Cervical Deciduosis and Intraepithelial Neoplasia George W. Chapman, MD, Edward W. Savage, MD, and Frank A. Salem, MD New York, New York, and Los Angeles, California
With the widespread use of routine cervical cytologic screening in pregnancy and the increasing use of colposcopy, the problem of coexistent decidual and neoplastic cervical changes becomes more frequent. This case report illustrates such a problem and discusses its management.
Decidual cells are often seen on Papanicoloau smears obtained during pregnancy. Sometimes these cells appear bizarre and simulate dysplasia, necessitating tissue examination to rule out neoplasia. The problem may be compounded when decidual cells coexist with actual cervical intraepithelial neoplasia (CIN). Colposcopy may serve to distinguish these conditions. The case presented here illustrates the problem of coexisting decidual and neoplastic changes and the limitation of colposcopic directed biopsy in the absence of complete visualization of the squamocolumnar junction. However, if the colposcopic examination is satisfactory, directed biopsy may replace cone biopsy even during pregnancy.
and an increased nucleocytoplasmic ratio. On colposcopic examination, there was a moderately abnormal surface pattern, interpreted as a Grade 1 abnormal transformation zone (Figure 2). The examination was unsatisfactory because the squamocolumnar junction could not be seen. The histological finding of the colposcopically directed biopsy was interpreted as squamous metaplasia, acute and chronic cervicitis, and decidual reaction. Because of the discrepancy between the cervical cytology and biopsy, the patient underwent cervical cone biopsy. The pathologic examination revealed severe dysplasia (CIN III) and
decidual changes suggestive of pregnancy (Figure 3). The patient did well postoperatively and was discharged on the second postoperative day to be followed in the Prenatal Clinic.
Discussion The pregnant cervix has a remarkable propensity for reacting to hormonal stimuli with modification of the histological appearance and transformation of the gross appearance of the cervix. Changes occur in the columnar
Case Presentation The patient was a 35-year-old Mexican-American female at 25-weeks gestation. On routine prenatal evaluation, a Class V Papanicoloau smear (Figure 1) was obtained. Clusters of abnormal cells were present with pleomorphism, hyperchromatic nuclei,
Requests for reprints should be addressed to Dr. Edward W. Savage, Director of Gynecology, Martin Luther King, Jr General Hospital, 12021 S Wilmington Avenue, Los Angeles, CA 90059.
00
.i;.. kO
Figre . Cuser of abora cells;4ar senwihaepemopi
ihhpr
Figure 1. Clusters of abnormal cells are seen which are pleomorphic with hyperchromatic nuclei, dense nuclear membranes, and increased nucleocytoplasmic ratio
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 8, 1979
787
V4
4
Figure 2. Colpo photograph showing the flat form of cervical decidual change. The lesion appears white and, in addition, there are a few punctate vessels present
and squamous epithelium as well as the stroma. The stratified squamous epithelium reacts to the presence of estrogens with a specific hyperactivity. There is an increase in the metabolism and synthesis of DNA in the basal cell layers. Progesterone inhibits cellular maturation and produces thickening of all layers of epithelium. Basal cell hyperactivity manifests itself by increased mitosis and poor differentiation at the level of the intermediate and superficial layers.1 Decidual changes in the stroma are well known and are characteristic of pregnancy. Large fields of decidual cells are often noted in the cervical stroma but may also occur in small patches. The cells become very bizarre and resemble carcinoma in some cases.2 Klein described a case in which decidual cells surrounding a cervical gland suggested invasive disease.3 The origin of the decidual cell in the cervix is unknown but has been attributed to transformation of a focus of endometriosis or to evolution of undifferentiated embryonic cells.1 The more commonly accepted thesis is that the decidual change is simply a reaction of normal stromal cells to hormonal stimulation. The incidence of deciduosis is difficult to determine but has been variously estimated as occurring in from ten to 34 percent of all pregnancies. '12 The earliest changes are seen at approximately 16-weeks gestation and disappear rapidly after delivery. 788
_-s;OFzu^,W-~ 1-,> ft~~~~4
4',
Figure 3. An area of cervical cone biopsy showing severe dysplasia of the surface squamous epithelium with loss of maturation and hyperchromatic nuclei. The underlying stroma shows pronounced chronic inflammation and a few aggregates of decidual cells (left lower corner)
~~~~~~~~~.~~~~~~k
44 Figure 4. An area from the cervical cone biopsy showing stromal cells which have become large and polygonal with a wide zone of foamy cytoplasm surrounding
the nucleus
The decidual reaction or decidualization is the most specific histologic finding of the pregnant cervix' and is of great interest because it creates colposcopic images which are unknown to many gynecologists. Colposcopy is an excellent means of evaluating abnormal
cytology but does not afford great precision in the diagnosis of deciduosis, because it does not register more than those decidual reactions close to the surface. Deciduosis may appear in several forms depending on the depth, density, and extent of the underlying
