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VOLUME 5 


MARCH-APRIL 
1961 


NUMBER 2 


ACTA CYTOLOGICA 


THE JOURNAL OF EXFOLIATIVE CYTOLOGY 


Honorary Editor: GEORGE N. PAPANICOLAOU 


Editorial Board: 


Editor: GEORGE L. WIED 


CLARICE AMARAL FERREIRA, RUTH M. GRAHAM, EMMERICH von HAAM, 
LEOPOLD G. KOSS, J. PAUL PUNDEL, JAMES W. REAGAN 


National Editors: NILO P. LUZ (Brazil), PETER STOLL (Deutschland), JEAN A. de BRUX (France), 
LUIGI CUSMANO (Italia), MARIO GONZALEZ RAMOS (Mexico), A. E. RAKOFF (U.S.A.) 


GENERAL POLICY 


T. ANTOINE, Vienna, Austria 
N. BLOKHIN, Moscow, USSR 


L. T. COGGESHALL, Chicago, 
Ill., USA 


P. F. DENOIX, Villejuif, France 


A. de MORAES, Rio de Janeiro, 
Brazil 


H. de WATTEVILLE, Geneva, 
Switzerland 


GYNECOLOGY AND 
OBSTETRICS 


W. BICKENBACH, Munich, 
Germany 
R. BOURG, Brussels, Belgium 


M. EDWARD DAVIS, Chicago, 
Ill., USA 


G. DELLEPIANE, Torino, Italy 


P. FUNCK-BRENTANO, Paris, 
France 


E. HELD, Ziirich, Switzerland 

Th. KOLLER, Basel, Switzerland 

J. V. MEIGS, Boston, Mass., USA 

E. NAVRATIL, Graz, Austria 

H. RUNGE, Heidelberg, Ger- 
many 

L. C. SCHEFFEY, Philadelphia, 
Pa., USA 


Editorial Advisory Board for 1961: 


PATHOLOGY 


H. BETTINGER, Melbourne, 
Australia 


J. CAMPOS R. de C., Lima, Peru 
J. DELARUE, Paris, France 
H. LAX, Berlin, Germany 


J. H. MULLER, Ziirich, Switzer 
land 


C. W. TAYLOR, Birmingham, 
England 


ENDOCRINOLOGY 


W. M. ALLEN, St. Louis, Mo., 
USA 


J. BOTELLA-LLUSIA, Madrid, 
Spain 
J. FERIN, Louvain, Belgium 


A. E. RAKOFF, Philadelphia, 
Pa., USA 


B. ZONDEK, Jerusalem, Israel 


PUBLIC HEALTH 


E. DAY, New York, N. Y., USA 


R. F. KAISER, Bethesda, Md., 
USA 


K. MASUBUCHI, Tokyo, Japan 





BASIC CYTOLOGY 
SIR ROY CAMERON, London, 
England 


T. O. CASPERSSON, Stockholm, 
Sweden 


I. GERSH, Chicago, Ill., USA 
G. O. GEY, Baltimore, Md., USA 


A. GLUCKSMANN, Cambridge, 
England . 


H. LETTRE, Heidelberg, Ger- 
many 
R. C. MELLORS, New York, 
N. Y., USA 
K. L. MOORE, Winnipeg, 
Manitoba, Canada 


W. SANDRITTER, Frankfurt 
a. M., Germany 


NON-GYNECOLOGICAL 
EXFOLIATIVE CYTOLOGY 


P. A. HERBUT, Philadelphia, 
Pa., USA 


C. E. RUBIN, Seattle, Wash., 
USA 


H. H. WANDALL, Copenhagen, 
Denmark 


J. B. LIPPINCOTT COMPANY 
PHILADELPHIA — MONTREAL 


© Copyright 1961 by J. B. Lippincott Company—All Rights Reserved 














ACTA CYTOLOGICA 





Vol. 5 March-April 1961 No. 2 





CONTENTS 


Original Article 


The Small Histiocyte: Its Morphology and Significance, Ruth M. 
Graham, Buffalo, New York 7 


“I 


Symposium on Probable or Possible Pre-Malignant Cervical Lesions 


II. Ectopy, Ectropion and Epidermization (continued from Jan.-Feb. issue) 


Colposcopy of Ectopy, Ectropion and Epidermization, Jules-André 
Bret, Fernand Coupez, Paris, France, Robert Ganse, Dresden, Ger- 
many, Otakar Nyklicek, Nachod, Czechoslovakia, Hans Klaus Zinser, 
Cologne, Germany 83 


Colpomicroscopy of Ectopy, Ectropion and Epidermization, T. Antoine, 
K. Brandl, V. Griinberger, E. Kofler, H. Kremer, Vienna, Austria, 
Wolfgang Walz, Brenz, Germany 9] 


Clinical Viewpoint: Management of Ectopy, Ectropion and Epidermi- 
zation, Viktor Griinberger, Vienna, Austria, Maria Kawecka, Jania 
Skalska-Vorbrodt, Gliwice, Poland, Frantisek Luksch, Prague, 
Czechoslovakia, Otakar Nyklicek, Nachod, Czechoslovakia 95 


Interrelationship: Ectopy-Ectropion-Epidermization and _ Cervical 
Carcinoma, Jean A. de Brux, Henriette Wenner-Mangen, Paris, 
France, Robert Ganse, Dresden, Germany 100 


III. Leukoplakia 


Histomorphology of Leukoplakia, Friedrich Bajardi, Graz, Austria 103 
Histochemistry of Leukoplakia, José Botella-Llusia, Madrid, Spain 105 


Exfoliative Cytology of Leukoplakia, Arturo A. Arrighi, Buenos Aires, 
Argentina, Marcel Dargent, Jacqueline Mouriquand, Lyon, Rhéne, 
France, Emmerich von Haam, Columbus, Ohio 108 


Animal Experiments, Emmerich von Haam, Columbus, Ohio 115 


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Colposcopy of Leukoplakia, Friedrich Bajardi, Graz, Austria, Jules- 
André Bret, Fernand Coupez, Paris, France, Warren R. Lang, Phila- 
delphia, Pennsylvania, Wolfgang Walz, Brenz, Germany 115 


Colpomicroscopy of Leukoplakia, T. Antoine, K. Brandl, V. Griin- 
berger, E. Kofler, H. Kremer, Vienna, Austria, Wolfgang Walz, 


Brenz, Germany ] 


ie) 
ids | 


Clinical Viewpoint on the Management of Leukoplakia, 7. Antoine, 
Vienna, Austria 128 


~ 


Interrelationship: Leukoplakia and Cervical Carcinoma, Friedrich 
Bajardi, Graz, Austria 129 


IV. Reserve Cell Hyperplasia, Basal Cell Hyperplasia and Dysplasia 


Histomorphology of Reserve Cell Hyperplasia, Basal Cell Hyperplasia 
and Dysplasia, Friedrich Bajardi, Graz, Austria, Jean A. de Brux, 
J. Dupré-Froment, Paris, France 133 


Exfoliative Cytology of Reserve Cell Hyperplasia, Basal Cell Hyper- 
plasia and Dysplasia, Jean A. de Brux, J. Dupré-Froment, Paris, 
France, Ruth M. Graham, Buffalo, New York, Emmerich von Haam, 
Columbus, Ohio 142 





The following articles will conclude the Symposium on Probable or Pos- 
sible Pre-Malignant Cervical Lesions and will appear in the May-June 
issue along with papers presented at the meeting of the Inter-Society 
Cytology Council, 1960. 


Histochemistry of Reserve Cell Hyperplasia, Basal Cell Hyperplasia 
and Dysplasia 


Fluorescence Microscopy of Hyperplasia in Gynecological Cytodiagnosis 
Animal Experiments 
Reserve Cell Hyperplasia, Basal Cell Hyperplasia and Dysplasia 


Colpomicroscopy of Reserve Cell Hyperplasia, Basal Cell Hyperplasia 
and Dysplasia 


Clinical Viewpoint on the Management of Reserve Cell Hyperplasia, 
Basal Cell Hyperplasia and Dysplasia 


Interrelationship: Reserve-Cell Hyperplasia, Basal-Cell Hyperplasia, 
Dysplasia and Cervical Carcinoma 





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ACTA GYTOLOGICA 





Vol. 5 


March-April 1961 No. 2 





The 


Small Histiocyte: Its Morphology and Significance 


RutH M. GraHam, Sc.D. 


From the Roswell Park Memorial Instilute 
Buffalo, New York 


DuRING recent years there has been in- 
creasing interest in the possibility that the 
natural resistance of the host plays an 
important, and perhaps critical role in the 
treatment of the cancer patient. This im- 
pression has developed almost entirely from 
clinical observations. Two patients with 
similar histologic type and clinical extent 
of tumor, treated in an identical fashion 
may have quite different outcomes, one 
surviving for years, while the other suc- 
cumbs to her disease promptly. In some 
instances the tumor does not disappear but 
seems to remain quiescent over long periods 
of time. Obviously, there is some marked 
difference between the two patients, and 
this difference is often explained as “host 
resistance.” This impression of some nat- 
ural defense mechanism against cancer has 
remained largely a_ clinical impression 
because there are no adequate methods 
Investi- 
gators!: 3 have demonstrated that there are 
circulating antibodies in the blood against 


for measuring “host resistance.” 


some components of the cancer cell, but it 
has been difficult to correlate these findings 
with the course of the disease. 

It may be that those patients who appear 
to exhibit some natural resistance against 


the cancer cell have a different kind of 
“tissue immunity.” The components which 
are directed against the tumor may not be 
circulating antibodies. “It is possible that 
some kind of cellular reaction takes place 
around the cells, limiting their 
growth, and in a rare instance—the sponta- 
neous regression—actually destroying them. 

If this hypothesis is to be tested, it is 
necessary to have a method to measure 
such cellular immunity. We must consider 
what cell could possibly be involved in such 
a cellular defense mechanism. The small 
histiocyte is one of the classic cells of an 


tumor 


immune response and its role in immunity 
is established. It is the cell which plays an 
important part in circumscribing an infec- 
tion once it has passed the acute phases 
when the major defense mechanism rests 
upon the leukocyte. It would appear rea- 
sonable to examine these particular cells in 
the cancer patient to determine: first, if 
patients show differences in the numbers 
of these cells present in the vicinity of the 
cancer, second, if differences are present, 
do they have any correlation with the out- 
come after treatment. This paper is an 
analysis of the significance of the small 
histiocyte in cancer of the cervix treated 
by radiation. 








78 


Cancer of the uterine cervix lends itself 
well to such a study because by examination 
of the vaginal secretion, one can determine 
the type of cells present and their numbers 
in relation to other cells present. The re- 
sults presented in this paper are based on 
differential counts on vaginal smears, pre- 
pared from aspiration from the posterior 
fornix. One hundred consecutive cells were 
counted, including benign squamous epi- 
thelial cells and histiocytes, but ignoring 
any malignant cells present. In this way, 
it is possible to determine what percentage 
of the benign cells are histiocytes. If either 
the squamous epithelial cells or the histio- 
cytes are in clusters of more than six cells 
they are not included in the count. Inclu- 
sion of large aggregates of cells in the difter- 
ential count tends to make the counts diffi- 
cult to reproduce. 


In order to accurately count the per- 
centage of histiocytes, it is necessary to be 
extremely familiar with the morphology of 
these cells. No cell encountered in the 
vaginal smear will show so much variation 
as the histiocyte. Because in diagnostic 
cytology we are always dealing with fixed 
material, there is a great tendency to forget 
that the cells observed at one time were 
living, moving entities. The histiocyte is 
capable of active movement and this fact 
alone accounts for much of the variation in 
shape of the cell. If active, living histio- 
cytes are observed in phase microscopy, the 
movement of the cytoplasm is particularly 
conspicuous. The cell will send out long 
pseudopodia of cytoplasm in many direc- 
tions at the pole of the cell opposite from 
the nucleus. The cell may become ex- 
tremely long and thin in order to move in 
narrow spaces. The photomicrographs be- 
ginning with Figure 3 have been chosen to 
show the variation in size and shape of 
these phagocytes. Though these cells are 


GRAHAM 





Acta Cytol. 
Mar.-Apr. 1961 


from a fixed specimen, they give the im- 
pression of great activity and movement, 
much like a still photograph from a movie. 

