• Vol. 51 No. 6, 386–387
  • 28 June 2022

Cause of vaginal spotting in an older woman

215



0 Citing Article
215 Views
31 Downloads

Download PDF

A 77-year-old Chinese woman with a past medical history of Sjogren’s syndrome, nodular goitre and right-sided neck lymphadenopathy, presented to the gynaecological service for per-vaginal spotting. On clinical examination, she was noted to have a cervical polyp. A polypectomy was performed and the specimen was sent for histological examination.

The specimen consisted of multiple small fragments of pale tissue measuring 1.2cm in maximum dimension.

The polypoid pieces of tissue contained a dense infiltrate in the submucosal stroma (Figs. 1A and 1B). The stroma is composed of sheets of cells of uniform appearance with a moderate amount of cytoplasm, slightly eccentrically placed round and ovoid nuclei—many with small nucleoli—and occasional nuclear pseudoinclusions (Fig. 1B). Small lymphocytes were interspersed. The infiltrate percolated around residual endocervical glands and the surface endocervical mucosa that was focally attenuated. No gland formation, keratin, pigment or mucin production was seen. Immunohistochemical stains for HMB-45, MNF-116 and CD20 were negative.

Which is the most likely diagnosis?

  1. Invasive squamous carcinoma of the cervix
  2. Invasive adenocarcinoma of the cervix
  3. Florid cervicitis
  4. Marginal zone B cell lymphoma
  5. Spread from an endometrioid endometrial carcinoma

Answer: D

Additional immunohistochemical staining subsequently performed showed positivity for CD38, CD138 and lambda light chain restriction (Fig. 3). CD3 confirms scattered interspersed small lymphocytes.

Results of the previous neck lymph node biopsy were not known at the time of the cervical biopsy, but subsequent information revealed that a nodal marginal zone B cell lymphoma with plasmacytic differentiation had been previously diagnosed, with tumour cells immunopositive for CD38 and CD138, and which demonstrated lambda light chain restriction.

Discussion. The commonest primary tumours of the cervix are squamous cell carcinoma with its variants, and adenocarcinoma.1-3 The most common haematopoietic neoplasm involving the cervix, whether primary or secondary, is diffuse large B-cell lymphoma.4

Secondary involvement of the cervix represents less than 0.3% of all cervical malignancies.1 The most common secondary tumour is endometrial carcinoma by direct contiguous spread, followed by metastases from carcinomas of ovarian (42.1%), gastrointestinal tract (19.8%) and breast (4.5%) origins.2,3

Only 6% of cervical metastases are of haematopoietic origin, of which 75% are diffuse large-cell B cell lymphoma, followed by non-Hodgkin lymphoma (10%) and chronic lymphocytic leukaemia (3%).4 Cervical involvement in multiorgan disease is more common than a primary lymphoma of the cervix, and hence one should consider the possibility of metastasis when encountering a lymphoproliferative neoplasm in the cervix. The cervix is also the most common location in the female genital tract in which lymphoma may arise.5

REFERENCES

  1. Zannoni GF, Vellone VG, Petrillo M, et al. Secondary malignancies of the uterine cervix: a potential diagnostic pitfall. Virchows Arch 2013;463:23-9.
  2. Pérez-Montiel D, Serrano-Olvera A, Salazar LC, et al. Adenocarcinoma metastatic to the uterine cervix: a case series. J Obstet Gynaecol Res 2012;38:541-9.
  3. Lemoine NR, Hall PA. Epithelial tumors metastatic to the uterine cervix. A study of 33 cases and review of the literature. Cancer 1986;57:2002-5.
  4. Hilal Z, Hartmann F, Dogan A, et al. Lymphoma of the Cervix: Case Report and Review of the Literature. Anticancer Res 2016;36:4931-40.
  5. Thyagarajan MS, Dobson MJ, Biswas A. Case report: appearance of uterine cervical lymphoma on MRI: a case report and review of the literature. Br J Radiol 2004;77:512-5.
  6. Duggal R, Srinivasan R. Primary amelanotic melanoma of the cervix: case report with review of literature. J Gynecol Oncol 2010;21:199-202.
  7. An J, Li B, Wu L, et al. Primary malignant amelanotic melanoma of the female genital tract: report of two cases and review of literature. Melanoma Res 2009;19:267-70.