Turkish Journal of Pathology 2007;23(3):173-176 Bizarre atypia of the cervical epithelium due to chemotherapy with busulfan and cyclophosphamide Servikal epitelde busulfan ve siklofosfamid kemoterapisine ba¤l› bizar atipi Özgür EK‹NC‹, Ifl›lay Bilge YILMAZ, Ömür ATAO⁄LU Gazi Üniversitesi T›p Fakültesi Patoloji Anabilim Dal›, ANKARA ABSTRACT ÖZET We present a 20 year-old female patient with highly aty- Yaz›m›zda uterus serviksinde sitoloji ve biyopsi ile a¤›r pical epithelial changes in the uterine cervix discovered epitelyal atipik de¤ifliklikler gösterilen 20 yafl›ndaki on cervical smear and biopsy specimens. She had re- kad›n hastay› sunmaktay›z. Hasta yak›n zamanda akut cently been diagnosed with acute lymphoblastic lenfoblastik lenfoma tan›s› alm›fl olup alkilleyici ajanlar lymphoma and received alkylating agent chemothe- ile kemoterapi alm›flt›r. Hastam›zda izlenen atipik de¤i- rapy. We thought that the epithelial atypia was related fliklikler, konuyla ilgili literatürün de ›fl›¤›nda kullan›- to chemotherapy in the light of the reports in the litera- lan alkilleyici ajanlara ba¤lanm›fl olup, bu yaz›da ilgili ture which are discussed in the present text along with histopatolojik ve sitolojik kriterler tart›fl›lm›flt›r. a brief review of related histopathological and cytologi- cal criteria. Key words: Cervical dysplasia, chemotherapy, busul- Anahtar sözcükler: Servikal displazi, kemoterapi, bu- fan, cyclophosphamide sulfan, siklofosfamid INTRODUCTION ceived a regimen of busulfan and cyclophospha- mide. She had a cervical smear in her follow-up. Chemotherapy with alkylating agents has The smear slide stained with Papanicolaou stain been known to cause high grade dysplastic alte- revealed severely enlarged cells with hyperchro- rations in epithelial cells (1-4). These changes matic nuclei and irregular nuclear outlines whi- can lead to an erroneous diagnosis of true pre- le the nuclear/cytoplasmic ratio was not increa- neoplastic dysplasia in cervical smears. The pre- sed (Figures 1 and 2). The chromatin pattern sent case demonstrates this issue with a smear showed a homogenous basophilic staining wit- followed by a biopsy of the uterine cervix. hout coarse clumping. These cells had abundant cytoplasm, some with vacuolation. Mitotic figu- CASE REPORT res were absent. Necrotic diathesis was not ob- served. The cytology report stated that high gra- A 20 year-old female patient was diagno- de dysplastic changes had been observed while sed as acute lymphoblastic leukemia and she re- a possible drug effect could not have been ruled out. A cervical cone biopsy was obtained. The specimen was inked on surgical margins, fixed Corresponding Author: Ö¤r. Gör. Dr. Özgür Ekinci, Gazi Hastanesi Beflevler, 06500, Ankara in buffered formalin and processed. Sections 173 Turkish Journal of Pathology 2007;23(3):173-176 from the paraffin blocks were first stained with hematoxylin and eosin. The slides showed dif- fuse atypia in the epithelium of the uterine cer- vix. Figure 3. The cervical cone biopsy reveals highly anaplastic- looking cells in the middle and superficial layers while the ba- sal layer is occupied by small monotonous cells (HE x400). Figure 1. A group of cells with irregularly contoured hyperc- hromatic nuclei and abundant cytoplasm in the cervical sme- ar. Cytoplasmic microvacuolation is evident in the right lower hand (Papanicolaou x400). Figure 4. The squamous cells are pleomorphic but somehow maintain their polarity (HE x400). Figure 2. Another focus in the cervical smear shows pleo- morphic, enlarged cells. Some nuclei are about five times lar- ger than their normal counterparts. Cytoplasms are enlarged as well (Papanicolaou x400). The most prominent atypical changes we- re found in the squamous epithelium. Especially the keratinocytes of the middle and superficial layers exhibited bizarre, enlarged and hyperc- hromatic nuclei with significant pleomorphism throughout (Figure 3 and 4). Oddly, the overall polarity of individual cells was mostly maintai- ned. Hyperchromasia was homogenous; the Figure 5. An endocervical gland with large atypical nuclei. No mitoses were found (HE x400). 