The classical description of the histio- 
cyte is that it is a small round cell, with 
an eccentric nucleus with foamy vacuolated 
cytoplasm and an indistinct cell border 
(Fig. 1). Another type of histiocyte accu- 
rately identified is one similar to that shown 
in Figure 2. There is a large vacuole occu- 
pying almost the entire area of the cell, 
and the nucleus is on the rim of the 
cellular border. 

Emphasis is often placed on the fact that 
the histiocyte has a bean-shaped nucleus. 
On careful observation, it can be seen that 
of the eight histiocytes in Figure 1, only 
three have a distinct bean-shaped nucleus. 
It is true that histiocytes do have bean- 
shaped nuclei but this fact has received 
overemphasis and has tended to lead stu- 
dents of cytology to believe that only cells 
with bean-shaped nuclei are histiocytes. It 
appeared important to determine how 
many histiocytes do have this characteristic 
bean-shaped nucleus. One hundred small 
histiocytes were counted in ten vaginal 
smears, and the shape of the nucleus re- 
corded. Twenty-seven per cent of these 
thousand cells had bean-shaped nuclei. The 
most common shape encountered was an 
oval one, the nucleus appearing somewhat 
elongated, 38 per cent of the cells having 
this shape. Round forms were very com- 
mon—23 per cent or almost as common as 
the bean-shape. Ten per cent of the nuclei 
seen were flat on one side and oval on the 
other. The flattened side was usually next 
to a vacuole. There were 2 per cent of the 
nuclei with a distinct triangular shape. 
From these figures it is clear that the small 
histiocyte with a bean-shaped nucleus is in 
the minority and a good many histiocytes 
will not be classified correctly if the mor- 





Ficures 1-8 on facing page. 








Volum 
Numbe 





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Volume 5 THE SMALL HISTIOCYTE 79 


Number 2 











80 GRAHAM 


TABLE 1. Shape of Nucleus 





Round 23%, 
Oval 38%, 
Flat on one side 10% 
Bean- 27%, 
Triangular 2%, 





TABLE 2. Shape of Cell 





Round 73% 
, i a 
Elongated 13%, 
Bizarre 14%, 





phologist depends on shape of nucleus as 
a prerequisite for identification (Table 1). 
The shape of the histiocyte is usually 
round but other forms are by no means 
uncommon. In a second thousand histio- 
cytes in which the shape of the cell was 
recorded, 73 per cent were round, 13 per 
cent (Fig. 3, 4) elongated and 14 per cent 
had bizarre, ameboid forms (Fig. 7, 8). 
Probably the most reliable criterion for 
identification of the small histiocyte is the 
position of the nucleus in a fine foamy, 
vacuolated cytoplasm. The small histiocyte 
has a nucleus which is eccentric in position 
and sits right on the cellular border. The 
cell wall and the nuclear wall appear to 
merge making it impossible to distinguish 
them as separate walls. However, occasion- 
ally, a small histiocyte may have a centrally 
placed nucleus. In an effort to find out 
how often this happened, a third thousand 
small histiocytes were counted and the posi- 
tion of the nucleus recorded (Table 3). In 
88 per cent, the nucleus appeared at the 
cell border, and it was not possible to dis- 
tinguish between cell wall and nuclear wall. 
This is clearly illustrated in Figure 8. 


Taste 3. Position of Nucleus 





At Cellular Border 88% 


Not a Border 12% 








Acta Cytol, 
Mar.-Apr. 1961 


Twelve per cent of the histiocytes had the 
nucleus almost central in position as illus- 
trated by the large histiocyte in the center 
of the field in Figure 7. The histiocyte with 
the centrally placed nucleus has _phago- 
cytosed a small black particle. . This is 
important because the great majority of 
these histiocytes with centrally placed nu- 
clei contained phagocytosed material. It 
appears that once the histiocyte has accom- 
plished the act of phagocytosis the nucleus 
moves inward in the cell. It is unusual to 
find small histiocytes without phagocytosed 
material with a centrally placed nucleus. 


To attempt to describe the small histio- 
cyte as a cell with a constant form is to 
completely ignore the function of this cell— 
phagocytosis. The pseudopodia which the 
histiocyte puts forth are extremly fine. In 
phase microscopy many times the pseudo- 
podia would not have been observed except 
for their rapid movement. These long thin 
strands as those shown in Figure 8 are often 
regarded as degenerating cytoplasm, when 
actually they indicate actively moving cells. 
The small histiocyte is also an exceedingly 
tough cell. Active movement can still be 
seen after 14 hours at 37 C., long after all 
movement of the granules of the leukocyte 
has ceased. 

By counting 100 consecutive cells, includ- 
ing benign squamous epithelial cells and 
small histiocytes, it has been possible to 
determine in 339 consecutive cases of in- 
vasive cancer of the cervix, the percentage 
of histiocytes present. Table 4 indicates 
the results. The majority of invasive cancer 
of the cervix patients have few histiocytes. 
Thirty-six per cent of patients had 9 per 
cent or less histiocytes. There were 38 cases 
or Il per cent whose vaginal smears con- 
tained no histiocytes. In 61 cases or 18 per 
cent, 50 per cent or more of the benign 
cell population was composed of small 
histiocytes. 

Does the number of histiocytes present in 
the pre-treatment vaginal smear have any 


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significance if the patient is treated by 
radiotherapy? To test this point, 119 pa- 
tients in Stages I and II, treated by radio- 
therapy and followed for two years or 
longer were used. Only cases in Stages I and 
II were used for comparison since it is in 
this group that radiotherapy is the most 
effective. These cases with two-year follow 
up are considered here even though their 
follow up is not as long as one would 
prefer, because all of these patients were 
treated in a uniform manner. They all 
had full pelvis radiation to a dosage of 
5,700 rads. in six weeks followed by 2,000 
mg. hrs. of radium at the cervix. In doing 
studies on cancer of the cervix patients 
treated with radiation, it is often difficult 
to interpret the results, because the patients 
are not treated in a uniform fashion and 
such factors as dose, time of treatment, etc., 
come into consideration. This particular 
series makes for more accurate comparison 
since all of the patients were treated in a 
uniform manner. 

Table 5 compares the results in these 
patients correlated with the percentage of 
histiocytes present in their pre-treatment 
smear. It can readily be seen that the pa- 
tients who have the lowest symptom-free 
rate are those with no or few histiocytes. 
The group of patients whose symptom-free 
rate is the greatest are those with more than 
50 per cent histiocytes in the pre-treatment 
vaginal smear. It is also of interest that 
the symptom-free rate rises in each group 
as the percentage of histiocytes increases. 
The difference of a 79 per cent symptom- 


TABLE 4, 





Percentage of 
patients symptom free 
at two years 


Percentage 
histiocytes 





0- 9%, 23 /44-52%, 
10-19%, 15/22-68%, 
20-19%, 18/24-75%, 
50%, ‘ 23 /29-79%, 





PHE SMALL HISTIOCYTE 


TABLE 5. 





Number of 
cases 


Percentage of 
histiocytes 





0- 9% 123-36%, 
10-19%, 63-19%, 
20-49%, 92-27% 
50% 61-18%, 

339 





free rate in those with more than 50 per 
cent histiocytes and of a 52 per cent in those 
with 9 per cent or less is not quite significant 
at a probability of .01, since the sigma is 
2.57. However, it is significant at a proba- 
bility of .05, indicating that the possibility 
of such a correlation as this being due to 
mere chance is less than 5 per cent. 

The presence of histiocytes in the pre- 
treatment smear appears to be more critical 
as the disease advances. The most advanced 
cases Clinically in this group are those classi- 
fied as Stage IIb. These are invasive cancer 
of the cervix cases with involvement of the 
cervix and the parametrial tissue, but not 
involving the pelvic wall. There were 27 
such cases in this series. Sixteen had less 
than 20 per cent histiocytes in the control 
smear and of these only two are symptom- 
free at two years. Of the 11 whose pre- 
treatment smear contained more than 20 
per cent histiocytes, eight are symptom-free 
and without any evidence of disease. 
Though the number of cases are few, such 
marked differences as these suggest that the 
histiocyte does play an important role in 
the control of cancer of the cervix treated 
by radiotherapy. 

Discussion 

If the small histiocyte is regarded as evi- 
dence of “tissue immunity” there is some 
evidence of an immune response in some 
patients with cancer of the cervix. How- 
ever, the majority of the patients show very 
little evidence of active proliferation of the 
small histiocyte or of concentration of that 


82 GRAHAM 


cell at the tumor bed. If histiocytes are 
present in great numbers, they appear un- 
usually active as evidenced by phagocytosed 
material and bizarre pseudopodia. In the 
small percentage of patients whose vaginal 
smears do contain numerous histiocytes the 
clinical outcome appears to be considerably 
better than in those in whom the histio- 
cytic response is lacking. 

It is impossible at the present time to 
determine why there should be _ these 
marked differences. The number of histio- 
cytes present appears to be independent of 
the clinical stage of the disease, or the his- 
tologic type or grade of tumor. In general, 
older, post-menopausal patients are more 
likely to have great numbers of histiocytes 
than the young menstruating patient. In- 
formation concerning the influence of endo- 
crinologic factors on the immune response 
is meager. There is also the possibility that 
these patients are lacking in their ability to 
create any kind of a tissue immune response, 
whether to cancer or other foreign agents. 
There is evidence that the cancer patient 
takes much longer to reject a skin graft 
from another individual than normal 
individuals.2 This would appear to indi- 
cate that there is a general deficiency in 
tissue immune response. 

Obviously it is impossible to know what 
particular factor or combination of factors 
are involved here. At present, from this 
study, it can be stated that the patient with 
cancer of the cervix is usually lacking in 
small histiocytes near the tumor, indicating 


Ma & n S {sei 
a poor response on the part of the reticulo- 
endothelial system to the tumor. When his- 
tiocytes are present in great numbers, it 
appears that they exert a beneficial effect 
on the course of the disease, if the patient 
is treated by radiotherapy. 


Summary 

A detailed description of the morphology 
of the small histiocyte in vaginal smears has 
been given. The histiocyte varies more in 
size and in shape than any other cell en- 
countered. Emphasis has been placed on 
the great activity of these cells in the cancer 
of the cervix patient when they occur in 
great numbers. 

The presence of histiocytes in the pre- 
treatment vaginal smear has been correlated 
with clinical outcome in a group of 119 
cases of invasive cancer of the cervix in 
Stages I and II. Those patients having more 
than 50 per cent histiocytes did rather well, 
having a two-year symptom-free rate of 79 
per cent. Those patients whose smears had 
few or no histiocytes did rather poorly, the 
symptom-free rate being 52 per cent at 
two years. 


Bibliography 


1. Finney, J. W., E. H. Byers and R. H. Wilson: 
Studies in ‘Tumor Auto-Immunity. Cancer 
Research. 20: 351, 1960. 

2. Grace, James T. and T. Kondo: Investigations 
of Host Resistance in Cancer Patients. Ann. 
Surg. 148: 633, 1958. 


3. Graham, John B. and Ruth M. Graham: Anti- 
bodies Elicited by Cancer in Patients. Cancer. 
8: 409, 1955. 








Forthcoming Meeting 
First International Congress of Exfoliative Cytology 


Vienna, Austria, August 31-September 2, 196] 











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Symposium on Probable or Possible 
Premalignant Cervical Lesions 


II. Ectopy, Ectropion and Epidermization 


(Continued from January-February Issue) 


Colposcopy of Ectopy, Ectropion and Epidermization 


JuLes-ANbRE Bret, FERNAND Couprz 


Paris, France 


From our point of view, the terms ectopy 
and ectropion have two uses. An ectropion 
is only a form of an ectopy. We will call 
ectopy the colposcopic pattern of the col- 
umnar papilli usually found in the endo- 
cervical canal. When the lower part of the 
canal is eversed, the single-layered cylin- 
drical tissue becomes visible and gives the 
appearance of ectopy. It is a mechanical 
process and not any particular colposcopic 
picture. 
girls and in children. 


Ectopies exist in nulliparas, in 
In these cases, the 
presence of cylindrical papilli on the exte- 
rior of the orifice corresponds to congenital 
morphological anomalies or to hyper-hor- 
monal impregnations (Wespi). 

