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26 Benign Epithelial Tumors and Tumor-Like Lesions, Pathology of the Cervix
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Microscopy
Arias-Stella reaction is an incidental finding in
specimens obtained because of cervical neoplasia,
dysfunctional uterine bleeding, etc. The changes
can affect superficial or deep glands and are usually focal, involving only a portion of the gland, a
single gland or a small number (2–3) of glands.
Occasionally, the involvement is confluent or
extensive. Arias-Stella reaction can involve endocervical glands as well as ectopic endometrial
glands or endocervical glands with tubal or tuboendometrioid metaplasia within the cervix. The
glandular epithelium is replaced by large cells
with abundant vacuolated, glycogen-rich, and
clear or oxyphilic cytoplasm (Arias-Stella 2002).
Hobnail cells (with nuclei protruding into the
glandular lumen and little accompanying cytoplasm) are present. The nuclei are enlarged, pleomorphic, hyperchromatic, with dense, smudged
chromatin but may also be vacuolated, due to
optically clear chromatin (Fig. 1). Nuclear atypia
is sometimes striking. Nuclear pseudoinclusions
may be present. Architecturally, the endocervical
glands have a normal lobular configuration and
location, but are more tortuous and present epithelial stratification filling the glandular space and
tufting, thin papillary projections or cribriform
pattern can be present. The surrounding cervical
stroma is normal in appearance or may present
decidual changes. The pathologist Javier AriasStella originally described five variant patterns:
minimal atypia, early secretory, secretory/
Benign Epithelial Tumors and Tumor-Like Lesions,
Pathology of the Cervix, Fig. 1 Arias-Stella reaction
within endocervical glands
hypersecretory, non-secretory (regenerative/proliferative), and monstrous cell pattern, with no
clinical relevance.
Immunophenotype
Napsin A and hepatocyte nuclear factor-1β
(HNF-1β) have poor specificity and are usually
positive in both Arias-Stella reaction and clear cell
adenocarcinoma and could also be positive in normal cervix or other lesions including in situ adenocarcinoma, so they are not helpful in distinguishing
between these lesions. However, estrogen receptor
(ER) positivity (nearly all cases, although the positivity can be attenuated) and arginosuccinate synthase (ASS1) negativity are potentially helpful for
identifying Arias-Stella reaction versus clear cell
adenocarcinoma (Ji et al. 2020). Racemase is negative in Arias-Stella reaction and positive in clear cell
adenocarcinoma, being helpful to differentiate
between these two lesions. Also, in Arias-Stella
reaction, Ki-67 index is low, p16 is negative
(patchy , non-block type), and p53 is wild type
(Ip et al. 2019).
Molecular Features
So far, specific molecular studies are not
available.
Differential Diagnosis
Arias-Stella reaction may be confused with either
invasive or in situ adenocarcinoma, especially in a
small biopsy or curettage and when the pathologist is unaware of the patient age, pregnancy, or
hormonal exposure. The main differential diagnosis is with clear cell adenocarcinoma of the cervix.
This is a rare tumor, which in contrast to AriasStella reaction occurs in older patients, presents as
a tumor mass, usually associated with clinical
symptoms (such as vaginal bleeding), while
microscopically, an infiltrative component is present with tumor cells forming solid, tubulo-cystic,
or papillary structures, surrounded by a
desmoplastic stroma and associated with
hyalinized areas. Also, mitotic figures and apoptotic bodies may be encountered in clear cell
adenocarcinoma, unlike in Arias-Stella reaction.
