Colin R. Laverty

Malignant melanoma metastases in the placenta: a case report.

Summary Although the coincidence of pregnancy and maternal malignancy is not rare, only 29 cases of metastases to the products of conception have been previously reported and of these, 14 have been of malignant melanoma. The present case of widespread maternal malignant melanoma metastasizing to the placenta further emphasizes this trend. The mother died of melanomatosis two weeks after induced labour at 36 weeks gestation. The infant, despite widespread placental involvement including apparent foetal vascular invasion, is well and without clinical evidence of disease five months after delivery.

Clear cell adenocarcinoma of the uterine cervix: a histological and histochemical study.

Summary A case of Mullerian clear cell adenocarcinoma of the uterine cervix occurring in a young woman is presented. A detailed histological and histochemical study of this type of tumour is important so as to separate it from the clear cell tumour of mesonephric origin. The association of Mullerian clear cell adenocarcinoma and other abnormalities of the vagina and cervix with the administration of maternal nonsteroidal oestrogens has been recently stressed in the literature. However, our patient is illustrative of the 30–50% of cases reported to date which have few if any of the associated abnormalities of the genital tract and have no known exposure to nonsteroidal oestrogens.

Test and teach Number Six Part 2

Histologically this tumour is composed of large papillary folds of well differentiated squamous epithelium showing hyperkeratosis (Fig. 1). The cells are polygonal with abundant eosinophilic cytoplasm and, in the deeper half of the epithelium, there is some loss of nuclear polarity. The rete pegs are thickened and bulbous with some compression of the underlying stroma which shows a slight infiltrate of neutrophils, lymphocytes and plasma cells. At one point (arrow) there is a focus of early micro-invasion of the stroma seen in higher power in Fig. 2. The term ‘verrucous carcinoma’ was introduced by Ackerman in 1948 to describe soft, warty, papillomatous tumours of low-grade malignancy arising in the oral cavity. Synonyms are papillary epidermoid carcinoma arising in condyloma acuminatum, papillary squamous invasive carcinoma and giant papillary carcinoma. Similar tumours have been reported in or on the penis, scrotum, vulva, vagina, larynx,.skin, nasal fossa and oesophagus (Kraus & Perez-Mesa, 1966). Verrucous carcinoma of the cervix displays the same macroscopic and microscopic appearances as it does in other sites. Judging from the 15 cases so far described (Qizilbash, 1974), invasive verrucous carcinoma of the uterine cervix does not metastasize, but invades locally and may recur. Ackerman (1948), van Nostrand & Olfsson (1972) and others have stressed that the clinical history, the macroscopic and the microscopic findings must be correlated in order to distinguish verrucous carcinoma from the various benign hyperplasias as it is important to distinguish this lesion (particularly on the cervix and external genitalia) from condyloma acuminatum and simple papilloma. Condyloma acuminatum shows the same general configuration of squamous epithelium but in this lesion there is also prominent cytoplasmic vacuolation and no evidence of atypia or keratinization. The base of the lesion tends to be flat rather than composed of bulbous rete pegs. True squamous papillomas are probably closely related to the verrucous squamous carcinomas and in the cervix, at least, may show severe atypia. Simple excision appears adequate treatment for verrucous squamous carcinoma whenever it arises. In regard to other sites, several authors (Kraus & Perez-Mesa, 1966; van Nostrand & Olfsson, 1972) warn against radiotherapy stating that failure of treatment may lead to recurrence or even anaplastic alteration in the tumour with widespread dissemination. It is not known if this also applies to the cervix. UTERINE CERVIX WITH MICRO-INVASION

A pathological study of the relationship between lichen sclerosus et atrophicus and squamous carcinoma of the vulva

When examined histologically, clinical leukoplakia of the vulva in the postmenopausal female exhibits features of lichen sclerosus et atrophicus (LSA) in most cases. Leukoplakia of the vulva has long been regarded as premalignant and in a number of previous series of invasive squamous carcinoma of the vulva, LSA was reported to be seen in association with the carcinoma in only 10–50% of cases. During the 12-yr period 1966–77, we have examined 924 tissue specimens of the vulva. Of these, 157 were malignant lesions, 106 being invasive squamous carcinoma and 36 being carcinoma in situ . A review of the pathological material taken from vulvectomy specimens of all the invasive squamous carcinoma in postmenopausal females disclosed that when 5–10 tissue blocks of the tumour and the vulval skin were examined, the association with LSA was 20–30%. However, when 15–30 blocks were examined, the association was 60–70%, many showing multifocal microinvasive carcinoma arising in areas of LSA while others showed adjacent LSA with dysplastic epithelium. Therefore, to assess reliably the distribution, incidence and premalignant potential of vulval LSA with squamous carcinoma, adequate tissue sampling of the primary tumour and the adjacent skin has to be done.

