Cervix
Adenocarcinoma
Gastric type adenocarcinoma


Minor changes: 19 June 2020

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PubMed Search: Gastric type adenocarcinoma cervix [TIAB]

Gulisa Turashvili, M.D., Ph.D.
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Cite this page: Turashvili G. Gastric type adenocarcinoma. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/cervixGAS.html. Accessed August 14th, 2020.
Definition / general
  • A subtype of human papillomavirus (HPV) negative mucinous adenocarcinoma with gastric differentiation
Essential features
  • Second most common subtype of endocervical adenocarcinoma
  • Most common subtype of non HPV associated endocervical adenocarcinoma (Am J Surg Pathol 2018;42:214)
  • Minimal deviation adenocarcinoma (MDA) is part of the spectrum and can be difficult to diagnose in small specimens and cytology preparations
  • Worse prognosis compared with HPV associated usual type endocervical adenocarcinoma
Terminology
  • Minimal deviation adenocarcinoma (adenoma malignum) refers to a well differentiated gastric type adenocarcinoma
ICD coding
  • ICD-O: 8482/3 - Mucinous adenocarcinoma, endocervical type
  • ICD-10: C53.0 - Malignant neoplasm of endocervix
  • ICD-11: 2C77.Z - Malignant neoplasms of cervix uteri, unspecified
Epidemiology
Sites
  • Endocervix
Pathophysiology
Etiology
  • Unclear
Clinical features
  • Abnormal cervical cytology in asymptomatic patients
  • Mucoid or profuse watery vaginal discharge (Mol Clin Oncol 2013;1:833)
  • Vaginal bleeding
  • Abdominal discomfort
  • Barrel shaped cervix
  • Cervical mass
  • Adnexal metastases
Diagnosis
  • Histologic examination of tissue
Radiology description
  • General:
    • Hypoechoic, heterogeneous mass on ultrasound examination
    • Mass lesion with a high signal relative to the low signal of the cervical stroma on magnetic resonance imaging
  • Minimal deviation adenocarcinoma:
    • Difficult to diagnose due to benign appearance
    • Multilocular cystic masses on ultrasound examination, sometimes with increased intralesional vascularity on color Doppler
    • Multiple irregular cystic lesions or cysts arranged in floret-like manner with aggregates of small cysts resulting in a cosmos pattern on magnetic resonance imaging (Int J Gynecol Cancer 2011;21:1287)
Radiology images

Images hosted on other servers:

Barrel shaped cervix on MRI in MDA

Ill defined cervical mass on MRI in MDA

Prognostic factors
Case reports
Treatment
  • Treatment does not significantly differ from other forms of adenocarcinoma (Gynecol Oncol 2019;153:13)
  • Surgical excision (trachelectomy, radical hysterectomy) and regional lymphadenectomy for stage I tumors at presentation
  • Neoadjuvant chemotherapy and radiotherapy for advanced stage tumors (Int J Gynecol Cancer 2018;28:99)
Gross description
  • In minimal deviation adenocarcinoma, the cervix may be grossly unremarkable or hypertrophic with multiple cystic lesions
  • Exophytic, papillary, polypoid or ulcerated mass
  • Induration of cervical wall
  • Diffuse or nodular enlargement of cervical wall
  • Tan to yellow, hemorrhagic, friable or mucoid cut surfaces
Gross images

Contributed by Gulisa Turashvili, M.D., Ph.D.

Radical hysterectomy for gastric type adenocarcinoma



Images hosted on other servers:
Missing Image

Bulging cervix in MDA

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Cervical swelling without a mass in MDA

Microscopic (histologic) description
  • Histologic criteria of gastric differentiation defined by Kojima et al (note that all features are cytologic and not architectural) (Am J Surg Pathol 2007;31:664):
    • Tumor cells with clear or pale eosinophilic and voluminous cytoplasm
    • Distinct cell borders
  • Histologic and cytologic features further refined (Int J Gynecol Pathol 2019;38:263):
    • Tumor cells usually contain tall apical mucin
    • Cytoplasm can be foamy
    • Nuclei are typically basally located and range from small round or ovoid to markedly enlarged and irregular with vesicular chromatin and prominent nucleoli
    • Variable mitotic activity
    • Intestinal differentiation may be present
    • Rarely, goblet cells and Paneth-like neuroendocrine cells
    • Rarely, mucin extravasation, adenocarcinoma in situ or gastric metaplasia
  • Architectural features range from well differentiated forms comprised of well defined glands with minimal to no desmoplastic stromal reaction (such as minimal deviation adenocarcinoma) to poorly differentiated forms comprised of infiltrating poorly formed glands, tumor nests or single cells, including goblet cells, eliciting desmoplastic stromal reaction
  • Minimal deviation adenocarcinoma is characterized by (Mol Clin Oncol 2013;1:833):
    • Neoplastic glands of variable shape and size with irregular or claw-like outlines
    • Deep cervical stromal invasion with haphazardly distributed glands and minimal to no desmoplastic reaction
    • Low grade morphology with minimal to absent cytologic atypia and abundant apical mucin
    • Pure minimal deviation adenocarcinoma can be underrecognized or missed due to deceptively bland morphologic appearance, although adequate sampling should allow for correct diagnosis as there is usually at least focal cytologic atypia (J Clin Pathol 2010;63:935)
  • Grading:
    • Grading of gastric type adenocarcinomas is not recommended as even well differentiated tumors may behave aggressively (Am J Surg Pathol 2007;31:664)
    • Gastric type adenocarcinomas are best regarded as inherently high grade (Surg Pathol Clin 2019;12:281)
    • Well differentiated and poorly differentiated areas may be admixed
    • In poorly differentiated gastric type adenocarcinomas, the tumor cells are markedly atypical with loss of the abundant cytoplasm and can grow as single cells and clusters; these tumors are called gastric type due to the pyloric gland type mucin but they are morphologically and immunophenotypically similar to pancreatobiliary adenocarcinomas (Surg Pathol Clin 2019;12:281)
  • There is morphologic overlap between HPV associated usual type endocervical adenocarcinoma and gastric type adenocarcinoma, with some HPV positive tumors showing limited human papillomavirus associated features and resembling gastric type adenocarcinoma (Am J Surg Pathol 2018;42:214, Am J Surg Pathol 2017;41:696)
  • Lymphovascular or perineural invasion may be seen
Microscopic (histologic) images