In colposcopy the ectopy looks like a set 
of small, regular, rounded or elongated, 
translucent 
permit the observations of a central, cork- 


formations, which sometimes 
screw-shaped capillary which opens below 
the surface. These formations are obvious 
only after the application of 3 per cent 
acetic acid; their size varies little from one 
patient to another 
Their number and grouping suggests a 
grape-like formation. The borders of the 
ectopy are well defined when the lesion is in 
the pure state. In the phase of cicatrization, 


(outside pregnancy). 


the borders are hazy; some peripheral sheets 


of ectopy are isolated like islands in the 
stratified epithelium. 

Pregnancy, which apparently changes the 
shapes of the lesions intp polypoid forms, 
very alarming when examined with the 
naked eye, is the origin of a large number 
of ectopies. Ectopies are the most easily 
recognizable colposcopic abnormalities. In 
the pure form, described previously, they 
are never related to any malignant proc- 
ess. ‘Therefore, their picture immediately 
changes as their histology changes. Infec- 
tion may make them unrecognizable mo- 
mentarily. 

Epidermization 

Cicatrization of the cervical areas free of 
epithelium occurs in two circumstances: 

(1) during the healing of an erosion or 
ulceration, with the connective tissue being 
exposed, cicatrization takes place by cen- 
tripital growth of the squamous epithelium; 

(2) during the healing of ectopies. 

If the ectopy is related to an ectropion 
of pregnancy, the regression occurs in the 
postpartum period by mechanical disap- 
pearance of the eversion of the lower part 
of the endocervical canal. 

In some cases (glandular hyperplasia, 
infection) the regression of the ectropion 





84 


is not sufficient and ectopy remains post- 
partum. 

Outside of delivery, the cicatrization of 
ectopy takes place in two ways: 

(1) by progression towards the center of 
the peripheral epithelium; this progression 
is slow and made difficult by the maceration 
due to the muc'is secreted by the glands of 
the ectopy; 

(2) by formation of metaplasias which 
build a multilayered tissue from the col- 
umnar epithelium. ‘The metaplastic mucosa 
resists effectively the mucus secretion which 
sometimes fills up the glands. ‘These meta- 
plastic areas extend by confluent wide- 
spreading; the borders join to the normal 
squamous epithelium which grows toward 
the center and passes over (“like a bridge’) 
the glandular os, thus forming the Naboth- 
ian cysts. Ectopic islands may remain a long 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II 





Acta Cytol. 
Mar.-Apr. 1961 
time at the cicatrization; they most often 
have a hyperactive gland in their center. 

Colposcopically, normal epidermization 
is seen as a red area, with numerous ves- 
sels and faint borders. It stains irregularly 
with Lugol’s solution. An _ intermediate 
area is formed by metaplastic sheets; they 
are translucent, iodine negative and slightly 
opalescent after acetic acid and have in- 
definite borders. These metaplastic areas 
include isolated ectopic islands and glandu- 
lar orifices. The center of the normal epi- 
dermization area, around the cervical os, 
stays for a long time or indefinitely, with 
a discrete crown of endocervical villi. Nor- 
mal epidermization of the ectopies leaves 
characteristic results. They are red areas 
with apparent vascularization. In the per- 
ipheral area (in the middle and central 
parts) they always have glandular cysts and 
functional glandular orifices. 





Rospert GANSE 


Dresden, Germany 


THE ECrorpy cannot be recognized cyto- 
logically. As the name indicates, we deal 
here with columnar epithelium in an ec- 
topical site, namely on the surface of the 
ectocervix, which is normally covered with 
squamous epithelium. Colposcopically the 
ectopy is characterized clearly by the forma- 
tion of grape-like structures after applica- 
tion of a few drops of 3 to 4 per cent 
acetic acid. ‘The ectopy can be acquired 
or connatal. Figure | shows this grape 
formation on the surface of the anterior lip 
of the uterine cervix. The squamous epi- 
thelium is here separated from the col- 
umnar epithelium by a sharp borderline. 


Similar findings are frequent on the cervix 
uteri. Colposcopically it cannot be deter- 
mined whether it is an ectopy or an ectro- 
pion. The epidermization, however, can 
be recognized as such colposcopically. 

Figure 2 shows a polypoid ectopy on top 
of which epidermization starts. ‘This proc- 
ess leads to a formation called, by Hinsel- 
mann, “transformation zone.” Up to now 
no satisfactory explanation has been found 
as to the cause of this type of transforma- 
tion. The theory of the constant border 
struggle between columnar and squamous 
epithelium will not suffice. 

Figure 3 shows a transformation zone 


Fic. 1. (Left, top) Ectopy with formation of grapelike structures. Fic. 2. (Right, top) Polypoid 


ectopy with beginning epidermization. Fic. 3. 
ectopic islets. Fic. 4. 
middle of the ectopy as well. 


(Left, bottcm) ‘Transformation zone with small te 
(Right, bottom) Ectopy with epidermization from the edge and in the 








Volu 
Num 








Volume 5 SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II 


Number 2 


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86 


with minute ectopic islets left. “his process 
can be followed very exactly colposcopically 
and the respective cytological findings are 
cells from a metaplasia (spider cells) as 
sign of an indirect metaplasia. 

In Figure 4 one sees how the squamous 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II 





Mare Ane You 
epithelium of the transformation zone rises 
from the margin and from the center of 
the lesion as well. The strip of epithelium 
which grows tonguelike from the edge cor- 
responds to an epidermization, just as it 
happens in normal wound healing. ° 


OTAKAR NYKLiCEK 


Ndachod, Czechoslovakia 


IN THE BEGINNING I will take the liberty 
of making an annotation to the nomen- 
clature used in this topic. “Ectopy” is a 
name used in colposcopy, “ectropion” is an 
anatomical expression and “epidermiza- 
tion” is a name employed in histology. I 
suggest employing a uniform nomenclature, 
and in this case I think that the most suit- 
able one for a clinician should be a colpo- 
scopic nomenclature. 

Ectopy is today a well known expression 
in colposcopic literature, which means the 
appearance of columnar epithelium coming 
from the canal of the uterine cervix into 
the ectocervix, where there should be a 
squamous epithelium. “Pure” pictures of 
ectopy, which means places with columnar 
epithelium sharply delineated against the 
squamous epithelium, are comparatively 
rare; on the contrary, much more often 
where these epithelia meet, the transforma- 
tion zone is encountered. In order to make 
the diagnosis more accurate, the use of the 
so-called enlarged colposcopy is recom- 
mended, as is well known, by means of a 
2 per cent solution of acetic acid, through 
which the “grape-shaped” spots of col- 
umnar epithelium stand out more clearly 


in the colposcope. But an experienced spe- 
cialist in colposcopy may well do without 
this method. 

“Ectropion” is, properly speaking, not a 
colposcopic expression and also has been 
dealt with neither by Hinselmann, nor 
by other prominent investigators in colpos- 
copy (Mestwerdt, Wespi, Glaathar, Ganse, 
etc.) in any independent way. In the colpo- 
scopic picture of ectropion we again see 
the columnar epithelium, which is properly 
speaking eutopically, that is, correctly local- 
ized in the canal of the cervix, and at the 
same time is secondarily everted, for ex- 
ample by the trauma of parturition. The 
columnar epithelium in this way enters the 
unsuitable vaginal medium, and ectropion 
is then very often associated with ectopy, 
for a columnar epithelium grows over the 
border of the external os and encroaches 
on the ectocervix. 

We think it more correct to use the col- 
poscopic expression “Transformation Zone” 
instead of “Epidermization.” 


It is probable 
that others will speak in other places in this 
Symposium of the opinions of histologists 
concerning the exchange of both epithe- 
lia (epidermization, regeneration, indirect 


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Volume 5 
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metaplasia, etc.). And again, it is univer- 
sally known that this expression means in 
the colposcopic literature replacing of an 
ectopic columnar epithelium on the ecto- 
cervix by a squamous epithelium. A mutual 
“conflict” between these two epithelia pro- 
duces the very variable pictures of the 
Transformation (TZ). From the 
point of view of the future destiny of TZ 
and its correct treatment, it is, according 


Zones 


to my opinion, proper to further divide the 
TZ. In order to be able to show the progress 
of epidermization or regeneration of ec- 
topies in the colposcopic picture, we have 
divided the 
three groups: 


Transformation Zones into 


TZI: It signifies the beginning of regen- 
eration. In ihe colposcope we see 
the linear stripes of squamous epi- 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II 87 


thelium growing from the periph- 
ery into the columnar epithelium. 

TZII: It signifies an advanced regenera- 
tion. We see a miscellaneous pic- 
ture—open glandular ducts, small 
and larger retention 
patches of columnar epithelium. 
The regeneration is finished. The 
whole of the portio is again entirely 
covered by squamous epithelium, 
in which there remains from the 
original columnar epithelium the 
open glandular ducts, or older re- 
tention cysts. 

Others, as is well known, divide the TZ 
into TZ quiet and unquiet (Wespi). 

Colposcopy with cytology allows a very — 
close observation of the “conflict” of both 
epithelia, out of which either a normal or 
a pathological state of the cervix may arise. 


cysts or 


F21TH; 


Hans KtaAus ZINSER 


Cologne, Germany 


IT MAY BE KNOWN that the colposcopical 
visualization of the cervix has brought 
about a more exact differentiation of find- 
ings, which have been included in the past 
under the collective terms of “erosion” or 
“pseudoerosion.” By means of the enlarge- 
ment yielded by the colposcope, two groups 
of pathological processes can be recognized: 

(1) the ectopy (ectropion) and 

(2) the variety of stages of the epidermi- 
zation (transformation zones). 

The cylindrical epithelium in an ectopy 
of the uterine cervix can be visualized par- 
ticularly clearly after application of 1 per 
cent acetic acid. Under the action of this 
substance a characteristic picture arises 


which we have called “grape formation” 
and which is clearly distinct from that part 
of the cervix which is lined by squamous 
epithelium. In our usage we mean by ec- 
tropion only the relatively rare finding of 
the cervical “‘arbor vitae.” 

An important advantage of the colpo- 
scope is that it permits the recognition and 
follow up of the various stages of epidermi- 
zation. It is possible to observe the process 
of overgrowth from the margins of an 
ectopy and to determine the 
phases of the continuing epithelialization. 
During this process covering of the cervical 
glands occurs, except, at first, the lumina 
(open transformation zone), until eventu- 


individual 





88 SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II iy hg = 
°%o is concerned. "These have to be given to 
cytology for clarification. 

| We have studied the incidence of the 
various definitely benign colposcopical find- 
60 _A Fo Originar ings, i.e., regular squamous epithelial lin- 
a % ing, ectopy and transformation zone, as 
50 \  d \ e to their frequency in the different ages of 
x ‘. the woman.” Figure | gives a graphic pres- 

40} sf ™ ‘, entation of the age distribution. 
; ~~ The frequency of ectopy decreases with 
30+ ; » Umwandiung = the age of the woman. Thus, in patients 
: é over 45 years of age one finds mainly closed 
20h : transformation zones and the cervices cov- 
J \ ered with normal epithelium. Finally dur- 
« ing menopause only the final stages of the 
. . ‘i “——- Ektopie overgrowth are recognizable. In most cases, 
however, we find a completely normal lin- 








0 25 30 35 40 45 50 55 60 65 Jahre 
Fic. 1 


ally the epidermization is completed and 
ovula Nabothii (closed transforma- 
tion zones). Apart from this regular over- 
growth process there are deviations of it 
which are marked by hypervascularization 
(transformation zones with marked vascu- 
larization). ‘The vascularity of such fresh 


arise 


transformation zones can considerably sur- 
pass the physiological norm. The terminal 
capillary network forms highly branched, 
fish-bone-like vessel formations and _net- 
works which extend under the thin epithe- 
lial lining. 

