense collection of lymphocytes and plasmocytes. Next there appeared to have been a proliferation of angiomatous capillaries rising perpendicularly to the epithelium, giving it a glove-finger appearance (Fig. 11). Later there followed ulceration, leaving naked a granulomatous and hypervascularized stroma, producing the appearance that the colposcopists term “red zone without special character,” which is often observed adjacent to cancers. Finally by a kind of sliding displacement, the ulceration is invaded by the carcinoma (Fig. 12’). In one case (Fig. 13 ) , a large area of normal epithelium, caught between two zones of ulceration with secondary cancerization? was raised above the carcinoma. occurred

IN

Fig. 11. Preulceration of the “cylindroid” carcinoma: diffuse pushing up the epithelium.

i87

appearing squamous

SITU

CANCERS

BORDERING

THF.

IN\‘ASIVE

The in situ cancers,I, 5 whether “isolated and pure,” or bordering an invading carcinoma, appear in two histological forms : ( 1) the undifferentiated type? tnaniC.~RCINOMAS.

Fig. 10. Serial sections of a vertical junction between the normal epithelium and the carcinoma; Repair of an ulceration by the carcinoma “spraying” on the surface.

cervix

normal squamous epithelium lymphocytic infiltration, and

bordering angiomatous

an invasive capillaries

188

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and

Fig. 12. Cancerous ulceration squamous

produced epithelium

Fig. 13. A large caught between by the carcinoma.

two

September 15. I!%5 ,Atn. J. Obst. & Gynec.

Dupre-Froment

sliding displacement along the by the raising of the healthy by angiomatous capillaries.

zone of normal epithelium is zones of ulceration repaired

Fig. 14, Squamous

cell

carcinoma,

festing the classic appearance of cyanophilic cells, undifferentiated, monomorphic, piled in columns arranged perpendicularly to the basal membrane and showing a marked degree of anaplasia; and (2) the differentiated form, resembling the structure of a squamous epithelium of dysplastic type (Fig. 14). When such a lesion later becomes invasive, this deceptive appearance of its earlier stage may lead to the erroneous conclusion that “cancerization of a dysplasia” has occurred. From the tabulation shown in Table III on the distribution of the types of the 31 marginal carcinomas in situ found among the 75 specimens of uterus with invasive cancers, we may reach certain important conclusions. In half of the cases, the marginal carcinoma in situ was of the differentiated the differentiated intype, and further vading carcinoma was nearly always accompanied by a zone of carcinoma in situ of the same type (6 cases out of 7). The “cylindroid” carcinomas on the other hand were practically devoid of carcinoma in situ at their borders. The other varieties of undifferentiated or faintly differentiated carcinomas tended to be accompanied by a marginal carcinoma in situ of variable type but with a predominance of the undifferentiated forms.

resembling

a dysplastic

epithelium.

Squamous

Table III. Types imrasive cancers

of marginal

in situ cancers

found

with

cell

different

carcinoma

of

the

No. of invasive cancers

-

10 14 41 10

-_Totals

75

Histological

type

No. of marginal in situ cancers

“Epidermal” “Epidermoid” Undifferentiated “Cyclindroid”

_-...--_

%

7 8 15 1

I uide,,,,ri-~~~~,.n,n-;n~ ated

70 57 37 10

6 3 6 1 ___--_... 16

31

Manner of extension of the cancer into the normal squamous epithelium at a distance from the junctional zone. The extension of the cancer at some distance from the junctional zone seems to occur by means of three processes (namely, progressive cancerization; development of neighboring epithelial dystrophies; and appearance of multiple cancerous foci). Progressive cancerization occurs as a distant prolongation of the tangential zone of junction above described with considerable preservation of normal architecture and cellular morphology. Hyperplasia of the basal layers, anisonucleosis and an anaplastic arrangement of the nuclei, with many mitoses and irregular chromatin arrangement is observed. Above these abnormal cellular layers is found a cornified layer of normal cells (Fig. 15) . Thus. the basal layer appears already malignant, but the regular arrangement and maturation of the other layers re-

Fig. 15. Progressive cancerization, stroma, and great cellular density.

