IMAGES IN CYTOLOGY Section Editor: Shahla Masood, M.D. Rare Endocervical Tumour may be a Diagnostic Dilemma on Papanicolaou Smear Yashwant Kumar, M.D., D.N.B., 1 * Anjali Bhutani, M.D., 1 and Seema Sharma, M.S. 2 Cervical cancers with glandular component remain a major challenge in gynaecologic cytopathology. 1 This is due to difficulty in interpreting the morphological abnor- malities of glandular cells in Papanicolaou (Pap) stained smears or because of sampling error of a neoplasm pri- marily located in the endocervical canal. The glandular component sometimes may be overlooked because of the predominance of abnormal squamous cells as seen in ade- nosquamous carcinoma. 2 It is important to recognise these glandular cells as they are associated with poorer progno- sis than a tumour comprising purely of squamous cells. 3 Here, we describe cytological features in a rare case of endocervical carcinoma, which was a diagnostic problem for the reporting cytopathologists. A 48-year-old lady from North India presented with complains of bleeding per vaginum and backache during menstrual period for the duration of 2 weeks. On exami- nation, an infiltrating endocervical growth was seen oblit- erating the fornices. Clinically a malignancy was sus- pected and a Pap smear was taken followed by cervical biopsy. The air-dried Pap smear was examined independ- ently by two cytopathologists. There were large number of atypical epithelial cells arranged in clusters and few lying discretely. The cells were of variable size with sig- nificant atypia. Tumour diathesis was noted in the back- ground. Therefore Pap smear was unanimously reported as ‘‘positive for epithelial cell abnormality consistent with carcinoma’’ by both the cytopathologists. Subtyping how- ever was kept pending due to lack of consensus among the two. One of them strongly believed it to be a squa- mous cell carcinoma while other was in favor of reporting it as an endocervical adenocarcinoma. When the biopsy was examined it showed a tumour in the form of glands with back to back arrangement. No squamous element could be seen. The cervical biopsy therefore was signed out as ‘‘endocervical adenocarcinoma.’’ Subsequently, a radical hysterectomy with bilateral pelvic lymphadenec- tomy was performed. On gross examination, the uterus measured 9.5 3 5.0 3 3.2 cm with 3.5 cm length of cer- vix. Right and left ovaries were 3.0 3 2.5 3 1.0 cm and 4.0 3 2.0 3 2.0 cm, respectively. Each fallopian tube was 4.5 cm long. Serosal surface of the uterus was smooth. On slicing, a growth measuring 3.0 3 3.0 3 2.0 cm was identified in the endocervical region. The growth was located 1.3 cm proximal to cervical os and extending up to the body-isthmus junction. The cut surface of the growth was solid yellowish-white with infiltrative margins (Fig. C-1). Maximum invasion was noted in the endocer- vical region where it was just 3.0 mm from the peripheral resection limit. The endomyometrial thickness was 1.7 cm with no gross abnormality. Microscopically, the tumour predominantly exhibited a glandular configuration with back to back arrangement of the glands and little intervening stroma (Fig. C-2a). In addi- tion to these, the other areas showed sheets of malignant cells typical of a squamous cell carcinoma. At places, the above two components were noted in close proximity to each other. Few tumour glands with both squamous and adeno components within the same gland were also present (Figs. C-2b and c). The squamous areas comprised nearly 20% of the tumour tissue. The pelvic lymph nodes did not 1 Department of Pathology, Grecian Super speciality Hospital, Mohali, Punjab, India 2 Department of Gynaecology and Obstetrics, Grecian Super speciality Hospital, Mohali, Punjab, India *Correspondence to: Yashwant Kumar, M.D., D.N.B., The Pine, near Ashiana Regency, Chhota Shimla, Shimla 171002, India. E-mail: yashwantk74@yahoo.com Received 16 February 2010; Accepted 4 May 2010 DOI 10.1002/dc.21465 Published online 14 October 2010 in Wiley Online Library (wileyonlinelibrary.com). ' 2010 WILEY-LISS, INC. Diagnostic Cytopathology, Vol 39, No 7 505