Another differential diagnosis is with in situ
adenocarcinoma of the cervix, a lesion which is
Benign Epithelial Tumors and Tumor-Like Lesions, Pathology of the Cervix 27
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either human papillomavirus (HPV)-associated or
independent, both occurring at or close to
squamocolumnar junction and presenting with a
preservation of normal lobular glandular architecture. HPV-associated in situ adenocarcinom a is
characterized by glandular epithelium showing
mucin depletion, nuclear stratification, elongated
nuclei perpendicular to the basement membrane,
atypia, hyperchromasia with coarse chromatin,
and loss of polarity, while apoptotic bodies
(basal location) and mitoses (luminal location)
are characteristic and constant features (Stolnicu
et al. 2020). P16 and HPV testing can also assist in
differential diagnosis, both being positive in HPVassociated in situ adenocarcinoma, with p16
block-type positivity. HPV-independent in situ
adenocarcinoma of gastric type has been recently
described, presenting with typically round vesicular and basally located nuclei and mucin-rich,
clear or eosinophilic cytoplasm, while mitoses
and apoptotic bodies are rare (McCluggage
2016; Talia et al. 2017; Talia and McCluggage
2018; Stolnicu et al. 2020). This lesion is p16
and HPV negative (or mosaic, non-block type)
but can be at least focally positive for markers of
gastric-pyloric-type mucins, such as MUC6 and
HIK 1083, in contrast to Arias-Stella reaction.
Condyloma Acuminatum of the Uterine
Cervix
Synonyms
Exophytic condyloma; Genital wart; Low-grade
squamous intraepithelial lesion (LSIL).
Definition
Papillary, exophytic benign neoplasm, caused by
human papillomavirus (HPV) infection, mostly
with low-risk 6 and 11 genotypes, typically
through sexual contact. It is considered a productive viral infection.
Clinical Features
• Incidence
With the increased use of colposcopy, condyloma acuminatum is believed to be more frequent as in the past, but not regarded as common.
• Age
It occurs in reproductive-age women, but cases
affecting postmenopausal patients have been
described.
• Sex
Female.
• Site
It involves the ectocervix (more common) and
the transformation zone. Some patients
(especially immunocompromised ones) pre-
sent with multiple similar lesions in the cervix,
vulva, and vagina. When large in size, it
occupies the upper vagina.
• Treatment
Conservative surgical excision is indicated,
especially in young women in whom fertility
preservation is desired. In addition, treatment
using immune modulators has been recently
introduced.
• Outcome
Condyloma acuminatum is a benign lesion
which may spontaneously regress or may per-
sist for many years, depending on the immune
status of the patient. Also, the tumor may
locally recur.
Macroscopy
The tumor is usually solitary and presents with an
exophytic, sessile, and cauliflower-like appearance, of white color and soft consistency. The
margins are well demarcated. The size is variable,
usually small but when becoming large (giant
condyloma), it raises concern for malignancy.
Microscopy
Condyloma acuminatum has a very characteristic
papillary microscopic appearance, represented by
multiple delicate fibrovascular cores, lined by
stratified squamous epithelium with an undulating
surface (Fig. 2). The squamous epithelium presents hyperkeratosis and hypergranulosis. Mitotic
activity is mainly seen at the basal and parabasal
layers. Presence of koilocytosis (due to HPV
effect) is a pathognomonic feature for this tumor,
but one have to bear in mind that it may be focal or
even absent in some cases. Koilocytes are large
squamous cells with mild enlarged and hyperchromatic nuclei, presenting nuclear membrane
B
28 Benign Epithelial Tumors and Tumor-Like Lesions, Pathology of the Cervix
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Molecular Features
HPV in situ hybridization for low-risk HPV is
positive (Guimarães et al. 1992; Evans et al. 2014).
Differential Diagnosis
The main differential is with squamous papil loma,
a cervical benign tumor with papillary architecture but represented by a single papillary frond
with a fibrovascular core, lined by mature squa-
Benign Epithelial Tumors and Tumor-Like Lesions,
Pathology of the Cervix, Fig. 2 Condyloma
acuminatum: characteristic papillary microscopic appearance, represented by multiple delicate fibrovascular cores,
lined by stratified squamous epithelium with an undulating
surface. (Courtesy of Dr. Kay J. Park)
mous epithelium, lacking koilocytes. Squamous
papilloma is not associated with HPV infection
and does not present koilocytes, which is helpful
in differentiating between the two lesions.
Another differential is with HSIL, which some times can present with exophytic architecture and
has potential to progress to a malignant infiltrative
tumor. This differential is particularly difficult
when a condyloma harbors areas of HSIL, as a
result of low-risk and high-risk HPV co-infection.