189

types of

-Total

cervix

.~ .-

tiated 1 .5 9 0

-

15

fleets the restriction of the malignant process the deeper zone. In the apparently normal areas of the exocervix there are often found small sharp digitations directed toward the stroma, which seem to be the forerunners of malignant change.l”l lB Nothing in the cellular morphology distinguishes these projections from the normal basal layer, except the excessive multiplication and density of the cells and a few discreet nuclear anomalies. Epithelial dystrophies with associated necroses sometimes occur at a considerable distance from the zone of invasion, sometimes as far as the vaginal wall. Although the cellular morphology is generally normal. there is an absence of glycogen, an hypertrophy of the squamous epithelium, and areas of superficial and middle layer necrobiosis, separating the epithelium into two levels (Fig. 16). The underlying stroma ma; show abnormally intense vascularization. to

with

wide

digitations

in

the

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Dupre-Fromeni

with congestive dilatation of the capillaries and edematous exudation. Of the 75 completely examined uteri, 55 exocervices and vaginal vaults showed such dystrophic states, often with surface necrosis. The occurrence of these manifestations in relation to the histological types of the carcinoma are shown in Table IV. Multiple cancer foci, most frequently found with the well-differentiated epidermoid carcinomas, were observed in 20 cases, of which 14 were associated with marginal carcinomas in situ. The exocervix, and sometimes the endocervix, may present multi-

Table IV. Occurrence epithelial

dystrophy

No. of cases and type of cancer 10 14 41 10

of outlying areas of and necrotic zones Dystrophic aspect of epithelium

“Epidermal” “Epidermoid” Undifferentiated “Cylindroid”

Occurrence of necrotic zones

5 12

3 8 28

29 9

9

centric zones of carcinoma appearing in the midst of areas of healthy or dystrophic epithelium? However, it should be noted that, because of irregularities of contour, an exocervical carcinoma may give an impression of multicentricity, if the orientation of the section is not correct. True multicentricity will of course be confirmed if, on semiserial sections, the cancerous foci are found to be very far apart and without a joining band. Comment

Marginal zones of invasive cancer and carcinomas in situ. Carcinoma in situ is far

Fig. 16. Superficial half

necrobiosis

involving

from invariably presenting the classical picture of a monomorphous, undifferentiated and immature lesion. Although half of the junctional carcinomas in situ do correspond to this histological type, the other half show

the upper

of the epithelium.

Fig. 17. Multiple exo-endocervical

cancerous junction.

foci

in the

vaginal

vault,

on the exocervix,

and

at the

Squamous

cell

carcinoma

Table V. Relative frequency of special histologic types in the true and the in situ cancers bordering invasive carcinomas

19

in situ

(42)

Inuasiue

cancers

Differentiated

----._

7 8 15 1

with

zones

“Epidermal” “Epidermoid” Undifferentiated “Cylindroid” --___-

of

carcinoma

1 5 9 0 15

!$.5%,

(45!5?%)

in situ (31 ,I -.__--. -__ 1 Differentiated

-_-.-...~

(48%)

Table VI. Extension of the cancer: Comparison between that of true in situ cancers and that of invasive carcinomas with and without bordering in situ cancers - -_____ __---~ Invasive carcinomas Inuasiue carcinomas Border

-

zone

Progressive cancerization Ulceration Multifocality Abrupt junction

without carcinoma

zone of in situ (44)

with carcinoma

7 30 6 6

191

in situ cancers

1 Undifferentiated

15 “Epidermal” 8 “Epidermoid”