By means of extensive colposcopy (with 
such tests as acetic acid and Schiller’s) these 
atypical transformation zones can, by the 
experienced clinician, be classified as be- 
nign changes for the most part. ‘There 
remain, however, 6 to 8 per cent of the 
so-called “atypical transformation zones” 
which do not allow an exact evaluation as 
far as the benignity of the epidermization 


ing of squamous epithelium. These in vivo 
observations are in full agreement with the 
histological results by Hamperl, Kaufmann 
and Schneppenheim.' The age-dependent 
in evolution and the simultaneous epithe- 
lialization of the ectopic cylindrical epithe- 
lium leads to displacement of the squamo- 
columnar junction and thereby to a shift, 
most likely, of the site of origin of cervical 
carcinomas into the depth of the endo- 
cervical canal, which now becomes a favored 
site of atypical epithelial proliferations. 
Hence, colposcopy has its limitations in 
recognition of epithelial atypias, limitations 
which are especially sensible when evalua- 
tion of findings of women of 45 and over 
is at stake. ‘The reason for this is that the 
epidermization zones, which were formerly 
located ectocervically now escape visualiza- 
tion, because they are endocervical. 
Bibliography 
1. Schneppenheim, P., H. 


and K. G. Ober: 
305, 1958. 


Hamperl, C. Kaufmann 
Archiv Gyniikologie 190: 


2. Zinser, H. K. and G. Kern: Geburtshilfe und 
Frauenheilkunde 2: 106, 1958. 


; 


} 


—— 


~~ 


——— 





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Discussion 

Jean Berger, Basel, Switzerland: ‘The colposcopic 
pictures of ectopy and the transformation zone are 
unequivocally and clearly defined by Hinselmann, 
Mestwerdt and others. 

We share the opinion of Nykligek that eclropion 
is not a colposcopic diagnosis but an anatomical 
term. Colposcopically one finds the ectopic, cylin- 
drical epithelium from the endocervical canal on 
the ectocervical surface. 

The ectopy may definitely be recognized colpo- 
scopically after painting with 2%, acetic acid. We 
deal here with a grape-like arrangement of cylin- 
drical epithelium which is very distinct from the 
remaining squamous epithelium of the ectocervix. 
Also typical for this condition is the fact that this 
epithelium bleeds easily and does not stain a 
brownish color with the Schiller test, but remains 
reddish in color. Macroscopically one usually recog- 
nizes merely a reddish area around the external 
os, and only viewing with the colposcope gives a 
better differentiation between cylindrical or squa- 
mous epithelium. 





In cases of regenerative processes on the cervix 
(ie., overgrowth of the cylindrical epithelium by 
squamous epithelium) we do not use the term 
“epidermization” but call it “transformation zone.” 
Different transformation zones may be observed 
according to the degree of growth exhibited by the 
process of regeneration. Either one recognizes the 
fine, still incomplete squamous epithelium over- 
growing the ectopy and which, for the reason of 
its incomplete content of glycogen, is still iodine 
negative, or the squamous epithelium already 
growing into the ectopy in a wide stripe of multi- 
layered epithelium. All these processes can be 
judged with the aid of the colposcope, but not 
with the naked eye. 





Herbert Janisch, Vienna, Austria: The recognition 
of typical physiological findings under the colpo- 
scope, such as normal mucosa, ectopy and trans- 
formation zone, in most cases does not offer any 
difficulties. The evaluation is rendered more diffi- 
cult by the additional presence of inflammation. 
Under such circumstances we pay special attention 
to the vascular pattern in ectopies and tranforma- 
tion zones. In addition, in transformation zones we 
regard changes in the transparency of the epithe- 
lium and probably present differences of the focal 
plane of the colposcopical picture important, since 
eventually they lead toward the “unusual” transfor- 
mation zone. The significance of the latter has been 
discussed elsewhere in this symposium. The fact 
that the squamo-columnar junction moves toward 
the endocervical canal in the higher age group, as 
mentioned by Zinser, is certainly important for the 
colposcopist. The junction thus escapes colpo- 
Scopical observation, and not in all cases of malig- 
nant changes of the ectocervical epithelium is an 
indication found in the sense of the “indirect indi- 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II 








Fic. 1. According to this illustration the original 
mucosa may be described as including none of the 
above characteristics. The unusual transformation 
zone, according to the figure, may be described as 
including all of the listed colposcopical features, 
but in an altered and strange shape and color. 


cator function of the atypical epithelium,” as 
Hinselmann has put it. 

We think that the main value of colposcopy lies 
in the recognition of the most frequent physio- 
logical changes on the cervical surface (ectopy and 
transformation zone). ‘The nonphysiological changes 
can be separated from the suspicious ones, thus 
avoiding unnecessary biopsies. 


Wolfgang Korte, Bonn, Germany: The experi- 
enced colposcopist is able to discern endocervical 
epithelium on the ectocervix with or without 
auxiliary methods. Only the histopathologist, how- 
ever, is able to precisely distinguish the ectopy from 
the ectropion. In the evaluation of the genesis of 
these two different alterations too little attenion 
is paid to the fibromuscular structures of the endo- 
cervix and ectocervix. The results reported by 
Zinser may be partially explained by the processes 
of traction and shrinkage in these tissues of women 
over 45 years of age. I believe that the macro- 
scopical or colposcopical demonstration of the 
arbor vitae is not necessary for the determination 
of an ectropion. Ectropions mostly originate by 
laceration. The processes which cause the lacera- 
tion ave also able to considerably impair the nor- 
mal picture of the arbor vitae, and quite often this 
is true. 


Ernst-Helmut Kriiger, Halle, Saale, Germany: 
We agree with the main authors. In addition to 
acetic acid for the recognition of the columnar 
epithelium on the external os, albothyl (Byk- 
Gulden) or Negatol have been used successfully. 


SYMPOSIUM ON PREMALIGN 


90 


However, we are not in favor of the routine appli- 
cation of these supplementary methods. ‘The ce- 
topy has to be recognized colposcopically without 
these methods. ‘The colposcopical recognition of the 
transformation zone is of great practical importance. 
Figure 1 shows schematically the features of the 
usual transformation zone: 
1. ectopic islets 
2. glandular openings 
3. yellowish appearing Ovula Nabothii with ves- 
sels running across and tapered towards the 
periphery. 


While the ectropionized cervical mucosa often 
may cause the colposcopical picture of the ectopy, 
one should be content with the colposcopical term 
ectopy only for endocervical epithelium visible on 
the external os. ‘The same applies to the colpo- 
scopical term “transformation zone,” which corre- 
sponds histologically to an epidermization. We do 
not believe that a subdivision of the transformation 
zones into three groups, as proposed by Nykliéek, 
is necessary. Of practical importance is the remark 
by Zinser that colposcopy allows definite statements 
amy for the visible portions of the cervix. In the 
of invisible precancerous changes within the 
cervix, appreciable “indicators” will always be 
found colposcopically on the external os. In regard 
to the graph by Zinser, we may deal here with old 
transformation zones, so-called “secondary original 
mucosa.” 








Warren R. Lang, Philadelphia, Pennsylvania, 
U.S.A.: A major hurdle in discussing benign cervical 
disease is the confused terminology. The definitions 
of Bret and Coupez for ectopy and ectropion, how- 
ever, will suffice: ectopy (a term coined by Hinsel- 
mann) signifying glandular epithelium on the 
portio; ectropion, signifying an eversion or opening 
up of the cervical canal. One could argue seman- 
tically with the term ectopy, meaning something, 
ie., glandular epithelium, out of place. Who is 
there to say that such epithelium should not be 
on the ectocervix? 

Colposcopic appearances must be the direct result 
of histologic structure and it is not surprising there- 
fore that the transformation zone, characterized 
colposcopically by an admixture of glandular and 


Closing Remarks 


Otakar Nyklicek: | am pleased to see that all who 
took part in the discussion agree in their opinions 
concerning uniformity of the nomenclature. T be- 
lieve Janisch is correct when he states that the 
main value of colposcopy lies in the recognition 
of the most frequent physiological changes on the 
cervical surface and that the non-physiological 
changes can be separated from the suspicious ones. 





T CERVICAL LESIONS—PART II Acta Cytol. 


Mar.-Apr. 1961 


squamous epithelium, is represented histologically 
by epidermization as pointed out by Nykligek. 

The graph of Zinser 
poscopic patterns of squamous epithelium, ectopy 
and transformation zone, summarizes an important 
facet of cervical changes during life. Some day some- 
one will extend this graph to the left, including 
the prenatal cervix and the cervix of childhood by 
colposcopy. ‘Fhen our knowledge of over-all portio 
changes will be complete. 


showins, the changing col- 


Enrique Vasquez Ferro, Buenos Aires, Argentina: 
I agree with Nykligek’s opinions about nomencla- 
ture, and the more descriptive the colposcopic 
nomenclature is the easier it will be for the clini- 
cian. In this way ectopy signifies the presence of 
the columnar epithelium outside the external os. 
Transformation zone signifies the different stages 
of epidermization. 
We use the following nomenclature: 
Ectopy: Columnar epithelium beyond the external 
Os. 
Early transformation zone: the 
tion zone around an ectopy. 
Open transformation zone: the occurrence of open 
glands and ectopic islands on the surface of the 
regenerated squamous epithelium. 
Closed transformation when the squamous 
epithelium does not exhibit the above character- 
istics. 


young transforma- 


zone: 


Atypical transformation zone: vascular 


abnormal patterns. 


presence of 


When we employ the above nomenclature in re- 
ports of the colposcopic examinations, the clinicians 
do not have trouble in understanding and deciding 
upon a treatment. 

We prefer the term ectopy instead of ectropion 
(Bret and Coupez). We agree with Ganse that it 
is difficult to recognize an ectopy by exfoliative 
cytology; nevertheless we use both methods as com- 
plements to one another in studying patients. Rou- 
tine vaginal and cervical smears have been taken 
before and we follow Zinser’s good advice by per- 
forming repeated colposcopy and cytology in those 
cases which are suspicious or which have atypical 
transformation zones. 


As to the suggestion of Kriiger about our sub- 
division of the TZ, I can only say that we have 
done it, if only for the sole reason that by putting 
down the abbreviations TZ I, TZ II, or TZ III, the 
time factor of this change on the cervix is in this 
way made clear very quickly and without any long 
description. In the past we added to this abbrevia- 
tion an expression “quiet,” or “unquiet” (for in- 
stance: “TZ II quiet”). A similarly aimed nomen- 


clature is also used by Ferro. 





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Volume 5 
Number 2 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IT 9] 


Colpomicroscopy of Ectopy, Ectropion and Epidermization 


‘TAssiLo ANTOINE, KuRT BRANDL, VIKTOR GRUNBERGER 
EKKEHARD KOFLER, HANNES KREMER 


Vienna, 


Unpber the healing of erosion or erythro- 
plakia such changes are included as ectopy, 
With the 
exception of true erosion, all of these condi- 


ectropion and pseudo-erosion. 


tions are characterized by the presence of a 
superficial layer of columnar epithelium. 
Histologically, one always finds columnar 
epithelium on the surface of the cervix. 
Distinction is made between glandular, 
glandulo-papillar and glandular-cystic ero- 
sion. Accordingly, one also sees with the 
colpomicroscope a columnar epithelium, 
in which a flat arrangement of uniform, 
densely lying, mostly round nuclei can be 
recognized. The cellular borders are fre- 
quently not present. In the majority of 
cases one finds the picture of the glandulo- 
papillary erosion. This condition displays 
grape-like formations, which correspond to 
the papillae which are squeezed by the 
tube of the colpomicroscope. On the mar- 
gin of these papillae one can, by the 
tangential way of viewing, recognize basally 
located nuclei and also often the cytoplasm 
with marked cellular borders. In the center 
of the papillae one sometimes finds the 
above mentioned columnar epithelial cells; 
more frequently, however, the epithelial 
lining is missing and the connective tissue 
is visible on the surface. On focusing into 


lustria 


the depth one almost always sees the capil- 
lary loop of the papilla. The surroundings 
of the papilla are usually blurred, since 
they are usually covered with mucus and 
cellular debris. In many cases one finds at 
the site of erosion glandular openings, 
which are lined by a small rim of columnar 
epithelium. In the center of these open- . 
ings one often observes mucus which con- 
tains cellular debris and leukocytes. ‘The 
true erosion is a localized lack of epithe- 
lium, whereby the underlying connective 
tissue is exposed. Accordingly, we find un- 
der the light a blurred connective tissue 
structure few well visible 
cells and in addition inflammatory elements 


with a stroma 
(leukocytes, lymphocytes, plasma cells, etc.). 