HSIL however shows loss of organization, polarity and maturation with immature squamous cells
extanding above the lower third of the epithelial
thickness while p16 is block-like positive and
Ki-67 index is high. Also, infiltrating squamous
Benign Epithelial Tumors and Tumor-Like Lesions,
Pathology of the Cervix, Fig. 3 Condyloma
acuminatum: presence of koilocytes is a pathognomonic
feature. (Courtesy of Dr. Kay J. Park)
cell carcinoma of the cervix has a papillary architecture when presenting as papillary carcinoma
growth pattern or may present koilocytes in
warty (condylomatous) growth pattern. Papillary
growth papttern shows a superficial papillary exo-
irregularities, binucleation, and multinucleation
and surrounded by perinuclear sharply demarcated cytoplasmic vacuolization (Fig. 3).
Koilocytes are found in mid and superficial layers.
In addition to koilocytic atypia, there are cells
with atypical features, predominantly within
lower third of the epithelium. Also, in some
cases when condyloma is associated with highgrade squamous intraep ithelial lesion (HSIL), epithelial squamous cells may present areas of more
atypia and increased mitotic activity, involving
the upper layers. There is chronic inflammatory
infiltrate in the underlying stroma, but the basal
membrane is intact.
phytic component and an infiltrative component
with tumor cells having either a basaloid appearance with atypical nuclei and frequent mitotic
figures or a transitional-like appearance (similar
to transitional carcinoma of urinary bladder) just
the koilocytes are missing. Warty growth pattern
is characterized by the presence of tumor cells
with koilocytic features involving both the deep
infiltrative component and the superficial component, frequently of exophytic type and represented
by papillary structures. Tumors diagnosed as
verrucous carcinoma are very rare in the cervix,
and the existence of this entity is controversial,
this being a tumor characteristically found in the
vulva. It is a highly differentiated and sharply
Immunophenotype
P16 is negative (mosaic-type staining, patchy).
Ki-67 immunohistochemical stain shows labeling
of nuclei above the parabasal cells.
circumscribed tumor, characterized by a broad
base and broad papillae lacking fibrovascular
cores, representing the exophytic component and
a pushing endophytic pattern of invasion,
Benign Epithelial Tumors and Tumor-Like Lesions, Pathology of the Cervix 29
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composed of bulbous nests, with chronic inflammation in the submucosa. The tumor cells are
large, with abundant cytoplasm and minimal or
no nuclear atypia. Hyperkeratosis is usually present but koilocytes are lacking. Studies have
shown that verrucous carcinoma may be HPVassociated (but not in all cases). Lastly, cytoplasmic vacuolization (pseudokoilocytes) in the
absence of nuclear atypia may occur as a reflection of atrophy-related vacuolar degeneration,
with prominent glycogen vacuolization of the
normal squamous epithelium or in non -HPVrelated infections, such as trichomoniasis,
Gardnerella vaginalis, and candidiasis. In contrast
to the focal distribution of koilocytes in condyloma acuminatum, cells of normal squamous epithelium that have perinuclear clearing are not
sharply demarcated, the nuclei are not enlarged
or atypical, and multinucleated cells are infrequent. Also, the papillary architecture is missing.
B
Deep Glands and Nabothian Cysts
Synonyms
Nabothian follicle.
Definition
Presence of normal endocervical glands, located
deep into cervical wall. Nabothian cysts are endocervical glands cystically dilated, usually due to
obstruction by squamous metaplasia and mucus
retention.
Clinical Features
• Incidence
Nabothian cysts are frequent.
• Age
Occur at any age, especially in multiparous
women.
• Sex
Female.
• Site
Any area of the cervix can be involved.
• Treatment
Not indicated.
• Outcome
Excellent.
Benign Epithelial Tumors and Tumor-Like Lesions,
Pathology of the Cervix, Fig. 4 Cut surface of the
cervix reveals superficial and deep Nabothian cysts
containing a mucinous material
Macroscopy
In deep glands, the cervical wall may be enlarged.
