Cytological diagnosis of invasive endocervical adenocarcinoma

While the Pap test is a sensitive test for CIN and early invasive squamous carcinoma of the cervix it is less sensitive for the detection of adenocarcinoma. The chances of detection is improved if an endocervical brush is used routinely to ensure the endocervical canal is sampled . The brush must always be used in conjunction with the spatula to ensure the transformation zone is sampled.
Adenocarcinoma in situ (AIS) It is difficult to distinguish between in situ adenocarcinoma and well differentiated invasive adenocarcinoma on the basis of the cytological findings. in AIS abnormal and normal endocervical epithelium may be found in close association in the same smear. In AIS is usually clean.
In well differentiated adenocarcinoma the glandular cells occur in sheets, clusters strips and rosettes . The individual cells have an obvious columnar appearance and may be in palisade or honey comb formation and are generally well preserved.
Unlike the normal palisade, the nuclei vary in size and shape. This is most apparent at the edge of the cluster.
Within the honey comb the nuclei are crowded and overlapping giving a hyperchromatic appearance to the group of cells although individually the nuclear chromatin may be finely granular Mitoses and nucleoli may be seen.
In moderately and poorly differentiated adenocarcinomas the glandular origin of the tumour is less apparent and the cytological presentation much more variable. The cell clusters may be so densely packed that it is only by examining the edge of the tumour or the occasional discrete tumour cell that the glandular nature can be ascertained. Variation in nuclear size, enlarged and multiple nucleoli, and mitoses may be seen.
Background : In adenocarcinoma in situ and in early stage adenocarcinoma the background to the smear is generally clean. In more advanced tumours the background may contain fresh and altered blood, polymorphs,and necrotic cell debris (the so called tumour diathesis).
Abnormal squamous cells may be present if there is a coexisting squamous lesion.

Adenocarcinoma in situ:

Cervical scrapes from a focus of AIS are often very cellular containing numerous sheets of glandular cells. This in itself should raise suspicion of glandular neoplasia unless the specimen has been taken with an endocervical brush. In this slide the nuclei are crowded , hyperchromatic but their columnar shape can be readily recognised.Note the clean background. Sheets of normal endocervical epithelium were also found in the smear. Note clean background.

A cluster of neoplastic cells from a focus of AIS. There is some loss of polarity, variation in nuclear size and an obvious nuclear hyperchromasia but the honeycomb pattern can still be discerned. The distinction between AIS and invasive adenocarcinoma cannot be made with a high degree of certainty

Well differentiated invasive endocervical adenocarcinoma:

Endocervical adenocarcinoma; Sheet of glandular cells in cervical smear showing feathering and palisade formation at the edges of the sheet.

Adenocarcinoma showing palisade formation at higher magnification Note uneven distribution of the nuclei in the palisade

Endocervical adenocarcinoma :Strips of crowded columnar cells showing pseudostratifiction with dense overlapping nuclei but the glandular architecture is still preserved.

Invasive endocervical adenocarcinoma: a three dimensional cluster of glandular cells. Apart from the background the morphology is similar to that found in AIS

Endocervical adenocarcinoma (poorly differentiated) Nuclei are large pleomorphic with irregular chromatin and the cytoplasm is abundant and delicate but little of the glandular architecture is retained.

Metastatic endocervical adenocarcinoma:

Other malignant neoplasms: Endometrial carcinoma in a cervical smear

Other malignant neoplasms: Metastatic colon adenocarcinoma in a cervical smear

Endocervical adenocarcinoma(poorly differentiated): The cluster is composed of undifferentiated tumour cells with scant cytoplasm and nuclei which vary in size. The delicate chromatin structure of the nuclei and the macronucleoli are consistent with adenocarcinoma.

Other malignant neoplasms: Ovarian carcinoma in a cervical smears

Poorly differentiated endocervical adenocarcinoma:

Endocervical adenocarcinoma:There is little to distinguish this hyperchromatic cluster of malignant glandular cells form those found in a poorly differentiated squamous carcinoma.