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LETTER TO THE EDITOR
Year : 2022  |  Volume : 20  |  Issue : 1  |  Page : 53-54

Immature squamous metaplasia of endocervix – A great mimicker of invasive squamous cell carcinoma of cervix


1 Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
2 Indira Gandhi Medical College and Research Institute, Puducherry, India
3 Department of Pediatrics, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India

Date of Submission02-Sep-2021
Date of Acceptance25-Oct-2021
Date of Web Publication04-Feb-2022

Correspondence Address:
Dr. Vijayan Sharmila
Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_75_21

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How to cite this article:
Sharmila V, Balakrishnan P, Babu TA. Immature squamous metaplasia of endocervix – A great mimicker of invasive squamous cell carcinoma of cervix. Curr Med Issues 2022;20:53-4

How to cite this URL:
Sharmila V, Balakrishnan P, Babu TA. Immature squamous metaplasia of endocervix – A great mimicker of invasive squamous cell carcinoma of cervix. Curr Med Issues [serial online] 2022 [cited 2022 Jul 1];20:53-4. Available from: https://www.cmijournal.org/text.asp?2022/20/1/53/337307



Dear Editor,

Histopathology is the gold standard investigation for diagnosis of squamous cell carcinoma of the cervix. There are numerous benign lesions of the cervix which mimic cervical intraepithelial neoplasia (CIN), in situ squamous cell carcinoma, and squamous cell carcinoma in histopathology.[1] Pathologists must know to differentiate squamous cell carcinoma from benign mimicking lesions in the cervix, thereby avoiding false-positive diagnosis and unnecessary radical therapy for a patient. Here, we report a case of immature squamous metaplasia of the cervix in a 40-year-old perimenopausal woman which mimicked invasive squamous cell carcinoma by histopathology.

A 40-year-old multiparous perimenopausal woman came with complaints of discharge per vaginum for 1 year. Per speculum examination revealed moderate amount of mucoid nonblood-stained vaginal discharge. Examination of the cervix revealed an incidental detection of 0.5 cm × 0.5 cm mass arising from the posterior lip of the cervix near the squamocolumnar junction. Histopathological examination of the biopsy from the cervical lesion revealed thickened surface squamous epithelium and nests of squamous cells in the cervical stroma in scanner view [Figure 1]a. In low-power magnification, majority of the endocervical glands were lined by both single layer of columnar cells and squamous cells with preserved glandular architecture and lumen [Figure 1]b. Few of endocervical glands were lined by single layer of columnar epithelium with preserved architecture and lumen [Figure 1]c. The tightly packed well-defined nests of squamous cells in the cervical stroma were endocervical glands completely lined by immature squamous metaplastic cells obliterating the lumen. In high-power magnification, squamous cells in the lower two-third of surface epithelium and in nests showed eosinophilic cytoplasm and round smooth nuclei, dispersed chromatin with prominent nucleoli with high nuclear-to-cytoplasmic ratio [Figure 1]d. The diagnosis of immature squamous metaplasia without atypia involving endocervical surface epithelium and glands was made based on the histopathological features. The patient was treated with tablet azithromycin 1 g and tablet cefixime 400 mg stat dose for cervical discharge (gray kit) as per syndromic approach. had Per speculum examination performed after one month revealed no abnormal discharge and normal cervix and vagina. She was advised to review if symptoms recur or at 6 months for a Pap smear examination.
Figure 1: (a) Photomicrograph showing nests of squamous cells in cervical stroma (H and E stain, ×40) (black arrow). (b) Photomicrograph showing endocervical glands lined by columnar cells and immature squamous metaplastic cells (black arrow) (H and E stain, ×400). (c) Photomicrograph showing normal endocervical glands lined by single layer of columnar epithelium with lumen (black arrow) (H and E stain, ×400). (d) Photomicrograph showing endocervical glands lined by immature squamous metaplastic cells obliterating lumen, appearing as nests of squamous cells (black arrow) (H and E stain, ×400)

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Immature squamous metaplasia of the cervix is a protective phenomenon wherein columnar cells in the endocervical surface and the glands are replaced by immature metaplastic squamous cells, due to chronic persistent irritation of the cervix. This is one of the mimickers of cervical malignancy. Histopathological features which mimicked squamous cell carcinoma in our case include the presence of nests of squamous cells in cervical stroma, high nuclear cytoplasmic ratio, prominent nucleoli, and presence of squamous epithelium lining endocervical glands. Endocervical glands have squamous epithelium lining when there is squamous metaplasia or glandular invasion by invasive squamous cell carcinoma. Features favoring benign squamous metaplasia of the endocervix include a well-defined border of nests of squamous cells, cohesion of squamous cells, uniform round smooth nucleus, dispersed chromatin, and absence of pleomorphic hyperchromatic nuclei of squamous cells and atypical mitotic figures.[1]

Immature squamous metaplasia of the cervix without atypia is not a premalignant lesion whereas immature squamous metaplasia of the cervix with mild nuclear atypical features is a precursor of cervical lesion. Hence, mild nuclear atypia in immature squamous metaplasia is an ominous clue for future progression of lesion to invasive carcinoma.[2]

In case of diagnostic difficulty with histopathological features, the combined use of immunohistochemical markers such as p16INK4a and ki-67 is advised.[3] p16INK4a is a marker for HPV-induced cervical dysplasia, and Ki-67 is nuclear proliferative marker. In immature squamous metaplasia, Ki-67 nuclear positivity is confined to basal and parabasal layers of surface epithelium, and p16INK4a is negative. In CIN 3, carcinoma in situ, and invasive squamous cell carcinoma, Ki-67 nuclear positivity involves full-thickness epithelium and p16INK4a shows diffuse strong cytoplasmic and nuclear positivity involving full-thickness epithelium.[4],[5] In our case, immunohistochemical analysis was not done due to affordability issues.

Histopathologists should be aware of histopathological features of benign mimics of CIN and squamous cell carcinoma and should make use of immunohistochemical markers, whenever there is diagnostic dilemma in reporting cervical biopsy specimen to improve diagnostic accuracy and to avoid unnecessary radical therapy for the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Manek S. Benign mimics of cervical cancers. J Diagn Pathol 2015;10:1-13.  Back to cited text no. 1
    
2.
Iaconis L, Hyjek E, Ellenson LH, Pirog EC. p16 and Ki-67 immunostaining in atypical immature squamous metaplasia of the uterine cervix: Correlation with human papillomavirus detection. Arch Pathol Lab Med 2007;131:1343-9.  Back to cited text no. 2
    
3.
Kalof AN, Cooper K. Our approach to squamous intraepithelial lesions of the uterine cervix. J Clin Pathol 2007;60:449-55.  Back to cited text no. 3
    
4.
Wright TC, Ronnett BM. Benign diseases of the cervix. In: Kurman RJ, Ellenson LH, Ronnett BM, editors. Blaustein's Pathology of the Female Genital Tract. 7th ed. Switzerland: Springer; 2019. p. 205-7.  Back to cited text no. 4
    
5.
Miyatake T, Ueda Y, Yoshino K, Shroyer KR, Kanao H, Sun H, et al. Clonality analysis and human papillomavirus infection in squamous metaplasia and atypical immature metaplasia of uterine cervix: Is atypical immature metaplasia a precursor to cervical intraepithelial neoplasia 3? Int J Gynecol Pathol 2007;26:180-7.  Back to cited text no. 5
    


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