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 8, 1979
lesion which reflects its influence upon the stratified squamous covering. The following varieties of colposcopic change may be distinguished: 1. The flat form is seen as a poorly demarcated, red congestive zone which becomes white after applying acetic acid. It is level with the undamaged mucosa. 2. The focal form appears as a small elevation above the surface and is modified very little by acetic acid. A red or purple pseudopolypoid lesion near the cervical os, which reacts only slightly to acetic acid application, characterizes the tumor form. 3. The ulcerated form usually evolves from the other forms and differs little from them in appearance. Acetic acid, however, coagulates its fibrinous exudate and produces a typical "white frost" on its surface. Laplan4 reported a case of deciduosis of the cervix and vagina grossly resembling carcinoma and suggests the differential diagnosis of deciduosis should include carcinoma, sarcoma, polyps of the endometrium, benign cervical adenomas, and epithelial polyps. Murphy5 similarly feels that
cervical decidual reactions are always associated with polyps or a polypoid reaction. The patient presented here demonstrated the flat form of cervical decidual change. The lesion appeared white with the application of acetic acid, but in addition there was white epithelium with punctate vessels.(This lesion must have been overlooked on punch biopsy.) The squamous epithelium extended well into the endocervical canal anteriorly; a cervical cone biopsy was performed and revealed severe dysplasia (CIN III) with marked deciduosis (Figure 4). When an abnormal Papanicoloau smear is detected and only decidual changes are present on colposcopic examination, the biopsy may be safely omitted if the examination is satisfactory (squamocolumnar junction seen in its entirety). If the colposcopic examination reveals decidual and neoplastic patterns, directed biopsy is indicated. Cone biopsy of the cervix may be limited to patients in which the smear is suspect for neoplasia and the examination is unsatisfactory, as in the patient presented here.
When decidual cells are seen in combination with neoplastic cells, the standard approach to rule out invasive cancer must be employed (ie, colposcopically directed biopsy and conization of the cervix if the examination is unsatisfactory). Colposcopic examinations, when satisfactory, will obviate the expense, the necessity for hospitalization, and potential short and long-term morbid complications of diagnostic cervical cone, including infection, hemorrhage, infertility, and occasional dysmenorrhea.6
Literature Cited 1. Dexeus Jr. S, Carrera JM, Coupez F: Colposcopy: Major Problems in Obstetrics and
Gynecology, vol 10. Philadelphia, WB Saunders, 1977, 239-244 2. Bowles HE, Tilden TL: Decidual reactions
of the cervix. Western J Surg Obstet Gynecol 59:168-170, 1951 3. Klein J, Domeier LC: An unusual reaction in the cervix. Am J Obstet Gynecol 51:423-426, 1946 4. Laplan B: Deciduosis of the cervix and vagina simulating carcinoma. Am J Obstet Gynecol 58:743-747, 1949 5. Murphy EJ, Herbut PA: Uterine cervix during pregnancy. Am J Obstet Gynecol 59:384-390, 1950 6. Savage EW, Chapman GW: Problems of cytological screening in a young urban population. Urban Health 6(2):31, 1977
Rochester Institute of TechnoIogy Announces Plans for Its I 50th Anniversary Scholarship Awards As part of its 150th Anniversary Celebration this year, Rochester (NY) Institute of Technology (RIT) will award individual $1,500 scholarships to 150 babies born on June 12, 1979. It was on that date 150 years ago that the Rochester Athenaeum, RIT's predecessor, was founded. Parents of all "anniversary" babies need only to submit a brief letter giving the name of their baby, and their home address and telephone number. The first 150 respondents, as determined by postmark of the letters, will be declared winners of the scholarships. However, they must be admitted to the Institute when ready for college. A list of alternates will be chosen by the same process. The scholarships will be available starting in 1997, when the recipients are ready for enrollment at RIT. The award JOURNAL OF THE NAtIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 8, 1979
winners will be known as the "McClure Scholars." The scholarships are applicable to full-time or part-time/day or evening education, and may be used until 2002. Parents should send their letters to: RIT McClure Scholars Rochester Institute of Technology (1829) One Lomb Memorial Drive Rochester, New York 14623 Deadline for this registration step is October 1, 1979. The Institute reserves the right to verify the date of birth of the baby. This scholarship offering is void where prohibited by law. The Institute will announce the names of the 150 winners, and the alternate list, during RIT's 150th Anniversary Celebration weekend, October 19-21, 1979. 789
With the widespread use of routine cervical cytologic screening in pregnancy and the increasing use of colposcopy, the problem of coexistent decidual and neoplastic cervical changes becomes more frequent. This case report illustrates such a problem and discusses its management.
