Phillip J. Baird

Squamous cell carcinoma in situ arising in inflammatory cloacogenic polyps: report of two cases with PCR analysis for HPV DNA

Summary Inflammatory cloacogenic polyp (ICP) is regarded as part of the spectrum of pathological changes encountered in mucosal prolapse syndrome (MPS)/solitary rectal ulcer. We present the clinicopathological features of two females with squamous cell carcinoma in situ arising in their ICPs. Human papillomavirus (HPV) type 16 was demonstrated in the areas of squamous carcinoma in situ in both polyps by polymerase chain reaction. These cases highlight the need for close scrutiny of the squamous components of these lesions.

Giant Condyloma Acuminatum of the Vulva and Anal Canal

Summary: This publication describes the second known reported case of benign giant condyloma acuminatum of the vulva and anal canal (Buschke‐Loewenstein tumour). The diagnosis of squamous cell carcinoma was made initially on clinical examination and could not be excluded by punch biopsy. A full pathological study of the tumour established the diagnosis. A defunctioning colostomy and a perineo‐ano‐vulvectomy with groin gland dissection was performed and the patient is free of disease 36 months later. The biology of this type of tumour is discussed.

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.

The pathogenesis of vulval lichen sclerosus et atrophicus: an immunofluorescence study

Most cases of diffuse leucoplakia of the vulva in the postmenopausal female are represented histologically by vulval dystrophy of either hyperplastic, hypoplastic or mixed type. All of these involve dermal and epidermal changes, including inflammatory cell infiltrates. However, Lichen Sclerosus et Atrophicus (L.S.A.) one of the hypoplastic dystrophies, represents a distinct histological entity showing oedema and homogenization of the dermis with a mononuclear infiltrate and epithelial atrophy. A review of more than 300 cases of L.S.A. of the vulva showed that various grades and combinations of the above features were seen, often in the same microscopic field. The inflammatory nature of this condition and the associated hyaline changes in the dermal collagen, around the blood vessels and along the epithelial basement membrane led to an investigation of vulval dystrophy using F.I.T.C. conjugated antisera to human IgM, IgA. IgG, IgE. C 3 and fibrin. During 1976-8 102 vulval biopsies from 39 patients were examined. Fifty-three were diagnostic of L.S.A., the rest included normal skin (11), hyperplastic dystrophy (23), and epithelial squamous carcinoma (15). The non L.S.A. groups were negative for all the antisera. Negative and positive controls for antigen specificity gave uniform results. The L.S.A. group all showed 2-4 + positive reaction for fibrin which was localized to the basement membrane, the papillary dermis and around papillary blood vessels. Twenty-seven biopsies of L.S.A. also gave 1 +−2+ positive reaction for complement (C 3 ). The positive sections for fibrin (together with parallel untreated sections) were fixed in Zenkers acetic acid solution and stained with PTAH, PAS and Massons trichrome. All these stains were negative for fibrin when only oedema was present; however, they were variably positive in sections showing some homogeneous change in the dermis. Those sections which showed a dense sclerotic dermis were negative for fibrin both histologically and by immunofluorescent techniques. It is proposed that to remove extravascular fibrin by fibrinolytic and phagocytic mechanisms leads to the characteristic dermal morphology of L.S.A.