Nabothian cysts may be visible when large (more
than 1 cm diameter) at clinical examination, and on
cut section, they contain mucinous material (Fig. 4).
Microscopy
Benign-looking endocervical glands are found at
microscopic examination beyond the normal limit
of 5 mm, deep into cervical stroma. Both deep
glands and Nabothian cysts are lined by benignlooking columnar or flat epithelium (Fig. 5).
Immunophenotype
Not clinically relevant.
Molecular Features
Not clinically relevant.
Differential Diagnosis
Main differential is with endocervicosis (usually
forming a mass) and minimal deviation
30 Benign Epithelial Tumors and Tumor-Like Lesions, Pathology of the Cervix
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Benign Epithelial Tumors and Tumor-Like Lesions,
Pathology of the Cervix, Fig. 5 Nabothian cysts lined
by flat epithelium
adenocarcinoma (the latter is however associated
with stromal desmoplasia, gastric-type morphology, transmural infiltration, focal cytologic atypia
at least, and positivity for gastric type of markers)
(Soslow et al. 2021).
Benign Epithelial Tumors and Tumor-Like Lesions,
Pathology of the Cervix, Fig. 6 Diffuse laminar endo-
cervical hyperplasia: superficially and well-demarcated
proliferation of highly packed small-sized endocervical
glands. (Courtesy of Dr. Kay J. Park)
Diffuse Laminar Endocervical
Hyperplasia
Definition
This lesion is characterized by a proliferation of
endocervical glands, with a diffuse laminar (bandlike) architecture.
Clinical Features
• Incidence
Diffuse laminar hyperplasia is a rare finding.
• Age
It occurs in reproductive age but mostly in
premenopausal patients.
• Sex
Female.
• Site
Involves the inner third of the cervical wall,
along the endocervical canal.
• Treatment
No treatment is indicated.
• Outcome
Excellent.
Macroscopy
This is an incidental finding but cases presenting
as a cervical mass have been described (asso ciated
with a watery or mucoid discharge).
Microscopy
Microscopic examination reveals a superficially
and well-demarcated proliferation of highly
packed small-sized endocervical glands, with
round, oval, or irregular contour, surrounded by
abundant acute or chronic inflammatory infiltrate
(Fig. 6) (Maruyama et al. 1995). The glands are
lined by a mucinous columnar epithelium, with
bland nuclei (Fig. 7). Mitotic figures are absent.
Immunophenotype
Not clinically relevant.
Molecular Features
Not clinically relevant.
Differential Diagnosis
Minimal deviation adenocarcinoma can mimic
diffuse laminar hyperplasia but is characterized
Benign Epithelial Tumors and Tumor-Like Lesions, Pathology of the Cervix 31
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Benign Epithelial Tumors and Tumor-Like Lesions,
Pathology of the Cervix, Fig. 7 Diffuse laminar endo-
cervical hyperplasia: glands with round, oval, or irregular
contour, lined by a mucinous columnar epithelium, with
bland nuclei. (Courtesy of Dr. Kay J. Park)
Benign Epithelial Tumors and Tumor-Like Lesions,
Pathology of the Cervix, Fig. 8 Ectopic tissue: seba-
ceous glands
by gastric m orphology, at lea st focal atypia,
stromal desmoplasia, and is usually infiltrating
the cervical wall. Lobular endocervical glandular hyperplasia (LEGH) and tunnel clusters in
contrast to diffuse laminar hyperplasia are char-
Macroscopy
This is an incidental finding but can rarely present
as a mass, in association with vaginal bleeding.
acterized by a lobular con figuration (Jones
et al. 1991).
Microscopy
Various types of tissues can be found: ectopic
prostate tissue (some of these cases reported in
Ectopic Tissues of the Uterine Cervix
Definition
Various types of ectopic tissue can be identified
within the cervix.
association with long-term testosterone therapy),
epidermoid metaplasia (represented by sebaceous
glands, basaloid cells, hair follicles, excretory
ducts, melanin pigment), ectopic bone, glial tissue, and adipose tissue (Fig. 8). All these tissues
have a mature appearance.
