Neoplasia Case Studies II


CASE 1: Squamous cell carcinoma of the cervix


History:

A 44-year-old woman comes to you because of irregular spotting of blood, but not a heavy volume, between menstrual periods. She tells you that she had an abnormal Pap smear "about 10 years ago" but did not return to the clinic to follow up on it. Further history reveals that she has had multiple sexual partners over the last 30 years. On physical examination, you find a large fungating area with erosion on the cervix. You take a Pap smear. The results of the Pap smear confirm your suspicions, and you refer the patient to a gynecologist, who finds only the cervical lesion. The uterus and adnexae appear normal in size. The patient has no abdominal or pelvic pain. There is no lymphadenopathy palpable. A cervical biopsy is taken.

Image 1.1:

This is the original Pap smear. How would you describe the cells? The cells are "atypical" and show variation in size and shape as well as increased nuclear chromatin (hyperchromasia).

Image 1.2:

This is representative of the lesion from which the cells on the Pap smear came. What is the process? Normal squamous epithelium merges into a more disordered epithelium that is dysplastic.

Image 1.3:

The gross appearance of the cervical lesion is seen. Describe the lesion. A mass is present that has an exophytic (growing outward from the epithelial surface) appearance. The surface is rough, irregular, and different in color from the surrounding epithelium.

Image 1.4:

The high power microscopic appearance of the lesion is seen. Describe the appareance. Cells are arranged in irregular sheets and nests. The cells show pink cytoplasm and have occasional intercellular bridges. The nuclei are quite atypical.
  1. Why do you think the Pap smear showed 10 years ago? What natural history of neoplasia could be represented here?

    2. The Pap smear showed a dysplasia. There are increasing severities to dysplasia and, if left untreated, there is a good possibility of progression to carcinoma. This illustrates the concept of metaplasia- dysplasia-carcinoma.

  2. What factor or factors may have played a role in the development of the neoplasm?

    3. In this case, the sexual history suggests the possibility of association with human papillomavirus (HPV) infection. This is an example of viral oncogenesis. Other examples include Epstein-Barr virus and lymphomas or nasopharyngeal carcinomas, as well as hepatitis virus and hepatocellular carcinoma.

  3. What are the pathologic features that provide clues to the diagnosis?

    4. The gross appearance is a mass lesion. It is arising on an epithelial surface, which suggests a carcinoma. Cytologic features of neoplasia include: hyperchromatism, pleomorphism, increased nuclear/cytoplasmic ratio. Cells with such features are said to be less "differentiated" from the normal counterpart. Tumor cells that do not resemble the cell of origin are said to exhibit anaplasia.

  4. How would you grade and stage this neoplasm?

    5. Grading is based upon the degree of differentiation. Most tumors are graded on a scale of I to III or I to IV, with the III or IV representing the least amount of differentiation. Staging is based upon the extent of spread of the tumor. Stages are usually given as I to IV, or as a TNM classification for local, nodal, and distant spread.