During the healing of a glandular ero- 
sion (ectopy) one sees areas of squamous 
epithelium varying in size, the nuclei of 
which may display minor differences in 
shape, size and chromatin content. Gener- 
ally, the nuclei in these areas are somewhat 
larger than normal ones, often appearing 
inflated, and cytoplasm appears darker. In 
this newly formed squamous epithelium, 
cellular borders can almost always be dem- 
onstrated. From a differential diagnostic 
standpoint, this seems to point, in our view, 
to this condition being benign. 


WOLFGANG WALZ 


Heidenheim 


IN Ficure 1, I have tried to combine, in 
a partly schematic three-dimensional draw- 
ing of a cervical section, all the findings 


, Brenz, Germany 


which are encountered in the case of an 
ectopy or an ectropion. I endeavor to 


show how it is possible to draw histological 








Fic. 1. Partly schematic three-dimensional draw- 
ing of a cervical section; the surface being the colpo- 
microscopical finding, the sides being the corre- 
sponding histological finding. From left to right: 
normal squamous epithelium, epidermization zone, 
papillary ectopy.: At the front corner of the draw- 
ing: indirect metaplasia. Upper right corner: ero- 
sion vera bordering towards an inflammatory epi- 
thelium. Fic. 2. Squamous epithelium border 
towards a papillary ectopy. Upper half of picture, 
surface of the normal epithelium. Lower part, 
papillary ectopy with columnar epithelium, thus 
details of cells colpomicroscopically not visible. 
(This and the following Figures stained by Tolu- 
idine blue.) 


conclusions with the aid of the colpomicro- 
scope from lesions of the surface. The sur- 
face of the drawing shows the colpomicro- 
scopical findings, whereas the sides show 
the corresponding histological findings. As 
an example we can demonstrate with great 
precision the structure of the epidermiza- 
tion. 

As an ectopy and an ectropion possess 
the same structure histologically as well as 
colpomicroscopically, we can treat them 
together. Both are covered by a cylindrical 
mucus-forming glandular epithelium (col- 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II 





Acta Cytol. 
Mar.-Apr. 1961 
umnar epithelium) which is situated on the 
ectocervix. Colpomicroscopically this yields 
findings which may differ depending on 
the shape of the ectropion or ectopy (for 
example, either more papillary or more 
level) and furthermore on the functional 
state of the columnar epithelium and on 
irritations, which have morphologically 
influenced the columnar epithelium in 
some particular way. 

1. The 
lium shows scarcely any details under the 


normal mucus-forming  epithe- 


colpomicroscope, since the mucus is in the 
upper part of the cell and is usually stained 
to a certain extent. Sometimes cell “-boun- 
daries are visible but practically never the 


Fic. 3. Papillary ectopy. Here the mucus forma- 
tion of epithelium has mostly decreased. At the 
border of the papillar ectopy the cylindrical cells 
with spindle-shaped nuclei are clearly visible. Fic. 
1. Epidermization zone. Mostly parabasal cells and 
lower intermediate cells (predominantly lower part 
of picture). 





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SYMPOSIUM ON 


Volume 5 
Number 2 
nucleus at the base (Fig. 2). The diagnosis 
is based essentially on the structure of the 
ectopy (i.e., papillar, glandular openings, 
etc.). 


2. If the mucus production diminishes, 
the cell boundaries appear clearly recog- 
nizable by their honeycomb structure. Also 
nuclei appear more frequently. In incident 
view they appear in different magnitude, 
mostly round to oval-shaped, occasionally 
with clear chromatin structure. 


3. If mucus production is absent due to 
(i.e., inflammation) the 
nuclei appear very clearly. ‘They are poly- 
morphic; frequently they are seen no longer 


regressive lesions 


vertical but rather are disposed a little side- 
ways as the beginning dissolution of the 
cytoplasm loosens the positioning of the 
cells. 
shaped, occasionally greatly swollen. A cer- 


The nuclei appear rather spindle- 


tain polychromasia_ is observed, probably 
depending on the sensitivity of the partic- 
ular cell towards regressive influences (Fig. 
3). Pertaining to the epidermization of an 
ectopy and an ectropion, there are two 
possibilities, first; epidermization —begin- 
ning at the squamous epithelium border 
and second; the formation of squamous 
The 
latter will be discussed later in this Sym- 
posium. 


epithelium by indirect metaplasia. 


In the state of equilibrium concerning 
both kinds of epithelium there is a sharp 
border between them (Fig. 2). Much more 
frequently, however, there is a zone be- 
tween both epithelia which is not covered 
by epithelium. If an ectopy were 
located here we must colpomicroscopically 


ever 


find gland openings which lead right to 


the surface in the midst of connective 


tissue. Blood vessels free of epithelium 
can be observed clearly in this zone. If 
there is any pronounced inflammatory in- 
filtration recognizable by the existence of 
inflammatory cells in the connective tissue, 
then the squamous epithelium as well as 


PREMALIGNANT CERVICAL LESIONS—PART II 











Border between 


Fic. 5. 
(right) and normal squamous epithelium 
Fic. 6. Gland openings in a squamous epithelium. 


zone 
(left). 


epidermization 


the columnar epithelium can exhibit con- 
siderable regressive lesions (Fig. 1, upper 
right of the picture). 

The epidermization of an ectopy yields 
various findings depending on the state 
of development of the regeneration epi- 
thelium. At the extreme border of this re- 
generation epithelium in a zone of varying 
width, we find basal cells, recognizable by 
their round nuclei, lying close to each 
other. The cell cytoplasm is scarcely visible. 
The colpomicroscope shows clearly how 
the basal cells grow into the ectopy, dis- 
placing columnar epithelium. The zone 
of basal cells borders on a zone of para- 


basal cells and lower intermediate cells 
(Fig. 4). ‘This zone is rich in connective 





94 SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II 


tissue papillae with blood vessels which 
reach right under the surface. They are 
recognizable by the concentric position of 
the cells, which occasionally have spindle 
shapes. Gland openings in this zone lead 
through the squamous epithelium to the 
surface. Between the epidermization zone 
and the original squamous epithelium 
there nearly always is a very characteristic 
sharp borderline (Fig. 5). After the termi- 
nation of an epidermization one can oc- 


Discussion 

Marcel Dargent and Pierre Haour, Lyons, Rhone, 
France: The cytologist is interested in observing 
the topography of cervical cells in situ as compared 
with the exfoliated cells of the smears. 

This is particularly evident in the study of 
ectopy, ectropion and epidermization. Such epi- 
thelial changes sometimes give a remarkable variety 
of cells in smears which are not easy to identify. 
Therefore, it is sometimes advantageous to locate 
them and especially to observe the progressive 
changes of cell morphology from the columnar to 
the squamous type, in both direct and indirect 
metaplasias. 

Walz gave details of the variations observed in 
the columnar epithelium under functional or re- 
gressive modifications. These variations could be 
found by us in comparative cervical smears made 
after microcolposcopy. This is particularly evident 
in exfoliation of Walz’s type of columnar epithelium 
(honey-comb structure) and in exfoliation of transi- 
tional and columnar cell clusters after radium 
treatment. However, I would appreciate Walz giv- 
ing any details concerning the polychromasia he 
observed in this cell type. The excellent photo- 
graphs he presents are from zones colored with 
‘Toluidine blue. Metachromasia was noticed by us 
in the center of gland openings, very rarely at the 
cell surface: it appears that the mucus has to be 
liberated from the cells in order to show 
chromasia. Toluidine blue 


meta- 


sometimes intensely 


Ma By aig 
casionally find, in the midst of a normal 
squamous epithelium, gland openings 
leading to the surface, which indicate that 
there has been an ectopy (Fig. 6). 


Bibliography 

1. Antoine, T. and V. Griinberger: Otlas der Kol- 
pomikroskopie. Stuttgart, G. Thieme, 1956. 

2. Meyer, R.: Handbuch der Pathologie. Vol. VII, 
Berlin, Henke-Lubarsch, Julius Springer, 1929. 

3. Walz, W.: Z. Gerburtsh. 136: 225, 
4. Walz, W.: Z. Geburtsh. 144: 117, 


1952. 


1955. 


colors the nuclei in the healing zones, and one has 
to be accustomed to this type of stain in order to 
make a correct diagnosis. 


Closing Remarks 
Tassilo Antoine: The nuclei are stained deeply 
blue with Toluidine blue in the area of a “healing 
zone” (epidermization—replacement of a columnar 
epithelium by squamous epithelium) and do not 
show any marked irregularity of their chromatin 
content. Thus, we can consider these areas as benign. 


Wolfgang Walz: ‘To Haour and Dargent: The 
polychromasia of the cervical mucus-producing 
epithelium is caused by varying degrees of mucus 
production. When the cells are at the height of 
their function the nuclei, located on the base of 
the cell, are not visible. When the mucus produc- 
tion decreases, the nucleus becomes visible. When 
there is no mucus present, the nucleus stains nor- 
mally. Since in an ectopy all the various functional 
stages occur simultaneously, polychromasia results. 
Certainly the question of whether or not poly- 
chromasia depends upon the choice of the stain 
is justified. According to my own experience this 
is not the case. I have performed control studies 
with Evan's Blue and hematoxylin and the results 
were the same. However, I prefer the Toluidine 
blue because it stains the nuclei more quickly and 
more intensely. Moreover, using a neutral solution, 
it is independent from the pH in regard to the qual- 
ity of the stain and gives more uniform results. 








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Volume 5 
Number 2 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II 


Management of Ectopy, Ectropion and Epidermization: 


A Clinical Viewpoint 


VIKTOR GRUNBERGER 


Vienna, Austria 


THE CLINICAL diagnosis: ectopy, ectropion 
and epidermization (collective noun: 
erosion) has, in any case, to be confirmed 
by special examination before starting 
therapy. In numerous papers, we and other 
authors have again and again emphasized 
that the routine clinical examination with 
the palpating finger and the unaided eye 
is insufficient, since it does not allow one 
to appreciate most of the cases of early 
the cervix. We have been 
able to prove statistically that by perform- 
ing more than one type of diagnostic pro- 
cedure there is a greater probability of 
detecting all of the early carcinomas of 
the cervix, than by merely using one pro- 
cedure. For this reason we perform, in all 
cases of macroscopically visible alterations 
of the uterine cervix, (1) ‘on three subse- 
quent days a vaginal smear according to 
Papanicolaou, (2) a colposcopical examina- 
tion after Hinselmann and (3) a colpomi- 
croscopical examination after Antoine and 
Griinberger. According to the cytological 
classifications after Papanicolaou we have 
also the colposcopical 


carcinoma of 


and _ colpomicro- 
scopical findings divided into five Classes, 
whereby the comparison of the results of 
the three methods is facilitated. If one of 
the diagnostic procedures reveals a Class 
III, that means that the case has to be 
studied further. When inflammatory con- 
ditions are present in the vagina we give 
terramycin tablets vaginally and repeat 
the examination after several days. In post- 
menopausal women we “clear up” with 





estrogens and then repeat the examination. 
If there is still a Class III finding present, 
we have to clarify the situation by biopsy. 
Also, in cases where a Class IV or V was 
diagnosed, the final decision as to the 
malignancy of the lesion has to be left to. 
histology, since none of the three methods 
allows a definite diagnosis of carcinoma, 
and invasive growth can only be appreci- 
ated by histology. The bigpsy is performed 
in our institution in the form cf a ring 
biopsy and in addition a cervical curettage 
is performed. When all three procedures 
yield a negative result (Class I or II), then 
it is our opinion that every erosion has to 
be actively treated, even though it seems 
to be in the process of healing, because 
there is always the danger that later on a 
carcinoma will develop. Electrocoagula- 
tion into the healthy tissue and up into 
the endocervical canal has proven to be 
the best therapy. All other methods, such 
as swabbing with various caustic liquids, 
application of sticks, tablets, suppositories, 
etc., are very tedious since one has to 
repeat this treatment several times, and 
furthermore the results of this treatment 
are always only partial ones. The reason 
for this is that often the result is only a 
superficial epidermization, while under- 
neath cervical glands persist and frequently 
again give rise to the formation of an 
erosion. 

the other 
integrum” is 
achieved and, proper execution provided, 


By electrocoagulation, on 
hand, a “restitutio ad 


96 


the site of the coagulation can be recog- 
nized merely by the whitish color of the 
epithelium after complete healing. His- 
tologically also, there will be a normal 
squamous epithelium again on the cervix 
after healing is accomplished. A properly 
coagulated erosion should be healed at the 
most after six weeks. A check-up at that 
time is recommended since sometimes 
granulations develop at the site of coagu- 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II 


Acta Cytol. 
Mar.-Apr. 1961 
lation. These have to be removed in order 
to avoid recurrence of the erosion. A com- 
plete healing of the erosion is, furthermore, 
a reliable sign that the conditions on the 
cervix certainly have been benign in na- 
ture. As mentioned above, we do.not per- 
form a biopsy when all three methods have 
yielded negative results. This again turns 
out to be an advantage, since the number 
of biopsies can be considerably decreased. 





