New Insights in the Diagnosis of Rare Adenocarcinoma Variants of the Cervix-Case Report and Review of Literature

Abstract

We report the case of a 29-year-old patient with low-grade squamous intraepithelial lesion (L-SIL), negative human papilloma virus (HPV), positive p16/Ki-67 dual-staining and colposcopy suggestive for severe dysplastic lesion. The patient underwent a loop electrosurgical excision procedure (LEEP), the pathology report revealing mesonephric hyperplasia and adenocarcinoma. The patient also opted for non-standard fertility-sparing treatment. The trachelectomy pathology report described a zone of hyperplasia at the limit of resection towards the uterine isthmus. Two supplementary interpretations of the slides and immunohistochemistry (IHC) were performed. The results supported the diagnosis of mesonephric adenocarcinoma, although with difficulty in differentiating it from mesonephric hyperplasia. Given the discordant pathology results that were inconclusive in establishing a precise diagnosis of the lesion and the state of the limits of resection, the patient was referred to a specialist abroad. Furthermore, the additional interpretation of the slides and IHC were performed, the results suggesting a clear cell carcinoma. The positive p16/Ki-67 dual-staining prior to LEEP, the non-specific IHC and the difficulties in establishing a diagnosis made the case interesting. Given the limitations of cytology and the fact that these variants are independent of HPV infection, dual staining p16/Ki-67 could potentially become useful in the diagnosis of rare adenocarcinoma variants of the cervix, however further documentation is required.

Keywords: adenocarcinoma; cervix; clear cell; dual-staining; immunohistochemistry; mesonephric; p16/Ki-67.

Figure 1

(a,b) (detail)—H&E stain—conization specimen—atypical mesonephric hyperplasia with a malignant transformation zone—mesonephric adenocarcinoma with moderate cell pleomorphism, moderate mitotic activity, without invasion of the lymphovascular space.

Figure 2

H&E stain—Vaginal wall with non-specific chronic inflammation, at the level of the subepithelial stroma we find micro focaries of mesonephric remains within the histological limits of benignity.

Figure 3

H&E stain—Trachelectomy specimen—Uterine isthmus—endocervix—upper limit of resection with benign mesonephric hyperplasia with areas of atypical mesonephric hyperplasia, showing moderate atypia.

Figure 4

(a–c)—detail—H&E stain—Trachelectomy specimen—Cervix with previous conization—chronic ulcero-granulomatous cervicitis, condilomatous squamous epithelium; at the level of the subepithelial stroma there is a tumoral proliferation consisting of delimited tubular structures of cubic cells, non-ciliated, with moderate, eosinophilic or clear cytoplasm, presenting in the lumen an eosinophilic hyaline secretion producing a histological appearance of atypical mesonephric hyperplasia; zone of stromal invasion and malignant transformation—endocervical mesonephric adenocarcinoma with moderate cell pleomorphism and mitotic activity, intraluminal detritus, added inflammation.