TEST AND TEACH Number Four Part 1

A girl aged 12 years presented with abdominal swelling and lower abdominal pain. She had never menstruated and development of secondary sex characteristics had not commenced. A soft, left ovarian mass approximately 15 cm in diameter was removed at laparotomy. The cut surface of the tumour was very haemorrhagic and necrotic. No tumour was found elswhere in the body either at laparotomy or on physical examination. The girl, nevertheless, pursued a rapidly deteriorating post-operative course and died with disseminated tumour within six months of diagnosis.

Cervical wart virus infection: cytological, histological and ultrastructural studies

Genital warts are due to an increasingly prevalent venereally spread virus infection. Typical condylomas affect vulval, vaginal and both original and metaplastic cervical squamous epithelia. The cervix is involved more commonly than formerly realized. A significant number of cervical lesions are not typical condylomas, but have a rather flat contour and such cases have been under-diagnosed in the past. Cellular atypia is common, confusion with dysplasia has occurred and wart virus infection is thought to be the basis of many reported so-called mild dysplasias which regressed spontaneously. There has been speculation about the possible premalignant significance of cervical warts. This suggestion is supported to some extent by the known but rare occurrence of malignant change in condylomas, and by the fact that flat cervical warty lesions resemble histologically epidermodysplasia verruciformis, a non-genital wart virus infection which is frequently followed by squamous carcinoma. The cytological, histological and ultrastructural features of two illustrative non-condylomatous cervical wart virus lesions will be shown.

Placental inflammatory lesions—their incidence and histopathology

A macroscopic and histological study was performed on placentas of all infants delivered within the King George V Memorial Hospital over a 12-mth period. The aim was to establish the local pattern of incidence of intrauterine inflammatory lesions of the placenta. An overall incidence of approximately 11% was observed. A more detailed histological analysis was performed on 1000 consecutive singleton placentas, of which 112 showed inflammatory lesions. In 32 placentas there was chorioamnionitis and of these, 23 additionally showed vasculitis of the umbilical cord. Eighty-two placentas showed the pattern of placental villitis. The histology of these lesions is described and the clinical correlates in the associated infants are compared with a control series.

The recognition of viral and chlamydial infection in cervical smears

In the 12 mth ended 30 June 1976, 14,868 cervical smears (from 13,212 patients) were examined in the Cytology Department, King George V Hospital, Sydney. Forty-two smears (1 in 354), from 37 patients, showed features of viral or chlamydial infection. Appearances were considered diagnostic in 21 smears and suggestive of infection in a further 21 smears. Changes were seen which were attributable to herpes virus, the virus of condyloma acuminatum, cytomegalovirus, adenovirus and TRIC agents. Six smears showed changes consistent with infection by virus other than those mentioned. The most characteristic feature of viral and chlamydial infection is the presence of inclusion bodies in endocervical and metaplastic squamous cells. Intranuclear inclusions are seen in herpes (where the cells are often multinucleate), cytomegalovirus and adenovirus infection. These are eosinophilic in herpes and adenovirus and basophilic in cytomegalovirus infection. Eosinophilic intracytoplasmic inclusions are seen in TRIC agent infection and sometimes in cytomegalovirus infection. Recognition is important for several reasons. Cytologically, changes due to viral and chalmydial infection may be present in association with or may also to some extent simulate precancerous or cancerous changes. Epidemiologists have considered the possibility that a sexually transmitted viral carcinogen is important in the aetiology of cervical cancer. Clinically infection may be asymptomatic or be responsible for severe, even necrotizing, cervicitis. The presence of herpes, cytomegalovirus and TRIC agents in the genital tract in early pregnancy is associated with abortion, prematurity and dysmaturity. Some obstetricians consider the presence of herpes or cytomegalovirus in late pregnancy an indication for caesarean section before membrane rupture in order to prevent serious, and sometimes fatal, infection of the neonate occurring during delivery through an infected birth canal.