"Arias-Stella reaction"-like changes in endocervical glandular epithelium in cervical smears during pregnancy and postpartum states--a potential diagnostic pitfall

Arias-Stella reaction of the cervix: The enduring diagnostic challenge

Background:

The Arias-Stella reaction is a hormone-related atypical endometrial change characterized by hypertrophy and vacuolization of glandular epithelial cells, associated with marked nuclear pleomorphism, enlargement, and hyperchromasia. When presenting in extra-uterine sites, the differentiation of Arias-Stella changes from other more ominous clear cell lesions may pose significant difficulties.

Case Report:

We report a case of an endocervical clear cell lesion incidentally discovered during a prenatal visit of a young pregnant woman. Interpretation of the pathological findings was complicated by the small size and fragmentation of the specimen.

Conclusions:

Recognition of Arias-Stella reaction in extra-uterine sites, especially in young women, is critical to avoid misdiagnosis of this innocuous lesion as clear cell adenocarcinoma. Attention to cellular and nuclear detail, as well as careful consideration of the clinical scenario, is crucial for establishment of the correct diagnosis.

Arias-Stella reaction in a cervicovaginal smear of a woman undergoing infertility treatment: A case report

Arias-Stella reaction commonly is seen in gestational endometrium, but rarely is described outside the endometrium, particularly in nonpregnant women. Although the cytological diagnoses of Arias-Stella reaction by cervical Papanicolaou (Pap) smears in pregnant, postpartum, and postabortal women are documented, to our knowledge, this is the first report of Arias-Stella reaction in a cervicovaginal smear of a nonpregnant woman undergoing infertility treatment with clomiphene and beta-human chorionic gonadotropin (beta-HCG). The cytological features observed in this case were characteristic of Arias-Stella reaction but mimic malignancy leading to initial misinterpretation. It is of paramount importance to recognize this phenomenon in cervical Pap smears, especially in women receiving ovulation-inducing agents and exogenous hormonal treatment to avoid this potential cytological pitfall.

Atypical glandular cells in conventional cervical smears: incidence and follow-up

BACKGROUND

Atypical glandular cells on cervical smears are often associated with clinically significant uterine lesions. The frequency and accuracy of AGC-NOS (i.e. atypical glandular cells, not otherwise specified) diagnoses, regardless of the gland cell type or the degree of suspicion, and their outcome were investigated.

METHODS

From January 1, 1990 to December 31, 1999 a total of 261 patients had an AGC-NOS diagnosis made by conventional cervical Papanicolaou smear interpretation representing 0.05% of all Pap-smears analyzed at the national level. 191 (73.2%) patients had a subsequent histological examination, 8 samples were not representative by origin and were excluded.

RESULTS

Out of 183 AGC-NOS diagnosed, 56.3% (103/183) were associated with tissue-proven precancerous and/or cancerous lesions, 44% being of endocervical and 56% of endometrial origin. 75% of all AGC-patients were asymptomatic. 66.7% (6/9) of the patients with subsequent invasive endocervical adenocarcinoma (AC) and 56% (28/50) of those patients with invasive endometrial AC were without clinical symptoms. 3 patients out of 9 with an invasive endocervical AC were 35 years of age or less. 10.1% and 12.3% of all 'new' tissue-proven invasive endocervical or endometrial AC respectively recorded by the national Morphologic Tumour Registry (MTR) were first identified by a cytological AGC-NOS diagnosis.

CONCLUSION

Our findings emphasize the importance of the cytological AGC-category even in the absence of a precise origin or cell type specification. 56% of the AGC-diagnoses being associated with significant cancerous or precancerous conditions, a complete and careful evaluation is required.