B
Clinical Features
• Incidence
This is a rare finding, representing a variant of
normal anatomy, a developmental abnormality,
or a reparative process.
• Age
The lesion occurs at any age.
• Sex
Female.
• Site
Ectocervix, reaching the transformation zone.
• Treatment
No surgical treatment is indicated in incidental
findings; however, lesions that present as a
mass need surgical excision.
• Outcome
Excellent.
Immunophenotype
Prostatic tissue is positive for prostate-specific
antigen (PSA), prostate-specific acid phosphatase
(PSAP), AMACR, NKX3-1, p63, and androgen
receptor (AR). Glial tissue is positive for glial
fibrillary acid protein (GFAP) and S100 protein.
Molecular Features
Not clinically relevant.
Differential Diagnosis
Various types of malignant lesions can be associated with cartilage or osseous tissue, such as carcinosarcoma, embryonal rhabdomyosarcoma, and
immature teratoma. Careful sampling and microscopic examination should help to exclude these
malignant tumors. Ectopic prostate tissue can be
32 Benign Epithelial Tumors and Tumor-Like Lesions, Pathology of the Cervix
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also confused with mesonephric remnants, but
immunohistochemical stains are of help (Soslow
et al. 2021).
Endocervical Polyp
Definition
A very common non-neoplastic lesion, lined by a
mix of squamous and mucinous endocervical epithelium, covering a fibrovascular core.
Clinical Features
• Incidence
Endocervical polyps are very common.
• Age
It occurs over a wide age range but most
patients with an endocervical polyp are over
the age of 40.
• Sex
Female.
• Site
The lesion is located along the endocervical
canal.
• Treatment
Surgical excision is curative.
• Outcome
Excellent outcome if there is no association
with a malignant in situ or invasive tumor.
Sometimes however, endocervical polyps can
recur.
Macroscopy
Endocervical polyp presents as a rounded or elongated exophytic lesion, typically occupying the
endocervical canal and less often protruding
beyond the introitus. It has a smooth or lobulated
surface and a pedunculated or sessile base. It may
be small (usually less than 1 cm diameter) and
asymptomatic or large (very rare gigantic called
giant endocervical polyp) and associated with
vaginal bleeding, vaginal discharge, pain, and
profuse leukorrhea, due to hypersecretion of
mucus (Yi et al. 2009; Massinde et al. 2012).
Polyps are mostly solitary but sometimes two to
three simultaneous lesions can occur (Fig. 9).
When the superficial epithelium presents as areas
Benign Epithelial Tumors and Tumor-Like Lesions,
Pathology of the Cervix, Fig. 9 Two simultaneous
endocervical polyps
Benign Epithelial Tumors and Tumor-Like Lesions,
Pathology of the Cervix, Fig. 10 Endocervical polyp:
glands of various sizes and shapes surrounded by fibrovascular stroma
of ulceration, the polyp may be associated with
hemorrhage.
Microscopy
At microscopic examination, endocervical glands
of various sizes and shapes, some of them
cystically dilated, are surrounded by
normocellular or hypocellular fibrovascular
stroma (Fig. 10). The epithelium lining the glands
is columnar and mucinous, with small and basally
located nuclei (Fig. 11). Within the stroma, various number of thickened-wall vascular spaces can
be found (Fig. 12). Also, some polyps present
with a prominent inflammatory infiltrate, with a
Benign Epithelial Tumors and Tumor-Like Lesions, Pathology of the Cervix 33
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Immunophenotype
Not clinically relevant.
Molecular Features
Upregulation of pro- and anti-inflammatory genes
has been demonstrated in endocervical polyp,
suggesting that this is a reactive process.