cervix

invasive cancer associated with an in situ cancer survive longer than those having an invasive cancer without an in situ cancer, Is the invasive cancer necessarily preceded by the “in situ” stage? Certain carcinomas in situ of sIow evolution terminate, after a latent period of variable length, in invasion. Other cancers invade so rapidly that it is impossible to find any trace of an in situ stage. The question may arise in special cases, whether one is seeing an in situ cancer with invasion, or the zone of extension of a precociously invading cancer. Hence; we may suppose that there exist TWO varieties of invasive carcinomas: the one, in\rading rapidly, the other probably of slower evolution and corresponding to thr form with a marginal carcinoma in situ. As to these latter, it is at present impossible to determine whether in situ cancer is an essential forerunner of the invading cancer. We have followed for several months a number of in situ cancers diagnosed by conization. After some time, these present.ed small xones of invasion, generally differentiated in histology. The in situ stage in these cases may have been a necessary precursor of invasion. Progressive malignant transformation of the dysplasias. The colposcopists have often

an epidermoid differentiation, with a more or less mature architecture. Based on a comparative study of the junctional zones of 42 carcinomas in situ with glandular involvement, removed by hysterectomy, and classed according to the criteria used for the invasive cancers, we have distinguished three types: ( 1) Undifferentiated carcinomas in situ; (,2) differentiated carcinomas in situ of variable maturation; and (3) carcinomas in situ with both differentiated and undifferentiated zones. The endocervical part is more likely to be of undifferentiated and immature type, whereas the exocervical zone is generally differentiated. Table V demonstrates the similarity in frequency of the histologic types observable in the true in situ cancers and the in situ cancers bordering invasive carcinomas. Invasive carcinomas having a zone of in situ cancer often exhibit-as do the “true” in situ carcinomas-an extension of the malignant process, with multiple foci, and more rarely, ulceration (Table VI). From this one might conclude that the isolated carcinomas in situ and those associated with an invasive carcinoma possess an identical biology, and perhaps an identical evolution. We have observed that patients having an

Carcinomas - ---._ Undifferentiated (

of the

___.

zone of in situ (31)

6 3 6 1 -. 16 (52% )

..-- -..

True carcinomas in situ (42)

16 6 14

19r 2;

13

18

-.

~.--

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Dupre-Froment

emphasized the concept of transformation, basing their theory on observations which show, surrounding a colposcopically malignant lesion, images histologically interpreted as dysplasias. In a later period in such cases, they have observed the extension of the cancer to this zone, and this observation has led to the conclusion that the dysplasia had “prepared the bed” for the cancer. Examination of the junctional areas, as carried out in this study, shows that the dysplasia was actually already the carcinoma, but unrecognizable as such because of the still almost insignificant character of its anomalies. Conversely, moreover, certain atypical active, undifferentiated and immature epithelia, the so-called “epithelium of regeneration,” or “reserve cell hyperplasia,” notably the pregare often mistaken for nancy dysplasias, cancers and therefore the opposite errors, that a carcinoma in situ can heal or that a biopsy is sufficient to remove it, have arisen. From the study of the means of extension of the cancer, we discover how very far beyond the cancer itself we may find dystrophies, quite ordinary in appearance, with necrosis, ulceration, hyperplasia of the basal cells, and inflammatory infiltrates, which signify that the epithelium has already been attacked by the cancerigenic process, Roussy, Leroux, and OberlingIl wrote:

“

It is to be noted that these initial stages in the formation of the cancerous nodule can IX’ suspected only because of the presence of ever so slight anomalies in the form, dimensions and staining-reactions of the cells, whose cancerous nature is not revealed, actually, by any really specific morphologic character. Only the late1 stages of growth and local invasion comport themselves in such a way as to provide the signature of cancer. . .“* .

.

.

Summary

A morphologic study of 100 cases of invading “epidermoid” cancers of the uterine cervix removed by hysterectomy showed that 50 per cent of these cancers were undifferentiated or even “cylindroid” in type. Of 75 specimens of hysterectomy with vaginal excision, 43 per cent exhibited border zones of carcinoma in situ. This material has been used to examine the manner of superficial extension of the malignant process on the cervix and the development of signs of malignant change at a distance from the main lesion. Comparison has been made of the histological type of the cancer found in in situ and in invasive lesions and the question of whether carcinoma in situ is an essential step in the development of invasive cancer considered. *English translation of Roussy, G., Leroux, R., and Oberling, C.: Prhcis d’ilnatomie Pathologique, ed. 3, Paris, 1950, Masson et Cie, by permission.

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