CORRESPONDENCE
Squamous cell neoplastic change in patients with vaginal adenosis
precipitate unnecessarily radical treatment for adenosis in these young women, treatment perhaps associated with medical and emotional problems. Louis Burke, M.D., F.A.C.O.G. Department of Obstetrics and Gynecology Donald Antonio& M.D. Department of Pathology Beth Israel Hospital 330 Brookline Ave. Boston, Massachusetts 02215
To the Editors: We feel we must take exception to the implication that there is a high incidence of potentially malignant squamous cell neoplastic change in patients with vaginal adenosis as stated in the article, “Squamous neoplasia of vagina related to DES syndrome,” by William C. Fetherston, M.D., which appeared on page 176 of the May 15, 1975, issue of the AMERICAN JOURNAL
OF OBSTETRICS
AND
J
GYNECOLOGY.
Dr. Fetherston stated that 6 of the 46 patients (13 percent) in his series had biopsy-proved squamous dysplasia while a seventh patient showed squamous carcinoma in situ. This is in contrast to our experience, summarized in an article recently accepted for publication in the American Journal of Clinical Pathology, 1 in which we found no case of true squamous cell dysplasia in a group of 88 women with vaginal adenosis. In evaluation of almost 80 additional women, we have encountered only one patient with squamous cell dysplasia of a mild to moderate degree. Likewise, in a recent article, Herbst and associate? reported finding only four cases of mild squamous dysplasia after cytologic examination of vaginal scrapings or aspirates in 110 DES-exposed subjects, and “This change was not confirmed in any by multiple punch biopsies.” The differing incidences of dysplasia found in Dr. Fetherston’s series and in our own might be due to differences in histologic criteria for dysplasia. No criteria are given in Dr. Fetherston’s article, but we reserve the term “dysplasia” for lesions showing distinct nuclear abnormalities, including hyperchromasia, nuclear pleomorphism, and crowding with loss of polarity. In our experience, many of the atypicalities noted colposcopically, such as white epithelium, mosaicism, etc., correlate histologically with squamous metaplasia, poorly glycogenated mucosa, or regenerative responses to inflammation. These patterns lack nuclear abnormalities and have no known premalignant potential. Figs. 6 and 8 in Dr. Fetherston’s article seem to show active squamous metaplasia and basal cell reparative activity, respectively, while Figs. 7 and 9 lack sufficient detail to be adequately evaluated. We agree that the potential for dysplastic and malignant squamous lesions exists in vaginal adenosis. However, one should not, without more evidence, overemphasize the potential danger. To do so could
REFERENCES
Antonioli, D. A., and Burke, L.: Am. J. Clin. Pathol. 64: 1975. 2. Herbst, A. L., Poskanzer, D. C., Robboy, S. J., Friedlander, L., and Scully, R. E.: N. Engl. J. Med. 292: 334, 1975. 1.
625,
Reply to Drs. Burke and Antonioli To the Editors: The hard data emphasized in this presentation consists of colposcopically atypical squamous epithelium in the transformation zone of the patients exposed to diethylstilbestrol (DES). This atypical epithelium was present in 87 per cent of the patients followed. The slides of the squamous cell carcinoma in situ reported were reviewed by at least a dozen pathologists, all of whom agreed with the diagnosis without exception. I also know of at least seven other squamous lesions in situ which, as yet, have not been reported, all of which appeared in atypical transformation zone squamous epithelium in patients exposed to DES. It is true, as Drs. Burke and Antonioli have stared, that there is poor correlation histologically between the colposcopic findings and many of the biopsies. Correlation between these patterns and histology of the cervix is significantly better. This may be due to the relatively young age of this group of patients. We also have found considerable difficulty in interpreting many of the less severe changes histologically, but our criteria are essentially the same as those of Drs. Burke and Antonioli. We also caution against overtreatment of any but the frankly malignant lesions. The dangers in overtreatment in this otherwise normal group of young women are obvious, and we do share the concern of Drs. Burke 665
Squamous cell neoplastic change in patients with vaginal adenosis
precipitate unnecessarily radical treatment for adenosis in these young women, treatment perhaps associated with medical and emotional problems. Louis Burke, M.D., F.A.C.O.G. Department of Obstetrics and Gynecology Donald Antonio& M.D. Department of Pathology Beth Israel Hospital 330 Brookline Ave. Boston, Massachusetts 02215
To the Editors: We feel we must take exception to the implication that there is a high incidence of potentially malignant squamous cell neoplastic change in patients with vaginal adenosis as stated in the article, “Squamous neoplasia of vagina related to DES syndrome,” by William C. Fetherston, M.D., which appeared on page 176 of the May 15, 1975, issue of the AMERICAN JOURNAL
OF OBSTETRICS
AND
J
GYNECOLOGY.
