INTRODUCTION

Chemotherapy with alkylating agents hasbeen known to cause high grade dysplastic alte-rations in epithelial cells (1-4). These changescan lead to an erroneous diagnosis of true pre-neoplastic dysplasia in cervical smears. The pre-sent case demonstrates this issue with a smearfollowed by a biopsy of the uterine cervix.

CASE REPORT

A 20 year-old female patient was diagno-sed as acute lymphoblastic leukemia and she re-

ceived a regimen of busulfan and cyclophospha-mide. She had a cervical smear in her follow-up.The smear slide stained with Papanicolaou stainrevealed severely enlarged cells with hyperchro-matic nuclei and irregular nuclear outlines whi-le the nuclear/cytoplasmic ratio was not increa-sed (Figures 1 and 2). The chromatin patternshowed a homogenous basophilic staining wit-hout coarse clumping. These cells had abundantcytoplasm, some with vacuolation. Mitotic figu-res were absent. Necrotic diathesis was not ob-served. The cytology report stated that high gra-de dysplastic changes had been observed whilea possible drug effect could not have been ruledout. A cervical cone biopsy was obtained. Thespecimen was inked on surgical margins, fixedin buffered formalin and processed. Sections

ABSTRACT

We present a 20 year-old female patient with highly aty-pical epithelial changes in the uterine cervix discoveredon cervical smear and biopsy specimens. She had re-cently been diagnosed with acute lymphoblasticlymphoma and received alkylating agent chemothe-rapy. We thought that the epithelial atypia was relatedto chemotherapy in the light of the reports in the litera-ture which are discussed in the present text along witha brief review of related histopathological and cytologi-cal criteria.

Key words: Cervical dysplasia, chemotherapy, busul-fan, cyclophosphamide

ÖZET

Yaz›m›zda uterus serviksinde sitoloji ve biyopsi ile a¤›repitelyal atipik de¤ifliklikler gösterilen 20 yafl›ndakikad›n hastay› sunmaktay›z. Hasta yak›n zamanda akutlenfoblastik lenfoma tan›s› alm›fl olup alkilleyici ajanlarile kemoterapi alm›flt›r. Hastam›zda izlenen atipik de¤i-fliklikler, konuyla ilgili literatürün de ›fl›¤›nda kullan›-lan alkilleyici ajanlara ba¤lanm›fl olup, bu yaz›da ilgilihistopatolojik ve sitolojik kriterler tart›fl›lm›flt›r.

Anahtar sözcükler: Servikal displazi, kemoterapi, bu-sulfan, siklofosfamid

Bizarre atypia of the cervical epithelium due to chemotherapy with busulfan andcyclophosphamide

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

Corresponding Author: Ö¤r. Gör. Dr. Özgür Ekinci, GaziHastanesi Beflevler, 06500, Ankara

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from the paraffin blocks were first stained withhematoxylin and eosin. The slides showed dif-fuse atypia in the epithelium of the uterine cer-vix.

The most prominent atypical changes we-re found in the squamous epithelium. Especiallythe keratinocytes of the middle and superficiallayers exhibited bizarre, enlarged and hyperc-hromatic nuclei with significant pleomorphismthroughout (Figure 3 and 4). Oddly, the overallpolarity of individual cells was mostly maintai-ned. Hyperchromasia was homogenous; the

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 lowerhand (Papanicolaou x400).

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 4. The squamous cells are pleomorphic but somehowmaintain their polarity (HE x400).

Figure 5. An endocervical gland with large atypical nuclei. Nomitoses were found (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 enlargedas well (Papanicolaou x400).

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nuclear chromatin did not show clumping, vesi-cular appearance or conspicious nucleoli.Cytoplasms were again abundant and containedvesicular or vacuolar areas. No mitotic activitywas discovered despite a thorough search andserial sectioning. Importantly the basal cellslooked uniform and normal without crowding,hyperplasia or any cytological disturbances. Noevidence of an invasive neoplasia was observed.Endocervical glands focally contained cells withlost polarity and irregularly contoured, hyperc-hromatic nuclei (Figure 5). There was not atypiain the stromal or endothelial cells.