Decidual cells are often seen on Papanicoloau smears obtained during pregnancy. Sometimes these cells appear bizarre and simulate dysplasia, necessitating tissue examination to rule out neoplasia. The problem may be compounded when decidual cells coexist with actual cervical intraepithelial neoplasia (CIN). Colposcopy may serve to distinguish these conditions. The case presented here illustrates the problem of coexisting decidual and neoplastic changes and the limitation of colposcopic directed biopsy in the absence of complete visualization of the squamocolumnar junction. However, if the colposcopic examination is satisfactory, directed biopsy may replace cone biopsy even during pregnancy.
and an increased nucleocytoplasmic ratio. On colposcopic examination, there was a moderately abnormal surface pattern, interpreted as a Grade 1 abnormal transformation zone (Figure 2). The examination was unsatisfactory because the squamocolumnar junction could not be seen. The histological finding of the colposcopically directed biopsy was interpreted as squamous metaplasia, acute and chronic cervicitis, and decidual reaction. Because of the discrepancy between the cervical cytology and biopsy, the patient underwent cervical cone biopsy. The pathologic examination revealed severe dysplasia (CIN III) and
decidual changes suggestive of pregnancy (Figure 3). The patient did well postoperatively and was discharged on the second postoperative day to be followed in the Prenatal Clinic.
Discussion The pregnant cervix has a remarkable propensity for reacting to hormonal stimuli with modification of the histological appearance and transformation of the gross appearance of the cervix. Changes occur in the columnar
Case Presentation The patient was a 35-year-old Mexican-American female at 25-weeks gestation. On routine prenatal evaluation, a Class V Papanicoloau smear (Figure 1) was obtained. Clusters of abnormal cells were present with pleomorphism, hyperchromatic nuclei,
Requests for reprints should be addressed to Dr. Edward W. Savage, Director of Gynecology, Martin Luther King, Jr General Hospital, 12021 S Wilmington Avenue, Los Angeles, CA 90059.
00
.i;.. kO
Figre . Cuser of abora cells;4ar senwihaepemopi
ihhpr
Figure 1. Clusters of abnormal cells are seen which are pleomorphic with hyperchromatic nuclei, dense nuclear membranes, and increased nucleocytoplasmic ratio
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 8, 1979
787
V4
4
Figure 2. Colpo photograph showing the flat form of cervical decidual change. The lesion appears white and, in addition, there are a few punctate vessels present
and squamous epithelium as well as the stroma. The stratified squamous epithelium reacts to the presence of estrogens with a specific hyperactivity. There is an increase in the metabolism and synthesis of DNA in the basal cell layers. Progesterone inhibits cellular maturation and produces thickening of all layers of epithelium. Basal cell hyperactivity manifests itself by increased mitosis and poor differentiation at the level of the intermediate and superficial layers.1 Decidual changes in the stroma are well known and are characteristic of pregnancy. Large fields of decidual cells are often noted in the cervical stroma but may also occur in small patches. The cells become very bizarre and resemble carcinoma in some cases.2 Klein described a case in which decidual cells surrounding a cervical gland suggested invasive disease.3 The origin of the decidual cell in the cervix is unknown but has been attributed to transformation of a focus of endometriosis or to evolution of undifferentiated embryonic cells.1 The more commonly accepted thesis is that the decidual change is simply a reaction of normal stromal cells to hormonal stimulation. The incidence of deciduosis is difficult to determine but has been variously estimated as occurring in from ten to 34 percent of all pregnancies. '12 The earliest changes are seen at approximately 16-weeks gestation and disappear rapidly after delivery. 788
_-s;OFzu^,W-~ 1-,> ft~~~~4
4',
Figure 3. An area of cervical cone biopsy showing severe dysplasia of the surface squamous epithelium with loss of maturation and hyperchromatic nuclei. The underlying stroma shows pronounced chronic inflammation and a few aggregates of decidual cells (left lower corner)
~~~~~~~~~.~~~~~~k
44 Figure 4. An area from the cervical cone biopsy showing stromal cells which have become large and polygonal with a wide zone of foamy cytoplasm surrounding
the nucleus
The decidual reaction or decidualization is the most specific histologic finding of the pregnant cervix' and is of great interest because it creates colposcopic images which are unknown to many gynecologists. Colposcopy is an excellent means of evaluating abnormal
cytology but does not afford great precision in the diagnosis of deciduosis, because it does not register more than those decidual reactions close to the surface. Deciduosis may appear in several forms depending on the depth, density, and extent of the underlying