Contributed by Gulisa Turashvili, M.D., Ph.D.

Well differentiated gastric type adenocarcinoma

Poorly differentiated gastric type adenocarcinoma

Gastric type adenocarcinoma in hysterectomy

Well differentiated gastric type adenocarcinoma


Poorly differentiated gastric type adenocarcinoma

Gastric type adenocarcinoma involving fallopian tube

Cytology description
  • Single and crowded clusters of tumor cells (Int J Gynecol Pathol 2019;38:263)
  • Pale, foamy or vacuolated cytoplasm and well defined cytoplasmic borders (Int J Gynecol Pathol 2019;38:263)
  • Moderately pleomorphic round to oval nuclei with one or more nucleoli (Int J Gynecol Pathol 2019;38:263)
  • Necrotic debris an neutrophils may be seen (Diagn Cytopathol 2006;34:119)
  • Yellowish orange staining of cytoplasmic mucins in Pap cytology preparations is an important diagnostic clue to identify intracytoplasmic mucin on cytology (Cancer 1999;87:245)
  • Finding HPV negative atypical glandular cells in Pap cytology preparations should raise the possibility of gastric type adenocarcinoma
  • Minimal deviation adenocarcinoma:
    • May be missed on cytology as differentiation from reactive endocervical cells is often not possible (Am J Clin Pathol 1996;105:327)
    • Honeycombed sheets of glandular cells with abundant nonvacuolated cytoplasm, cytoplasmic extensions or tails, uniform round to oval nuclei with fine chromatin and small nucleoli, lacking significant pleomorphism and rare or no mitoses, sometimes prominent and displaced hyperchromatic nuclei with chromatin clumping (Am J Clin Pathol 1996;105:327, Taiwan J Obstet Gynecol 2015;54:447)
Cytology images

Contributed by Gulisa Turashvili, M.D., Ph.D.

Gastric type adenocarcinoma on Pap cytology

Positive stains
Negative stains
Electron microscopy description
  • In minimal deviation adenocarcinoma, double immunogold staining revealed localization of HIK1083 reactive mucin to the matrix and lysozyme to the core of the mucin granules suggestive of gastric phenotypes ultrastructurally (Ultrastruct Pathol 1999;23:375)
Molecular / cytogenetics description
Sample pathology report
  • Uterus with cervix, fallopian tubes and ovaries, radical hysterectomy and bilateral salpingo-oophorectomy:
    • Cervix: invasive endocervical adenocarcinoma, gastric type (see synoptic report)
    • Endometrium: proliferative
    • Myometrium: leiomyomata
    • Right fallopian tube: involved by adenocarcinoma
    • Right parametrium: involved by adenocarcinoma
    • Left fallopian tube: benign
    • Left parametrium: benign
    • Bilateral ovaries: benign
Differential diagnosis
Board review style question #1

    Which of the following immunoprofiles would be expected in this tumor?

  1. Negative HIK1083, PAX8, p16 and CEA
  2. Positive HIK1083, PAX8, negative p16 and CEA
  3. Positive HIK1083, PAX8, p16 and CEA
  4. Positive HIK1083, PAX8, p16, negative CEA
Board review answer #1
B. Gastric type adenocarcinoma (shown here) is positive for PAX8 and HIK1083 and negative or focally positive for p16 and CEA.

Reference: Gastric type adenocarcinoma

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Board review style question #2
    Which of the following statements is true regarding the clinical outcome of minimal deviation adenocarcinoma and gastric type adenocarcinoma compared to stage matched human papillomavirus associated usual type endocervical adenocarcinoma?

  1. Gastric type adenocarcinomas have less favorable clinical outcomes regardless of histologic grade
  2. Minimal deviation adenocarcinomas are well differentiated and usually have favorable prognosis
  3. Stage matched minimal deviation adenocarcinomas clinical outcomes are not significantly different
Board review answer #2
A. Gastric type adenocarcinomas usually have a worse prognosis compared to human papillomavirus associated usual type endocervical adenocarcinomas; even well differentiated tumors may behave aggressively and thus grading of gastric type adenocarcinomas is not recommended.

Reference: Gastric type adenocarcinoma

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