Differential Diagnosis
Many cervical lesions can present macroscopically as polypoid, such as benign lesions
(hyperplasia, polypoid decidua, granulation tissue, leiomyoma, adenomyoma, condyloma,
Benign Epithelial Tumors and Tumor-Like Lesions,
Pathology of the Cervix, Fig. 11 Endocervical polyp:
the epithelium lining the glands is columnar and mucinous,
with small and basally located nuclei
adenofibroma) or malignant lesions (squamous
cell carcinoma, adenocarcinoma, various types
of sarcomas or cervical metastases). Microscopically, the main differential of endocervical polyp
is with Mullerian adenosarcoma. This is a malignant tumor with leaf-like architecture, represented
by rigid benign endocervical glands, surrounded
by malignant mesenchymal component with stromal atypia, periglandular condens ation, and various number of mitoses. Sometimes, within an
endocervical polyp, unusual features may occur
and overlap with those of an adenosarcoma,
mostly represented by abnormal architecture,
periglandular stromal abnormalities, focal and
mild stromal cytologic atypia, and increased mitoses (Howitt et al. 2015). However, one study has
demonstrated that uterine polyps with features
Benign Epithelial Tumors and Tumor-Like Lesions,
Pathology of the Cervix, Fig. 12 Endocervical polyp:
within the stroma, various number of thickened-wall vascular spaces can be found
overlapping with those of Mullerian
adenosarcoma have a benign clinical course
(Howitt et al. 2015). Cervical adenofibroma is a
very rare lesion, having the typical gross and low-
predominance of plasma cells. The underlying
epithelium is usually columnar but may present
areas of squamous metaplasia, which sometimes
can be quite florid. Also, areas of surfa ce papillary
proliferation or ulceration, glandular (including
microglandular) hyperplasia, Arias-Stella reaction, stromal decidua, atypical bizarre cells, and
benign heterologous elements (such as fat, cartilage, glia) can be encountered within an endocervical polyp (Terada 2009). Occasionally,
endocervical polyps may harbor areas of in situ
or invasive carcinoma, usually confined to the
polyp.
power microscopic appearance of adenosarcoma
but caution must be taken when making such a
diagnosis because most adenofibromas when
extensively sampled proved to be adenosarcomas.
Other differentials are represented by endometrial polyp and polypoid endometriosis. Endometrial polyp is characterized by endometrial type of
glands within a fibrous stroma, but some polyps
develop in the upper endocervix/lower uterine
segment, presenting both endocervical and endometrial type of glands. Also, at microscopic examination, the infoldings of the normal endocervical
mucosa may mimic a polyp but the diagnosis of
B
34 Benign Epithelial Tumors and Tumor-Like Lesions, Pathology of the Cervix
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polyp should be made only to exophytic lesions,
represented by a prominent fibrovascular core.
Polypoid endometriosis contains cellular stroma
of endometrioid type and hemosiderin pigment
within macrophages cytoplasm, features helpful
to differentiate it from endocervical polyp.
In children, botryoides rhabdomyosarcoma
can present with a polypoid configuration, but
presence of subepithelial band-like condensation
of atypical round cells, with high nuclear-tocytoplasm ratio and rhabdoi d features, is characteristic at microscopic examination.
In fibroepithelial stromal polyp, a rare cervical lesion (more commonly encountered in vulva
and vagina), endocervical glands are absent,
being composed predominantly of bland mesenchyme, with characteristic stellate multinucleate
stromal cells and lined by benign squamous
epithelium.
In tubulosquamous polyp, more frequently
encountered in the upper vagina in older
women, well-circumscribed nests of squamous
cells admixed with small tubules at the periphery
of some of the nests are identified. The tubular
structures are positive for prostatic acid phosphatase and prostate-specific antigen as apparently
this lesion has origin in paraurethral Skene
glands.
In case of presence of heterologous mature
elements within a polypoid lesion, differential
diagnosis should be made with retained fetal
tissue. If heterologous immature elements are
identified, immature teratoma should be
ruled out.
Endocervicosis of the Uterine Cervix
Synonyms
Mullerianosis.
Definition
Presence of benign endocervical type of glands,
involving the outer cervical wall and paracervical
tissue, haphazardly oriented, probably developing
due to mechanical displacement of endocervical
epithelium, after surgery (Young and Clement
2000; Lee et al. 2017).
Clinical Features
• Incidence
This is a rare finding.
• Age
Occurs in reproductive or postmenopausal
patients.