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 8, 1979
lesion which reflects its influence upon the stratified squamous covering. The following varieties of colposcopic change may be distinguished: 1. The flat form is seen as a poorly demarcated, red congestive zone which becomes white after applying acetic acid. It is level with the undamaged mucosa. 2. The focal form appears as a small elevation above the surface and is modified very little by acetic acid. A red or purple pseudopolypoid lesion near the cervical os, which reacts only slightly to acetic acid application, characterizes the tumor form. 3. The ulcerated form usually evolves from the other forms and differs little from them in appearance. Acetic acid, however, coagulates its fibrinous exudate and produces a typical "white frost" on its surface. Laplan4 reported a case of deciduosis of the cervix and vagina grossly resembling carcinoma and suggests the differential diagnosis of deciduosis should include carcinoma, sarcoma, polyps of the endometrium, benign cervical adenomas, and epithelial polyps. Murphy5 similarly feels that
cervical decidual reactions are always associated with polyps or a polypoid reaction. The patient presented here demonstrated the flat form of cervical decidual change. The lesion appeared white with the application of acetic acid, but in addition there was white epithelium with punctate vessels.(This lesion must have been overlooked on punch biopsy.) The squamous epithelium extended well into the endocervical canal anteriorly; a cervical cone biopsy was performed and revealed severe dysplasia (CIN III) with marked deciduosis (Figure 4). When an abnormal Papanicoloau smear is detected and only decidual changes are present on colposcopic examination, the biopsy may be safely omitted if the examination is satisfactory (squamocolumnar junction seen in its entirety). If the colposcopic examination reveals decidual and neoplastic patterns, directed biopsy is indicated. Cone biopsy of the cervix may be limited to patients in which the smear is suspect for neoplasia and the examination is unsatisfactory, as in the patient presented here.
When decidual cells are seen in combination with neoplastic cells, the standard approach to rule out invasive cancer must be employed (ie, colposcopically directed biopsy and conization of the cervix if the examination is unsatisfactory). Colposcopic examinations, when satisfactory, will obviate the expense, the necessity for hospitalization, and potential short and long-term morbid complications of diagnostic cervical cone, including infection, hemorrhage, infertility, and occasional dysmenorrhea.6
Literature Cited 1. Dexeus Jr. S, Carrera JM, Coupez F: Colposcopy: Major Problems in Obstetrics and
Gynecology, vol 10. Philadelphia, WB Saunders, 1977, 239-244 2. Bowles HE, Tilden TL: Decidual reactions
of the cervix. Western J Surg Obstet Gynecol 59:168-170, 1951 3. Klein J, Domeier LC: An unusual reaction in the cervix. Am J Obstet Gynecol 51:423-426, 1946 4. Laplan B: Deciduosis of the cervix and vagina simulating carcinoma. Am J Obstet Gynecol 58:743-747, 1949 5. Murphy EJ, Herbut PA: Uterine cervix during pregnancy. Am J Obstet Gynecol 59:384-390, 1950 6. Savage EW, Chapman GW: Problems of cytological screening in a young urban population. Urban Health 6(2):31, 1977
Rochester Institute of TechnoIogy Announces Plans for Its I 50th Anniversary Scholarship Awards As part of its 150th Anniversary Celebration this year, Rochester (NY) Institute of Technology (RIT) will award individual $1,500 scholarships to 150 babies born on June 12, 1979. It was on that date 150 years ago that the Rochester Athenaeum, RIT's predecessor, was founded. Parents of all "anniversary" babies need only to submit a brief letter giving the name of their baby, and their home address and telephone number. The first 150 respondents, as determined by postmark of the letters, will be declared winners of the scholarships. However, they must be admitted to the Institute when ready for college. A list of alternates will be chosen by the same process. The scholarships will be available starting in 1997, when the recipients are ready for enrollment at RIT. The award JOURNAL OF THE NAtIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 8, 1979
winners will be known as the "McClure Scholars." The scholarships are applicable to full-time or part-time/day or evening education, and may be used until 2002. Parents should send their letters to: RIT McClure Scholars Rochester Institute of Technology (1829) One Lomb Memorial Drive Rochester, New York 14623 Deadline for this registration step is October 1, 1979. The Institute reserves the right to verify the date of birth of the baby. This scholarship offering is void where prohibited by law. The Institute will announce the names of the 150 winners, and the alternate list, during RIT's 150th Anniversary Celebration weekend, October 19-21, 1979. 789