Arias-Stella reaction of the endocervix: a report of 18 cases with emphasis on its varied histology and differential diagnosis

We report 18 cases of Arias-Stella reaction involving the endocervix with an emphasis on histologic features that can be encountered and result in the misdiagnosis of carcinoma. The patients ranged in age from 19 to 44 years. Two patients had a history of oral contraceptive use and 15 were pregnant; clinical information was not available in one case. Ten lesions presented as cervical polyps, and six were incidental findings in specimens obtained because of cervical dysplasia, dysfunctional uterine bleeding, fibroids, and a missed abortion. One patient was found to have a cervical "lesion" on a routine gynecologic examination. In the remaining patient, a cervical biopsy was obtained, for unknown reasons, at the time of termination of pregnancy. Microscopic examination showed a varied histologic appearance including vacuolated clear cytoplasm (18 cases), intraglandular tufts (16 cases), hobnail cells (14 cases), oxyphilic cytoplasm (13 cases), delicate filiform papillae (12 cases), intranuclear pseudoinclusions (10 cases), cribriform intraglandular growth (3 cases), and a single mitotic figure in 1 case. The histologic changes involved the superficial glands (6 cases), deep glands (4 cases), or both (8 cases); confluent or extensive gland involvement was seen in 8 cases. Follow-up information, available in four cases (4, 2, 1, 1 years), was unremarkable. The principal consideration in the differential diagnosis was clear cell carcinoma. The features most helpful in this distinction were the usual lack of a mass suspicious for cancer, absence of a desmoplastic response, lack of an infiltrative pattern, spectrum of cytologic atypia, low nuclear-cytoplasmic ratio, and usual lack of mitotic activity.

The many faces of atrophy in gynecologic cytology

As more attention is paid to cervical cancer screening in the postmenopausal population, increased numbers of atrophic specimens will be evaluated in the cytology laboratory. In addition, specimens that have cell patterns that mimic the nonestrogen or partially estrogen-stimulated state occur in a variety of situations, including pregnancy, the postpartum period, and in individuals who are treated with progesterone. A firm understanding of the cellular changes that are within the range of normal in such circumstances is critical to ensure the specificity of interpretation. This article has detailed the conditions under which nonestrogen stimulated patterns occur and addressed the cytologic changes that are noted. Hints to avoid pitfalls have been offered. There is no substitute for a thorough evaluation of each case, and with continued experience and understanding of these principles, the correct interpretations, and, ultimately, correct management of patients, can be optimized.

The Arias-Stella reaction: facts and fancies four decades after

Since its first description more than four decades ago, the atypical endometrial change associated with chorionic tissue effect has been widely confirmed in the literature. However, errors and inaccuracies in text books and other publications often occur. This review clarifies some of these misconceptions and presents a summary of new data on the histologic and immunohistochemical characteristics of the change. A brief discussion of the pathogenesis and biologic significance of the alteration is included.

Pregnancy-related changes: a retrospective review of 278 cervical smears

Pregnancy-related physiologic changes are well recognized. However, the normal range of changes as reflected in the cervical smear have not been adequately described. Review of 278 abnormal cervical smears from 153 pregnant/preabortal and 125 postpartum/ abortal patients revealed the following: 21 high-grade squamous intraepithelial lesion (HGSIL) cases, 46 low-grade squamous intraepithelial lesion (LGSIL) cases, 185 atypical squamous cells of undetermined significance (ASCUS) cases, and 26 atypical glandular cells of undetermined significance (AGUS) cases. Surgical correlation (excluding 18 products of conception and 153 placentas) was available in 98 (35%) of the cases. Dysplasia was confirmed on biopsy of 11 cases cytologically diagnosed as HGSIL (7 CINII/III and 4 CIN I), 19 cases cytologically diagnosed as LGSIL (6 CIN II/III and 13 CIN I), 35 cases of ASCUS (4 CIN II/III and 31 CIN I), and 2 cases of AGUS (1 CIN III and 1 CIN I). Decidualization was present in six cervical and three endometrial biopsies. The remaining 180 cases revealed pregnancy-related changes in most of the atypical groups and a few in the dysplasia groups. With pregnancy, both cervical glands and stroma undergo physiologic changes. These result in squamous metaplasia due to ectropion and cells with hypervacuolated cytoplasm and atypical nuclei reflecting endocervical gland hyperplasia and/or Arias-Stella reaction. The decidual cells are large, with variably staining cytoplasm and a large nucleus. Degenerated decidual or trophoblastic cells can also shed from the endometrium and mimic HGSIL. Despite the caution required in this population, dysplastic changes should not be underestimated.