Dr. Fetherston stated that 6 of the 46 patients (13 percent) in his series had biopsy-proved squamous dysplasia while a seventh patient showed squamous carcinoma in situ. This is in contrast to our experience, summarized in an article recently accepted for publication in the American Journal of Clinical Pathology, 1 in which we found no case of true squamous cell dysplasia in a group of 88 women with vaginal adenosis. In evaluation of almost 80 additional women, we have encountered only one patient with squamous cell dysplasia of a mild to moderate degree. Likewise, in a recent article, Herbst and associate? reported finding only four cases of mild squamous dysplasia after cytologic examination of vaginal scrapings or aspirates in 110 DES-exposed subjects, and “This change was not confirmed in any by multiple punch biopsies.” The differing incidences of dysplasia found in Dr. Fetherston’s series and in our own might be due to differences in histologic criteria for dysplasia. No criteria are given in Dr. Fetherston’s article, but we reserve the term “dysplasia” for lesions showing distinct nuclear abnormalities, including hyperchromasia, nuclear pleomorphism, and crowding with loss of polarity. In our experience, many of the atypicalities noted colposcopically, such as white epithelium, mosaicism, etc., correlate histologically with squamous metaplasia, poorly glycogenated mucosa, or regenerative responses to inflammation. These patterns lack nuclear abnormalities and have no known premalignant potential. Figs. 6 and 8 in Dr. Fetherston’s article seem to show active squamous metaplasia and basal cell reparative activity, respectively, while Figs. 7 and 9 lack sufficient detail to be adequately evaluated. We agree that the potential for dysplastic and malignant squamous lesions exists in vaginal adenosis. However, one should not, without more evidence, overemphasize the potential danger. To do so could
REFERENCES
Antonioli, D. A., and Burke, L.: Am. J. Clin. Pathol. 64: 1975. 2. Herbst, A. L., Poskanzer, D. C., Robboy, S. J., Friedlander, L., and Scully, R. E.: N. Engl. J. Med. 292: 334, 1975. 1.
625,
Reply to Drs. Burke and Antonioli To the Editors: The hard data emphasized in this presentation consists of colposcopically atypical squamous epithelium in the transformation zone of the patients exposed to diethylstilbestrol (DES). This atypical epithelium was present in 87 per cent of the patients followed. The slides of the squamous cell carcinoma in situ reported were reviewed by at least a dozen pathologists, all of whom agreed with the diagnosis without exception. I also know of at least seven other squamous lesions in situ which, as yet, have not been reported, all of which appeared in atypical transformation zone squamous epithelium in patients exposed to DES. It is true, as Drs. Burke and Antonioli have stared, that there is poor correlation histologically between the colposcopic findings and many of the biopsies. Correlation between these patterns and histology of the cervix is significantly better. This may be due to the relatively young age of this group of patients. We also have found considerable difficulty in interpreting many of the less severe changes histologically, but our criteria are essentially the same as those of Drs. Burke and Antonioli. We also caution against overtreatment of any but the frankly malignant lesions. The dangers in overtreatment in this otherwise normal group of young women are obvious, and we do share the concern of Drs. Burke 665