Immunohistochemistry for human papillo-ma virus (HPV), human herpes virus types I andII (HSV), cytomegalovirus (CMV), p53, p16,and Ki-67 were performed with streptavidin andperoxidase technique. Tests were negative forHPV, HSV and CMV. There was focal positivenuclear staining with p53. No positivity was fo-und with p16. Ki-67 only stained the nucle-i of the basal cells (Figure 6). Preservation of thenuclear/cytoplasmic ratio, detection of abundantvacuolized cytoplasm, degenerative-lookingchromatin pattern, absence of mitoses, accom-panying focal endocervical glandular dysplasia,negativity for p16 and p53 with a very low pro-liferative index with Ki-67, led us to make thediagnosis of epithelial atypia secondary to alk-ylating agent administration. Two months after,

a cervical smear result was in the normal range.

DISCUSSION

Alkylating agents are recognized causes ofnon-neoplastic, reactive, high grade cytologicalatypia in many organ systems such as the upperaerodigestive tract, lower respiratory tract, esop-hagus, stomach, uterine cervix, urothelium andskin (1-9). There is agreement in the literaturethat cyclophosphamide is the drug most strong-ly associated with epithelial dysplasia (2,4) ad-ministered either alone (6,7) or with busulfan(1,3). Moreover, these two drugs together wereresponsible for most of the cases reported. Aty-pia of uterine cervix associated with cyclop-hosphamide was shown before (2,6,7) but oppo-sing suggest that this drug does not cause abnor-mal cervical smears (10). The former studiesproposed that such chemotherapy increased therisk of cervical intraepithelial neoplasia (CIN)(2,6,7).

The pathologist has to be aware of chemot-herapy-related alterations in order not to makean erroneous diagnosis of malignancy. The cri-teria put forth for gastric chemotherapy-relatedatypia have great help in the diagnosis of CIN inother organs as well (11). Those features in fa-vor of chemotherapy-related alterations were bi-zarre atypia with marked cellular enlargementexceeding that seen in cancer, lower nuclear tocytoplasmic ratio, cytoplasmic eosinophilia andvacuolation, lower mitoses, atypia also invol-ving fibroblasts and endothelium and changesresembling radiation effect (11,12). In stratifiedepithelium, atypia in the superficial cells witho-ut accompanying hyperplasia of basal cells is aclue against malignancy (4,13). Prominent, mul-tiple or eosinophilic nucleoli (4,14) and smud-ging of the chromatin (13) are common in che-motherapy-related atypia. As can be expected,Ki-67 proliferation index is low in these lesions(4).

These changes are probably related to anarrest in nuclear division due to a metabolic ef-

Figure 6. Immunohistochemistry for Ki-67. Only few basalcells show nuclear positivity (Streptavidin-peroxidase x200).

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Bizarre atypia of the cervical epithelium due to chemotherapy with busulfan and cyclophosphamide

fect of the drug (3). The benign nature of thesecells was supported by the lack of an increase intheir nuclear DNA content (15).

The present case demonstrates a recogni-zed relation of alkylating agents with bizarreatypia of epithelial linings. The pleomorphiccells observed in the cervical cytology and thebiopsy specimens had anaplasic changes excee-ding those of a carcinoma, and most importantlythe nuclear/cytoplasmic ratio was preserved orincreased while there was microvacuolar andvesicular appearance of the abundant cytop-lasms. Mitoses were not found. Such alterationsshould have a higher index of suspicion and le-ad to an investigation for drug or radiation ef-fects. Our patient had not received radiotherapy.Other possible causes of enlarged or atypicalnuclei in cervical epithelium such as viral cyto-pathic effect or atrophy were also considered.As nuclear ground-glass appearance, multinuc-leation, Cowdry type A or cytoplasmic basophi-lic inclusions and immunohistochemical eviden-ce for viral involvement were lacking, viral in-fection was ruled out. Atrophy of the cervicalepithelium may exhibit high nuclear/cytoplas-mic ratio and may be confused with dysplasia.The bizarre cellular atypia and pleomorphism inour case which surpass that expected in atrophyas well as the young age of the patient helped torule out atrophy. The patient had a normal sme-ar in the subsequent second month. We couldnot perform a polymerase chain reaction test orother more definitive assays to rule out HPV,which forms a gap in our report. This caseshows that chemotherapy with busulfan andcyclophosphamide may cause bizarre reactiveatypia of the cervical epithelium, which shouldbe investigated with further studies. We conclu-de that in cytological and biopsy materials frompatients with a history of chemotherapy, highlyatypical epithelial changes are expected andshould not be overdiagnosed.

