Thames Valley Cytology Society

Glandular Neoplasia - A case study

Presented by Viv Marshall, QE II Hospital, Welwyn Garden City

Case presentation at Northwick Park Hospital 27th May 2002 by Vivien Marshall.

An 81 year old patient presented at the Gynae Clinic with a 'jelly-like' discharge which had persisted for several months. The lady was also diabetic and hypertensive.

The cervix could not be visualised. However, a smear was taken along with a pipelle specimen and a vaginal biopsy. The microscopic findings and diagnosis were found to be very similar for both specimens.

Figure 1 shows an area from the smear at high power (x400)

Cytology findings included:

• mucus
• signet ring cells
• strips and individual bizarre epithelial cells
• pleomorphic nuclei
• irregular chromatin
• prominent and pleomorphic nucleoli
  Diagnosis: Mucinous secreting adenocarcinoma

Figure 2 shows the pipelle sample at high power (x400) showing signet ring cells

Pipelle and vaginal biopsy findings included:

• pools of mucin
• cells showing signet ring formation
• strips and individual bizarre epithelial cells
• mitotic figures
  Diagnosis: possible mucinous secreting adenocarcinoma

Possible sites for a primary tumour would be the ovary and gastro-intestinal tract with a endocervical origin being the least likely. It has been suggested that glandular neoplasias represent 0.1% of the total workload and 1-2% of all abnormalities; of this last figure only 0.5% are of an extra uterine origin. (Mathers ME, Johnson SJ, and Wadhera V, Cytopathology 2002; 13: 83-91}

A TAH and BSO were performed one month later and showed the features detailed below. The panneth cells mentioned are a feature of the small intestine being located at the base of the intestinal crypts where they are normally a stable population with a secretory role.

Figure 3: Section of ovary at high power showing signet ring cells consistent with the findings in the smear.

TAH specimen consisted of Uterus, Ovaries, Peritoneal fluid.

Uterus

• tumour mass involving the wall and reaching the excision margin
• extensive mucin secreting adenocarcinoma
• pools of mucin with entrapped signet ring cells
• occasional cells showing granular cytoplasm - similar to panneth cells in GI tract; similar to cells seen in ovarian carcinoma; not seen in endometrial or endocervical carcinomas.

Ovaries showing metastatic deposits of signet cell carcinoma

Peritoneal fluid showing no malignant cells

Diagnosis: Possible gastrointestinal tumour with metastases

FINAL REPORT
The possibility of a gastro-intestinal primary tumour with metastasis to the pelvic organs must be considered. This tumour has a very poor prognosis