• Sex
Female.
• Site
Anterior outer cervix.
• Treatment
Surgical excision is curative.
• Outcome
Benign.
Macroscopy
The lesion forms a mass, presenting as cystically
dilated spaces on cut surface, filled with mucin, in
association with pelvic pain or dysmenorrhea.
Microscopy
Variable shape and size of endocervical glands,
some of them are cystically dilated, lined by
columnar or flat mucinous epithelium. Mitoses
are rare or absent and there is no cytologic atypia.
Mucin pools and inflammatory infiltrates can be
seen in the stroma.
Immunophenotype
Not clinically relevant.
Molecular Features
Not clinically relevant.
Differential Diagnosis
Main differential diagnosis is with invasive cervical adenocarcinoma and especially minimal deviation (gastric type) adenocarcinoma which in
most cases has a benign-looking morphology.
The deep location of endocervicosis without connection to the superficial part of the cervix,
absence of stromal desmoplasia, and absence of
gastric-type morphology together with negativity
for gastric type of markers can help with diagnosis. Caution must be taken when inte rpreting
immunohistochemical findings as MUC 5 and
MUC 6 can also be positive in normal endocervical glands. Also, normal glands are usually
Benign Epithelial Tumors and Tumor-Like Lesions, Pathology of the Cervix 35
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estrogen receptor (ER) and progesterone receptor
(PR) positive, while minimal deviation adenocarcinoma is usually negative. Endocervicosis can
also mimic metastases to the cervix, and differentiation between the two lesions can be problematic, especially when clinical history of the patient
is unknown and endocervicosis forms a mass and
has a reactive stroma.
Endometriosis of the Uterine Cervix
Definition
Presence of endometrial type of glands and/or
stroma in the cervix.
B
Clinical Features
• Incidence
According to some studies, it varies from 0.2%
of all endometriosis cases in a single institution
(Wang et al. 2011) to up to 43% of patients
undergoing cervical cautery, cold-knife cone
biopsy, or loop excisional procedures in other
studies (Gardner 1966).
• Age
Usually occurs in reproductive age.
• Sex
Female.
• Site
It may be located superficially (replacing the
mucosa or lying in the stroma underneath), fre-
quently in association with a prior biopsy or
cautery (suggesting implantation of menstrual
endometrium or trauma-induced metaplasia) or
deep into the cervical stroma (due to extension of
cul-de-sac involvement of pelvic endometriosis).
• Treatment
In large polypoid lesions, surgical excision is
recommended.
• Outcome
Excellent, if there is no association with atypia.
Cases in which atypia is presen t may poten-
tially progress to endometrioid type of adeno-
carcinoma of the cervix, if untreated.
Macroscopy
When small and superficially located, beneath the
surface epithelium, it is an incidental finding.
Benign Epithelial Tumors and Tumor-Like Lesions,
Pathology of the Cervix, Fig. 13 Large polypoid cer-
vical endometriosis
Occasionally, it may present as thickened, granular, hemorrhagic areas or blue/red nodules involving the mucosa. Rare cases of large polypoid
endometriosis have been documented, in association with pain and bleeding (Fig. 13) (Kano and
Kanda 2003; Jaiman et al. 2014).
Microscopy
The lesion is represented by variable number of
dark-blue endometrioid type of glands, with
round to oval contour, resembling proliferative
or weakly proliferative endometrium. The glands
are lined by columnar, single, or pseudostratified
epithelium, with occasional mitotic features and
sometimes with a secretory appearance. The
nuclei are elongated and have evenly distributed
chromatin. Sometimes, the glands may be more
crowded (hyper plastic changes) or cystically
dilated. The glandular component is surrounded
by a stromal component, composed of small cells,
with little cytoplasm and oval to round nuclei in
association with small arterioles, inflammation,
edema, hemorrhage, hemosiderin-laden macrophages, decidual changes, or smooth muscle
metaplasia. Some of the cases may presen t epithelial atypia, and recent studies have shown that
these lesi ons have a higher risk of developing
malignant tumors (Figs. 14 and 15).
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