REFERENCES

1. Castano E, Rodriguez-Peralto JL, Lopez-Rios F, Go-mez C, Zimmermann M, Diez LI. Keratinocyte dyspla-sia: an unusual finding after transplantation or chemot-herapy. J Cutan Pathol 2002;29:579-584.

2. Hughes RG, Colquhoun M, Alloub M, Chetty U, SmartGE. Cervical intraepithelial neoplasia in patients withbreast cancer: a cytological and colposcopical study.Br J Cancer 1993;67:1082-1085.

3. Stella F, Battistelli S, Marcheggiani F, De Santis M,Giardini C, Baronciani D, et al. Urothelial cell changesdue to busulfan and cyclophosphamide treatment inbone marrow transplantation. Acta Cytol 1990;34:885-890.

4. Westra HW. Holmes GF, Eisele DW. Bizarre epitheli-al atypia of the sinonasal tract after chemotherapy. AmJ Surg Pathol 2001;25:652-656.

5. Brien TP, Farraye FA, Odze RD. Gastric dysplasia-li-ke epithelial atypia associated with chemoradiotherapyfor esophageal cancer: A clinicopathological and im-munohistochemical study of 15 cases. Mod Pathol2001;14:389-396.

6. Ognenovski VM, Marder W, Somers EC, JohnstonCM, Farrehi JG, Selvaggi SM, et al. Increased inciden-ce of cervical intraepithelial neoplasia in women withsystemic lupus erythematosus treated with intravenouscyclophosphamide. J Rheumatol 2004;31:1763-1767.

7. Bateman H, Yazici Y, Leff L, Peterson M, Paget SA.Increased cervical dysplasia in intravenous cyclop-hosphamide-treated patients with SLE: a preliminarystudy. Lupus 2000;9:542-544.

8. Walker T, Mukerjee D, Levine TS. Bronchial epitheli-al atypia mimicking squamous cell carcinoma secon-dary to cyclophosphamide therapy. Cytopathol2002;13:330-332.

9. Slavin RE, Millan JC, Mullins GM. Pathology of highdose intermittent cyclophosphamide therapy. Hum Pat-hol 1975;6:693-709.

10. Belinson JL, Jarrell M, McClure M, Papillo J, KorsonR. The effect of cytoxan, adriamycin, and cis-platinumon cervical, vaginal cytology. Gynecol Oncol1985;20:78-82.

11. Petras RE, Hart WR, Bukowski RM. Gastric epithelialatypia with hepatic arterial infusion chemotherapy.Cancer 1985;56:745-750.

12. O'Morchoe PJ, Lee DC, Kozak CA. Esophageal cyto-logy in patients receiving cytotoxic drug therapy. ActaCytol 1983; 27:630-634.

13. Salomão DR, Mathers WD, Sutphin JE, Cuevas K,Folberg R. Cytologic changes in the conjunctiva mi-micking malignancy after topical mitomycin C che-motherapy. Ophthalmol 1999;106:1756-1760.

14. Becker SN, Sass MA, Petras RE, Hart WR. Bizarreatypia in gastric brushings associated with hepatic ar-terial infusion chemotherapy. Acta Cytol 1986;30:347-350.

15. Borgmann V, al-Abadi H, Friedrichs R, Nagel R. Ef-fect of different local and systemic therapy upon uri-nary bladder cytology. Urol Int 1993;50:21-26.

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