MARIA KAWECKA AND JANINA SKALSKA-VORBROD1 


Gliwice, Poland 


Ecrory and ectropion, usually appear- 
ing after delivery, due to the laceration of 
the cervix, is a pathologic condition of 
the female reproductive organs which is 
met with very often. It is frequently ac- 
companied by an inflammatory condition 
of the vagina, erosion of the vaginal part 
of the uterus and pathological epidermiza- 
tion. 

In such cases pharmacologic agents or 
surgical procedures are employed. In- 
travaginal administration of various tam- 
pons, globules or other agents, sometimes 
lasting for many years, does not bring de- 
sirable results; on the contrary, by the 
continual irritation the inflammatory 
process becomes more acute, or, by means 
of producing partial healing, the epi- 
thelium is stimulated to proliferation and 
pathologic epidermization. 

Ectropion in the persistent inflammatory 
condition has to be considered as the pre- 
cancerous lesion. 

There is in Poland a system of Oncologic 
Out-patient Centers. It is their task to 
diagnose and to transfer, for special treat- 
ment, asymptomatic early cases of malig- 
nant neoplasms and cases of pre-cancerous 
conditions. 


It is understood that during 
this often mass examination of healthy or 


apparently healthy women, we base ou: 
investigations mostly on the cytological 
findings of the vaginal smears. 

In cases of ectropion our aim is to heal 
this condition quickly and radically. Since 
pharmacologic therapy does not produce 
results there remains only surgical inter- 
vention. Emmet’s or Sturmdorf’s surgical 
procedure does not always yield favorable 
results. They often bring 
cicatricial deformation and 


marked 
even slight in- 


about 


of sutures im- 
mediately after the operation. 


fection may cause bursting 


During the follow up examination of pa- 
tients treated at the Institute of Oncology 
at Gliwice situ of the 
vaginal part of the uterus by means of 
electroconization, there has been noted im- 
provement in the shape of the cervix and 


for carcinoma in 


its canal in cases complicated by postpartum 
laceration. Eventually it was decided to 
treat ectropion by means of this method. 

One hundred and ten women presenting 
postpartum laceration and ectropion were 
examined and the procedure was carried 
out. Before the electroconization, cytologic 
examination was made on every patient for 
the purpose of excluding asymptomatic 
cancer or histopathologic examination was 
made to exclude invasive cancer. 


w 


— 





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Volume 5 
Number 2 


Electroconization is performed by means 
of an electric knife of triangular shape. By 
circular movement of the knife we cut off 
part of the mucous membrane of the canal 
together with the part of the ectocervix 
containing the ectropion. The recovery 
after this procedure was favorable. We did 
not notice any complications. 

Of the 110 patients mentioned, 99 had 
follow up examinations. In all these cases 
we found improvement in the shape of the 
cervix and the canal. The surface of the 
cervix was smooth, the external os was 
round and of 2-3 mm. in diameter. 

During further follow up we were in- 
terested in the influence of the performed 
procedure on the possibility of conception 
and delivery. We observed pregnancy after 
electroconization in 35 women. They were 
young patients with previous carcinoma in 
situ of the vaginal part of the uterus. Al- 
though the procedure was rather extensive, 
we observed no narrowing of the canal or 
any disturbance in the excretion of mucus 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IT 97 


. 


which could make conception difficult. 
Spontaneous abortions in the women men- 
tioned were not noted. ‘Twenty women had 
full-term pregnancies. Labor in these cases 
was normal. Eight women had interrupted 
pregnancies and the remaining are still 
pregnant.’ In the follow up examination 
after delivery the vaginal part of the uterus 
was smooth and the outlet round. This 
proves that healing after the surgical pro- 
cedure takes place via physiologic shrink- 
ing of the smooth muscles of the vaginal 
part of the uterus, with epithelization and 
without the appearance of _ inelastic 
cicatricial tissue. 

Summarizing the results of this study, 
it must be stated that (1) electroexcision. 
radically removes ectropion; (2) electro- 
excision is a safe procedure; easily endured 
by the patient, it may be performed in out- 
patient conditions with previous cytologi- 
cal examination excluding cancer; (3) elec- 
troexcision does not make the next con- 
ception difficult and does not bring about 
complications during or after labor. 





FRANTISEK LUKSCH 


Prague, Czechoslovakia 


‘THE VALUABLE experiences of the colpo- 
scopical and cytological search for carcin- 
oma demonstrate not only the necessity 
of early diagnosis of epithelial atypias, but 
also disclose the close connection between 
the so-called benign lesions of the cervix 
and cervical carcinoma. The high  in- 
cidence of such benign lesions among the 
female population, therefore, requires 
therapeutic measures which guarantee as 
radical and as lasting results as possible, 
without great effort for those concerned. 

I believe there is no better means at the 
present time than coagulation of the cervi- 
cal surface by high 
which we have used for years with the 


frequency current, 





best results. ‘The cure rate is from 95 to 
97 per cent. As to the mechanism of this 
therapy, there is some controversy. ‘Tischer 
emphasizes in an interesting histological 
study the depth effect of the electric arc 
which reaches even the deepest glandular 
acini. The mere technic of diathermic 
coagulation is so well known that I need 
not go into more detail. Recurrences seem- 
ingly arise most often from sites which have 
not been sufficiently coagulated. However, 
these can be removed very easily at a sec- 
ond time. 

The prerequisite for such treatment is 
thorough cytological, clinical and colpo- 





98 


scopical evaluation of the local status and 
the condition of the endocervical canal. 

Once, four weeks after coagulation treat- 
ment, we observed the rise of a cervical 
carcinoma. We are convinced, however, 
that in this case the primary focus had not 
been recognized and, therefore, could not 
be submitted to therapy. 

The coagulation of the cervix does not 
act only locally but also causes a general 
reaction. This may be proven by several 
cases where patients, even with longstand- 
ing sterility problems, became pregnant 
after this procedure has been applied. 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II 





Acta Cytol. 
Mar.-Apr. 1961 


Stress or excretion of gonadotropins may 
be considered the possible mechanisms. 

The cell changes which appear after 
coagulation of the cervix are very educa- 
tional. During regeneration one can find 
all degrees of increased cellular activity, 
ranging from ordinary nuclear atypias 
through dyskaryosis up to genuine atypias. 
Therefore, in order not to over-diagnose we 
would advise repeat smears as controls. 
However, where the cytological atypias per- 
sist, as is the case of incompletely healed 
defects, the possibility of malignant neo- 
plasms must be borne in mind. 





OrTAKAR NYKLiCEK 


Ndachod, Czechoslovakia 


‘THE CORRECT management of changes of 
the uterine cervix is dependent upon the 
right diagnosis. Only a combination of 
pre-biopsy examination methods (colpos- 
copy and cytology with biopsy) makes pos- 
sible a correct diagnosis. 

In a previous topic of this issue we have 
given reasons for the correct clinical, colpo- 
scopic nomenclature. 

For some years there has been in Czecho- 
slovakia a mass examination of women 
who are at the age most threatened by 
cancer. This is a preventive examination 
in which most gynecological specialists in 
our country take part. In order to unify 
the diagnosis and management of changes 
of the uterine cervix a “panel” meeting of 
the section of Obstetrics and Gynecology 
with the Pathologico-anatomical and Onco- 
logical section of the Czechoslovak Medical 
Association of J. Ev. Purkyne took place 
in April, 1959. 

A curative group of this meeting, di- 
rected by Professor Peter, set up the rules 
for management of changes of the uterine 
cervix. For the treatment of ectopy it was 


recommended that: he correct diagnosis 
be corroborated colposcopically and by an 
eventual cytological examination, the in- 
flammatory component be treated accord- 
ing to the vaginal biocenose. If during a 
period of six weeks no regeneration of the 
squamous epithelium takes place on the 
ectopy, then a diathermo-coagulation of 
this lesion be performed. It is necessary 
to observe colposcopically the 
progress of the regeneration. 
Management of Ectropion: The lesser 
ectropia are to be treated again according 
to the vaginal biocenose. If they do not 


whole 


heal, then a tracheloplasty is performed, 
for example that of Emmet. 

Management of the Transformation 
Zones: It is necessary to observe them at 
intervals of 10 to 14 days, first colpo- 
scopically and if necessary cytologically. 
When we follow the transformation zone 
in this way, we make it possible to evaluate 
correctly all the changes of the uterine 
cervix, either in the sense of regeneration 
(epidermization, indirect metaplasia), or 
in the sense of abnormality or atypia. In 








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“unquiet” transformation zones I or I, 
we always perform a colposcopically aimed 
excision and curettage of the endocervix 
for the sake of histological examination. 

The management varies according to the 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II 99 


results of pre-biopsy and biopsy examina- 
tions. Either a diathermo-coagulation is 
employed, or surgical treatment is used. 
This may be either a conization or a supra- 
vaginal amputation of the uterine cervix. 





Discussion 

Wolfgang Korte, Bonn, Germany: At regular time 
intervals we check by clinical, colposcopical and 
cytological means, the ectopies, ectropions and 
zones of epidermization which are incidentally dis- 
covered and which do not cause any subjective 
complaints. 

If complaints such as discharge, recurring colpitis 
from a chronic disturbance of the flora, contact 
bleeding or midcycle bleeding are present, we gen- 
erally recommend treatment of the ectocervix. We 
use electrocoagulation on the real ectopies on the 
dimple-like external os of the uterus. On the other 
hand, we excise the ectropions and perform plastic 
surgery on the os of the uterus according to Em- 
met and Sturmdorf. We always perform a curettage 
of the cavum and of the endocervix. 

We treat the zone of epidermization which is 
clinically and morphologically not entirely normal 
in the same manner. 

Thus we have the following possibilities: 

l. To treat lesions of the ectocervix quickly and 
intensively, thus restoring physiological condi- 
tions; 

2. ‘To verify by means of the histological examina- 
tion the colposcopical and cytological findings; 

3. To avoid wedge biopsies, thus retaining the nor- 
mal configuration of the ectocervix for later 
conizations and plastic surgery; 


To follow up every case in which the biopsy 
showed malignancy with extensive surgery or 
irradiation. 


At the University of Bonn, Department of Gyne- 
cology and Obstetrics (Chairman: Prof. H. Siebke) 
the treatment of the ectocervix is performed with 
very good plastic and functional success. We have 
no objections against methods other than the above 
four if they tend to restore the normal vaginal flora 
and do not disturb the function of the external os. 


Ernst-Helmut Kriiger, Halle a.d. Saale, Germany: 
We consider favorably Griinberger’s _ classifica- 
tion of colposcopical findings into five classes to 
correspond with the cytological classification. With- 
out a doubt the ectopy and the ectropion may be 
treated both well and definitely by electrocoagula- 





tion or electroconization. This fact may be espe- 
cially important for the German-speaking countries, 
since here the cauterization with the silver nitrate 
stick is widely practiced. Where the therapy of the 
ectopy is concerned a differentiation has to be 
made between the acquired ectopy (laceration ec- 
tropion) and the congenital ectopy, the latter of 
which is colposcopically recognized by the very 
sharply defined outlines and often by a fine mar- 
ginal mosaic pattern. The congenital ectopy in 
most cases resists therapy with silver nitrate cau- 
terization and may be definitely eliminated by 
coagulation alone or plastic surgery. The normal 
transformation zone does not need treatment. In 
treatment of the ectopy Albothyl (Byk-Gulden) has 
proved very useful. This is a 56 per cent aqueous 
solution of polycondensed Metatresolsulfonic acid 
with methanal with a pH of 0.6 which momentarily 
coagulates cylindrical epithelium only and, unlike 
the silver nitrate, does not affect the regenerating 
squamous epithelium. The regeneration of the 
latter will be enhanced, the Déderlein bacilli are 
saved, pathogenic germs are destroyed and fresh 
granulations are not attacked. Under the protec- 
tion of the acidity of the Albothyl concentrate, an 
ascension of germs is not possible. Applied cor- 
rectly, no ectopic islets remain. According to our 
experience, painting of the ectopy with Albothyl 
is superior to the application of silver nitrate and 
equals electrocoagulation. ‘Treatment of  post- 
partum ectopies lasted approximately four weeks 
when the agent was applied once a week. Important 
for the success of the treatment is the following 
technic: 

I. Removal of the cervical plug. If this cannot be 
done, it becomes easy after touching with 
Albothyl. 

2. Application of solution to the cervical canal 
with a cotton swab. 


3. Painting of the external os under firm pressure. 


Only with high postpartum ectopies must one 
expect a failure in about 10 per cent of the cases. 
These cases are then best treated by cauterization. 

