Title: Lobular Endocervical Glandular Hyperplasia Discovered in a Recently Postpartum Female
Authors: Amira Shaikh, OMS3; Keely Robino, OMS3; Michael Brunsman, MD
Introduction
Lobular endocervical glandular hyperplasia (LEGH) is a rare precursor lesion to minimal deviation adenocarcinoma. Minimal deviation adenocarcinoma is a vigorous form of cancer with a poor prognosis. The signs and symptoms which reflect malignant transformation of LEGH seem to overlap with common postpartum changes, such as an increase in the flow of lochia. This case report suggests potential screening recommendations to prevent malignant transformation in cases where normal postpartum lochia masks common signs of transformation.
Case Description
A 39-year-old G4P4 female with a history of an abnormal postpartum Pap smear, proceeded with recommended colposcopy and LEEP evaluation, thus revealing LEGH. Due to the malignant potential and no further desire for fertility, this patient elected for treatment with total laparoscopic hysterectomy and bilateral salpingectomy, resulting in complete eradication of this unique lesion.
Discussion
Postpartum lochia overlaps with the clinical signs of malignant transformation of LEGH. MRI and ultrasound have been shown to be useful tools in demonstrating early signs of the evolution of LEGH into its more malignant form. Therefore, there may be a clinical benefit of regular MRI and ultrasound screening in women with LEGH lesions who desire fertility or are postpartum.
I am one of the judges for your case study. You mentioned that the HPV vaccine is not effective with preventing this disease, therefore, do you think it is a disease that should be more thoroughly screened for by a medical provider? Why?
Thank you for your question. It is true that the HPV vaccine is not effective in preventing lobular endocervical glandular hyperplasia (LEGH) given that the lesion is not caused by HPV. This contrasts with squamous cell carcinoma of the cervix which is much more common and very highly associated with high-risk HPV infection. Widespread Pap smear screening has led to a dramatic decrease in the incidence of cervical squamous cell carcinoma, however, rates of endocervical adenocarcinomas have not improved. This is thought to be due to the overlapping cytological features between reactive and neoplastic glandular cells. Differentiation between the two is particularly difficult with early or well-differentiated adenocarcinomas such as minimal deviation carcinoma (MDA). Unfortunately, there is not a reliable, effective way to screen for LEGH or endocervical adenocarcinomas such as MDA other than with routine Pap smears in the clinic at this time.
Judge: Since it is very difficult to positively identify MDA (Minimal deviation adenocarcinoma) by pathology alone and Lobular endocervical Glandular Hyperplasia is a possible precursor, what additional tests might be done and is there any evidence in the current literature for additional tests?
Thank you for your question. Frequently, patients who have had pathology confirming LEGH or MDA will have already had a workup that consists of an abnormal Pap smear, colposcopy with biopsy, as well as a loop electrosurgical excision procedure (LEEP). Patients may also have had the lesion(s) identified incidentally following a complete hysterectomy performed for another reason. These tests are commonly used in sequence and lead to the diagnosis of LEGH and/or MDA on pathology reports.
We mentioned the use of repeat pelvic examinations, ultrasound, and MRI may be appropriate for early detection of transformation of LEGH to MDA. While these techniques may be capable of supporting a diagnosis of LEGH or MDA in theory, there is not enough evidence to support the routine use of these techniques for the initial identification of LEGH or MDA or to override negative pathology reports. We have been unable to find current literature that provides good evidence to support the use of any other tests to increase the detection of LEGH or MDA. I hope that this adequately answers your question.
Thank you for your presentation. Can you explain what Acetowhite changes are?
Thank you for your follow-up question. Colposcopy is a common office procedure performed by OB/GYN physicians for follow-up on an abnormal pap smear. After full visualization of the cervix using a speculum, 3-5% acetic acid is generously applied to the cervix. The solution dehydrates cells so that the abnormal cells (those with relatively large/dense nuclei) appear white. This change is termed “acetowhite change”. The Lugol or Schiller solution is typically applied next which consists of iodine and potassium iodide in water. This stains glycogen-containing, healthy cells brown which allows the abnormal acetowhite lesions to stand out. The provider can then target specific, abnormal areas of the cervix for biopsy.