174 Bizarre atypia of the cervical epithelium due to chemotherapy with busulfan and cyclophosphamide a cervical smear result was in the normal range. DISCUSSION Alkylating agents are recognized causes of non-neoplastic, reactive, high grade cytological atypia in many organ systems such as the upper aerodigestive tract, lower respiratory tract, esop- hagus, stomach, uterine cervix, urothelium and skin (1-9). There is agreement in the literature that cyclophosphamide is the drug most strong- ly associated with epithelial dysplasia (2,4) ad- Figure 6. Immunohistochemistry for Ki-67. Only few basal cells show nuclear positivity (Streptavidin-peroxidase x200). ministered either alone (6,7) or with busulfan (1,3). Moreover, these two drugs together were responsible for most of the cases reported. Aty- nuclear chromatin did not show clumping, vesi- pia of uterine cervix associated with cyclop- cular appearance or conspicious nucleoli. hosphamide was shown before (2,6,7) but oppo- Cytoplasms were again abundant and contained sing suggest that this drug does not cause abnor- vesicular or vacuolar areas. No mitotic activity mal cervical smears (10). The former studies was discovered despite a thorough search and proposed that such chemotherapy increased the serial sectioning. Importantly the basal cells risk of cervical intraepithelial neoplasia (CIN) looked uniform and normal without crowding, (2,6,7). hyperplasia or any cytological disturbances. No The pathologist has to be aware of chemot- evidence of an invasive neoplasia was observed. herapy-related alterations in order not to make Endocervical glands focally contained cells with an erroneous diagnosis of malignancy. The cri- lost polarity and irregularly contoured, hyperc- teria put forth for gastric chemotherapy-related hromatic nuclei (Figure 5). There was not atypia atypia have great help in the diagnosis of CIN in in the stromal or endothelial cells. other organs as well (11). Those features in fa- Immunohistochemistry for human papillo- vor of chemotherapy-related alterations were bi- ma virus (HPV), human herpes virus types I and zarre atypia with marked cellular enlargement II (HSV), cytomegalovirus (CMV), p53, p16, exceeding that seen in cancer, lower nuclear to and Ki-67 were performed with streptavidin and cytoplasmic ratio, cytoplasmic eosinophilia and peroxidase technique. Tests were negative for vacuolation, lower mitoses, atypia also invol- HPV, HSV and CMV. There was focal positive ving fibroblasts and endothelium and changes nuclear staining with p53. No positivity was fo- resembling radiation effect (11,12). In stratified und with p16. Ki-67 only stained the nucle- epithelium, atypia in the superficial cells witho- i of the basal cells (Figure 6). Preservation of the ut accompanying hyperplasia of basal cells is a nuclear/cytoplasmic ratio, detection of abundant clue against malignancy (4,13). Prominent, mul- vacuolized cytoplasm, degenerative-looking tiple or eosinophilic nucleoli (4,14) and smud- chromatin pattern, absence of mitoses, accom- ging of the chromatin (13) are common in che- panying focal endocervical glandular dysplasia, motherapy-related atypia. As can be expected, negativity for p16 and p53 with a very low pro- Ki-67 proliferation index is low in these lesions liferative index with Ki-67, led us to make the (4). diagnosis of epithelial atypia secondary to alk- These changes are probably related to an ylating agent administration. Two months after, arrest in nuclear division due to a metabolic ef- 175 Turkish Journal of Pathology 2007;23(3):173-176 fect of the drug (3). The benign nature of these REFERENCES cells was supported by the lack of an increase in their nuclear DNA content (15). 1. Castano E, Rodriguez-Peralto JL, Lopez-Rios F, Go- mez C, Zimmermann M, Diez LI. Keratinocyte dyspla- The present case demonstrates a recogni- sia: an unusual finding after transplantation or chemot- zed relation of alkylating agents with bizarre herapy. J Cutan Pathol 2002;29:579-584. 2. Hughes RG, Colquhoun M, Alloub M, Chetty U, Smart atypia of epithelial linings. The pleomorphic GE. 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