In a short time Albothyl created smooth, normal 
epithelial conditions. In our hospital this com- 
fortable, uncomplicated and innocuous procedure 
for the treatment of the ectopy has been proven 
very safe. 





SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II 


Acta Cytol 
Mar.-Apr. 196] 


Closing Remarks 


Viktor Griinberger: 
Albothyl, but 


We have sometimes used 
found that the effect is only 
good when the lesion is very superficial. After 
treatment with Albothyl, usually only a thin layer 
of squamous epithelium grows over the ectropion, 


we 


and the cervical glands rest in the depth and soon | 
cause a recurrence of the ectropion. ‘Therefore, we 
prefer in all cases the electrocoagulation which heals 
the ectropion in nearly 100 per cent of the cases and | 
with 


| 


no recurrence, 





Interrelationship: Ectopy-Ectropion-Epidermization 


and Cervical Carcinoma 


JeAN A. bE BRUX AND HENRIETTE WENNER-MANGEN 


Paris, France 


Ir is certain that a carcinoma never oc- 
curs on a sound ectocervix. The statistics 
compiled by Gagnon and by Ezes in the 
communities of cloistered Catholic nuns 
in Canada and in French North Africa 
showed an almost total absence of cervical 
carcinoma. Moreover, as is well known, 
there exists an undeniable ratio between 
the number of so-called “chronic ecto- and 
endocervicites” and the number of cervical 
carcinomas. 

Furthermore, our personal experience of 
ten years in the 


detection of cervical 


cancers enables us to affirm a very notice- 


able reduction of these cancers, because 
every patient having an ectropion is 
treated. Every ectropion, ectopy, regular 


and irregular dysplasia is 


removed by 
diathermo-coagulation 


and the scar_ re- 
studied to verify the second cicatrization. 
Sometimes the same architectural and cellu- 
lar anomalies begin again; these patients 
are then submitted to repeated examina- 
tions. 

Hence, it would seem that we have cause 
to believe that cervical carcinoma has some 


relationship with and thei 
epidermization. However, we do not wish 
to imply that there is a direct relationship 
between the number of observed ectropions 
and the percentage that develop into 
cancers which is probably minute. Never- 
theless, certain special characteristics are 


ect ropions 


encountered in the carcinomas not yet very 
evolved; they follow the contours of the 
endocervical fringes of the ectropion, pene: 
trate into the interior of the glands, and 
it is only at one point that there can be 





noted the penetration into the stroma. 
They tend to slip into the endocervix, fol- 
lowing the coluranar epithelial lining. But 
it is the epidermization of the ectropion 
which furnishes the the 
teriorization” ol 


pretext to “ex- 


the carcinoma. 
This epidermization, as we have ex- 
plained, may assume one of several aspects: 
(1) The metaplastic squamous cell epi- 
thelium may form in a strictly normal way, 
architecturally and functionally. 


(2) The architecture and cellular mor- 
phology of this neoepithelium are normal, 
but functionally, there is no appearance of 





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Volume 5 


Number 2 


elycogel 
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Volume 5 
Number 2 


glycogen, and in particular, the cornifica- 
tion is excessive. 

(3) The layer of basal cells is hyperplas- 
tic. with or without disturbance of vari- 
able importance in the cellular differenti- 
ation, stratification and maturation, lead- 
ing to dysplasias either of regular or irreg- 
ular architecture and morphology, raising 
the problem of possible malignancy. 

(4) The cells of the reserve layers pile 
up, and are: hyperplastic, active, undiffer- 
entiated, immature, and raise, to an acute 
and sometimes difficult degree, the prob- 
lem of differentiation from the carcinoma 
in situ: to such an extent, in fact, that we 
may wonder if a great number of healed 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART ITI 


101 


carcinomas in situ are not in reality hyper- 
plasias of the reserve cells. (In this connec- 
tion, we propose the substitution of the 
term “active undifferentiated immature 
metaplasia” for “hyperplasia of the re- 
serve-cells.”’) 

(5) Finally, in rare cases, a true carcin- 
oma develops, which is sometimes intra- 
epithelial, but most often already invasive. 

These various facts explain the range of 
lesions encountered on the uterine cervices. 
Although in the majority of cases one finds 
only one or two varieties of lesions, one 
may nevertheless find them all, mingled in 
the carcinomas in situ, but especially in 
the invasive carcinomas at their beginning 
(Mestwerdt’s microcarcinoma). 


Rosert GANSE F 


Dresden, Germany 


‘THE TRANSFORMATION process can go in 
three different directions. Usually entirely 


normal squamous develops. In other in- 


‘ 


stances the “atypical” or “abnormal” epi- 
thelium (Class I or II after Hinselmann) 
develops. This squamous epithelium grows 
in colposcopically easily recognizable areas, 
on top of the cervical mucosa in the form of 
a mosaic, base of a leukoplakia, or leuko- 
plakia. These areas are regularly iodine 
negative when the Schiller test is applied. 
Cytologically, one finds the presence of 
simple atypical epithelium with cornified 
or metaplastic cells only in rare cases. Fig- 
ure | shows such an area of base and mosaic 


mixed. 


Fic. 1. Ectopy on the edge of which is 


“grund” and “felderung.” 











102 





Also in the process of epidermization a 
differentiation of the squamous epithelium 
may occur tending towards the increas- 
ingly atypical epithelium (Class HII or IV 
after Hinselmann) which corresponds to 
the surface carcinoma or carcinoma in situ 
of other investigators. Cytologically these 
conditions yield a Papanicolaou Class IV 


or V. The described transformation process 


Discussion 


Rudolf Ulm, Vienna, Austria: In agreement with 
the main authors, I wish to re-emphasize the fact 
that we consider the ectopy and the ectropion to 
represent the matrix for carcinoma. In_ epider- 
mization, the proliferative activity becomes evident. 
If aberrant, this proliferative activity may lead to a 
malignant change of this new epithelial formation. 
In case of the development of endocervical car- 
cinoma the process may begin with a squamous 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART II 


Fic. 2. Whitish encircled gland developing 
from an ectopy. 


with all its various possibilities can reach 
up into the endocervical canal. 

In Figure 2 glands can still be recognized. 
These glands have a whitish rim which is 
cornified. ‘The glands in form of retention 
cysts indicate that formerly at this site 
cylindrical epithelium must have been 
growing, i.e., an ectopy must have been 
present, since glands can only be formed 
by cylindrical epithelium. 


metaplasia of the reserve cells (sub-cylindrical cells). 
On the surface of the ectocervix only, can the heal- 
ing of an ectopy or an ectropion cause epidermiza- 
tion. Thus the fewer causes for epidermization 
which are present, the fewer possibilities exist for 
carcinogenesis. Extensive statistical works on this 
problem have confirmed this theoretical considera- 
tion. Therefore, every ectopy and every ectropion 
should be cured in order to counteract 


a_ possible 
later carcinogenesis. 


Acta Cytol. 
Mar.-Apr. 1961 





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III. Leukoplakia 


Histomorphology of Leukoplakia 


FRIEDRICH BAJARDI 


Graz, Austria 


To BEGIN it may be remarked, in refer- 
ence to the definition of leukoplakia, that 
we understand by this term a circumscribed 
white spot. It may be macroscopically rec- 
ognizable, in which case it frequently sur- 
mounts the level of the surrounding cervix 
and is furthermore characterized by a 
nacreous lustre. Comparable changes of 
lesser extent are visible only by colposcopy. 
On application of iodine these spots re- 
main unstained. They are always sharply 
defined against their environment. 


Fic. 1. Parakeratosis of 
an “abnormal epithelium” 
displaying sharp border- 
line towards the normal 
epithelium. 


The optical phenomenon of the leuko- 
plakia has its cause in a decreased trans- 
parency of the epithelial tissue. Alterations 
of the surface in the form of cornification 
of the squamous epithelium, but also 
changes of the epithelial structure of the 
site involved, mostly in the form of an in- 
creased nuclear density, may be responsible 


for this decreased transparency. Often a 


combination of superficial changes and 
changes of the deeper layers is demonstrable 
in the histological section as well. 











Figure | shows, on the left, parakeratotic 
cornification of the most superficial epi- 
thelial cells. Extreme hyperkeratosis with 
a wide horn layer and pronounced stratum 
granulosum can be recognized in Figures 2 
and 3. In Figures | and 2 the epithelium 
is only slightly altered compared with the 
normal, whereas in Figure 3 the marked 
increase of the number of cells, the blurred 





Sa ee 





C298 


Fic. 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


9 


Acta Cytol. 
Mar.-Apr. 196] 


Hyperkeratosis 


of an “abnormal epithe- 
lium.” 


cellular borders and the polymorphia and 
polychromasia of the nuclei is all too evi- 
dent. We have called this epithelium a 
“maturating carcinoma in situ,” and the 


epithelium of Figure 2 and the one from 


the left section of Figure 1 has been called 


“abnormal epithelium. 


4 


In Figure 1, fur- 


thermore, the abnormal epithelium is very 


sharply delineated against the almost un- 


in 


Fic. 


situ. 


3. 


Hyperkeratosis 


of a maturating carcinoma 


er 


TT 








Volume 5 
Number 2 


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1961 


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Xotuber 2 
changed epithelial lining of the right half 
of the picture. As already mentioned above, 
these sharp border lines are a typical char- 
acteristic of leukoplakias. 

Effort has been made in the selection of 
the microphotographs to demonstrate the 
wide variety of changes that may appear 
under the designation of leukoplakia. ‘The 
extent of the true surface changes is from 
the parakeratosis over keratosis to hyper- 
keratosis. In regard to the structure of the 
epithelium, all kinds of pathological squa- 
mous epithelium of the cervix are included 
from abnormal epithelium to carcinoma 
in situ. 

If, as in the pictures presented, cornifica- 
tion is present, the leukoplakia will be rec- 
ognizable with the naked eye. If cornifica- 


Discussion 


Rudolf Ulm, Vienna, Austria: The only specific 
histomorphological finding in leukoplakia is the 
superticial cornification process, as already empha- 
sized by Bajardi. I can but confirm the statements 
of the author, especially those regarding the super- 
ficial cornification under which all kinds of epi- 
thelial changes may be hidden. For this very reason 
it is necessary in every case to study histomorpho- 
logically the underlying epithelial layers. Only in 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


105 


tion is missing, the recognition of the leuko- 
plakia will be restricted to the colposcope. 
The colposcope has, furthermore, the task 
of differentiating finer structures within 
the white spot, such as “Grund” (base) and 
“Felderung” (mosaic structure). 

Neither the macroscopical nor the colpo- 
scopical diagnosis permits an immediate 
conclusion as to the histological structure 
of the epithelium. Therefore, the diagnosis 
“leukoplakia” is a clinical one (E. Novak)? 
or a colposcopical one respectively (H. Hin- 
selmann). 

Bibliography 
1. Hinselmann, H.: Die Kolposkopie. Wupperial- 
Elberfeld, 1954, Girardet. 


2. Novak, E.: Gynecological and Obstetrical Pa- 
thology. Philadelphia, W. B. Saunders Co., 
1947. 


this manner will it be possible to coordinate the 
gross clinical finding of “leukoplakia” with a pre- 
cise diagnosis and thus determine the necessary 
therapy. 


Wolfgang Walz, Heidenheim/Brenz, Germany: I 
welcome the statements of Bajardi. It cannot be 
emphasized often enough that histologically a vari- 
ety of lesions may be found under the clinical pic- 
ture of a leukoplakia. 





Histochemistry of Leukoplakia 


Jost BoTre.La-LLusiA 


Madrid, Spain 


Previous research by Botella and No- 
gales? 3 corroborated by others,!: 7 has dem- 
onstrated that not all the PAS positive poly- 
saccharides (positive to the Periodic Acid 
Schiff’s reaction) in the vaginal and cervical 
epithelium are glycogen. The PAS posi- 





tive polysaccharides are resistant to diges- 
tion with amylase in the superficial corni- 
fied layer. Since that time, we have been 
speaking of a “superficial mucification of 
the human vagina and cervix.” 

In the following studies+ we have related 








Fic. 1.  Leukoplakia. Method: 
Periodic-Acid-Schiflf-Reaction 


Alcian Blue- 
(without digestion 


with amylase). There is no glycogen in the inter- 
mediate zone. Intense reaction of polysaccharides 
in the superficial zone which was resistant to 
the digestion with amylase (therefore mucopoly- 
saccharide). Activity in the basal, parabasal and 
intermediate zones (from x450). 





SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 





Acta Cytol 
Mar.-Apr. 196] 


such superficial mucification with a matura- 
tion of the epithelium which would possibly 
go through these three steps: 

Cellular type: 

immature cell — intermediate cell > superficial cell 


(basal and (semi-mature) 
parabasal) 


(mature) 


Polysaccharide: 


none > glycogen > mucopoly- 


saccharide 

We have studied the mucopolysaccharide 
content in 30 leukoplakia cases by using 
the Alcian-blue-PAS staining of Runge and 
Ebner® which has the advantage over the 
PAS of Hotchkis-MacManus in that one is 
able to distinguish between acid and 
neutral mucopolysaccharides by the blue 
staining reaction of the acid mucopolysac- 
charides. 

‘The material we used came from biopsies 
of ectocervices which were taken under col- 
poscopic control. In all of the cases (Vig. 
1-4) we have found the following: 

The immature cells of the basal and para- 
basal layers do not show mucopolysac- 
charide content either, or at best, scanty 
glycogen, much below the normal amount 
expected. In those two layers the nuclei 
showed high hyper-activity, a fact discov- 
ered long ago. The histochemical reactions 


Fic. 2. Equal to the 
latter, with Alcian Blue- 
Periodic - Acid - Schiff - 
Reaction and _ digestion 
with amylase. There is a 
zone of superficial muci- 
fication. The intermedi- 
ate zone is a quite thin 
layer (from x450). 











Volume 5 
Number < 


ric. 
Figure 
cation 


for n 
phat 
In 
posit 
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pres 
Alciz 
were 
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Cytol, 
, 1961 


ura- 


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Volume 5 
Number 2 


Fic. 3. One field of 
Figure 2 at high magnifi- 
cation (from x900). 


for nuclear activity (alkaline glycerophos- 
phatase, RNA) were highly positive. 

In all cases there was a very intense PAS 
positive reaction in the superficial layer 
which was resistant to digestion with amyl- 
ase; therefore mucopolysaccharides were 
present in superficial layer. The 
Alcian-blue-PAS reaction showed that they 
were neutral polysaccharides, only rarely 


the 


acid, 

Biopsies taken of “Grund” of leuko- 
plakias in eight cases have been treated in 
the same way histochemically. ‘The charac- 
teristics were those of the first two layers, 
lacking the layer of superficial mucification. 

In view of these findings we have defined 
the leukoplakia histochemically as “a hy- 
permaturation of the ectocervical epithe- 
lium” with an abrupt development from 
the immature cells (which form the 
“Grund”) to the very mature superficial 
cells. The leukoplakic cell would be an 
atypical cell, with high nuclear activity 
which would not form glycogen in its cyto- 
plasm, until the very last phases of its de- 
velopment, and in which a sudden aging 
would produce the mucoid transformation 
as seen in the superficial cornified epithe- 
lium. 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 








aforesaid 


in a zone near the 

Blue-Periodic-Acid-Schiff-Re- 
action with digestion with amylase. There is not 
mucification zone (from x900). 


Fic. 4. “Grund” 
leukoplakia. Alcian 








108 SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


Liu® has found vaginal cornification in 
cases of invasive carcinoma and Hellweg5 
has described his mucification in the mature 
Both confirmed — the 
“aging” reaction of the epithelium in the 
carcinoma. (unpublished data) 
has found a central mucification as a sign 


carcinoma. have 


Nogales 


of hypermaturation in the mature invasive 
carcinoma. 





Acta Cytol. 
Mar.-Apr. 1961 


Bibliography 

1. Berger, J.: Gynaecologia (Basel), 144: 321, 1957. 

2. Botella, J. and F. Nogales: Acta Ginecologica 
(Madrid), 6: 281, 1955. 

3. Botella, J. and F. Nogales: Arch. Gyniik. 189: 
382, 1957. 

!. Botella, J. and F. Nogales: Acta Ginecologica 
(Madrid), 7: 555, 1956. 

5. Hellweg, G.: Z. Krebsforsch. 61: 688, 1957. 

6. Liu, W.: Cancer. 8: 799, 1955. 

Matter, R.: Gynaecologia (Basel), 139: 227, 1955. 

Runge, H., H. Ebner and W. Lindenschmidt: 

Dtsch. med. Wschr. 81: 1925, 1953. 


x™ 





Exfoliative Cytology of Leukoplakia 


ARTURO ANGEL ARRIGHI 


Buenos Aires, Argentina 


LEUKOPLAKIA is an omnibus word. It 
includes all white plaques located on skin 
and mucosa. 

Cervical leukoplakia, a clinical condi- 
tion characterized by the existence of white 
plaques on the mucosa of the cervix uteri, 
has special importance because nearly 10 
per cent of them are actual cervical car- 
cinomas. 

Therefore, a clear-cut cytologic picture 
related to this clinical condition does not 
exist. However, usually observed in smears 
of patients with leukoplakia are: 


1. anucleated polygonal eosinophilic cells 
(squamous), more frequently in clusters. 

2. eosinophilic and cyanophilic superfi- 
cial epithelial cells, numerous enough to 
give the false picture of a high estrogenic 
level. 

3. atypical and/or malignant cells. In 
some cases of leukoplakia the malignant 
epithelium is situated under abnormal hy- 
pertrophic superficial layers, and it may 
prevent the exfoliation of the malignant 
cells (true false-negative smears). 





MARCEL DARGENT, JACQUELINE MouriQuAND 


Lyon, Rhéne, France 


Leukoplakia of the Oral Cavity: Cyto- 
logical investigation of leukoplakia of the 
oral cavity is rewarding. Indeed, only other 
rare chronic diseases may be seen there (the 
different types of glossitis), displaying cyto- 
logical signs of chronic inflammation. The 
cytological features of oral leukoplakia 


therefore may be considered specific of the 
disease and its eventual malignant. trans- 
formation will be characterized by typical 
changes of cellular morphology. 

One hundred and one cytological exami- 
nations were performed in 43 different 
cases, admitted either because of the pres- 


Volume 5 
Number ¢ 


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oral I 
corner 
becaus 
or yea 
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oral ¢: 
previo 
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ytol. Volume 5 SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 
1961 Number 2 
ence of one or several areas of primitive 
957. oral leukoplakia (tongue, jugal mucosa, 
zica corner of the lips, floor of the mouth) or 
89: because of the occurrence, several months 
or years after treatment of an oral malig- 
di nancy, of a leukoplakia in some area of the 
oral cavity, sometimes at distance from the 
previously treated lesion. 
is ae . . . 
The cases included in this paper were 
collected from 1954 on; those lacking suff- 
cient duration for accurate control of cy- 
| tology were discarded. ‘These cases were 
regularly investigated every three or six 
months and thanks to this follow up we 
have been able to see some of these leuko- 
plakias undergoing malignant changes and 
thus have observed the cytological signs 
previous to malignancy. 
Histopathological control was not always 
performed as shown in Table 1. In addi- 
tion, it is not of absolute value as the biopsy 
Ils may be done next to the malignant area 
or be too superficial and not suitable for 
im : earns 
fi. '  imterpretation. Clinical follow up there- 
to fore is the best control for cytology. 
ic First Grade: Simple leukoplakia is char- 
acterized by completely keratinized, true 
non-nucleated squamous cells with straw ‘ ‘ a 
in slats: ian auaialliaat die lies a be 4 Fic. 2. Active leukoplakia. Keratinized 
" yellow or orange cytoplasm, isolated or in enurleiniicleated Chinen. 
clusters of various size (Fig. 1). One may 
\- 
Z | 
Ly 
: “TABLE | 
nt 
Cyto- Histo- 
logical No.of logical 
exams cases control 
Simple leukoplakia oa 16 6 (confirma- 
| tive) E 
| Active leukoplakia 9 5 1 (confirma- 
(no treatment) tive) 
Active leukoplakia 17 13) 9 (5 confirm- 
having undergone ative) 
1e malignant changes (1 uncertain) 
. and under ( 3 negative) 
; investigation 
A Degenerated 20 9 7 (5 confirm- m 
leukoplakia ative) “df 
i- (1 non-con- 
firmative) : ; 
it | (1 false . : 4 
: nezative) Fic. 3. Active leukoplakia. Cluster of 
a is small dyskeratotic cells. 























110 





Fic. 4. Same patient as Figure 3, five 
months later. Degenerated leukoplakia. 





Fic. 5. Same patient as Figure 3, five months 
later. Degenerated leukoplakia. 





Fic. 6. Keratinized, multinucleated cluster on the 
left. Elongated cell with date-like nucleus on the 


right. Degenerated leukoplakia: squamous cell 
carcinoma. 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


Acta Cytol, 


Mar.-Apr. 1961 | 


sometimes identify some vestigial structure 
or the remnant of the nuclei. In the inter- 
mediate squamous cells one also may en- 
counter some atypical nuclei displaying a 
slight increase in size or irregularity of 
shape without hyperchromasia and_ with. 
out a nucleolus. 


Second Grade: Active leukoplakia. ‘This 
period is very interesting because it pre- 
cedes malignant transformation. Besides 
non-nucleated squamous cells, as described 
above, one may observe small-sized, rounded 
cells showing dyskeratosis, an orange-col- 
ored cytoplasm, the 
nucleus, or rather, thickening of chromatin 


hyperchromasia of 
at the nuclear membrane, thus well ou:- 
lining the nucleus (Fig. 2, 3). A nucleolus 
is present and this is highly abnormal in a 
keratinized cell. These cells may be elon- 
gated, with elongated well-drawn nuclei 
(Fig. 4, 5). The 
nuclear-cytoplasmic ratio is practically nor- 
mal. 


bearing a nucleolus 


Orange-colored, multinucleated and _hy- 
perkeratinized clusters are also seen. In 
the earlier stages nuclei may be irregularly 
disposed with a very granular chromatin 
looking totally inactive. Later these nuclei 
will show hyperchromasia and sometimes 
be nucleolated (Fig. 6, 7). 

In other words one observes the occur- 
rence of nuclei among the typical hyper- 
keratotic clusters of simple leukoplakia. 
These nuclei at first vestigial are to be- 
come more and more outlined, irregular, 
hyperchromatic then nucleolated. ‘These 
nuclear anomalies only concern the super- 
ficial cells. By histological control we were 
able to diagnose a leukoplakia undergoing 
malignant change without seeing any anom- 
aly in the intermediate or parabasal cells; 
nevertheless, intermediate cells with young 
and nucleolated nuclei may be present 





Volume 5 
Number 2 


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Volume 5 SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


Number 2 
(Fig. 8). The nuclear-cytoplasmic ratio 
remains normal. 

As intermediate and parabasal dyskary- 
oses increase in frequency, one passes on 
to Grade IV of Papanicolaou, that is to say, 
squamous cell carcinoma representative of 
the malignant leukoplakia, which we are 
not concerned with in this paper. 

These cytological features of the active 
leukoplakia transforming into a malignant 
lesion (a true Grade III of Papanicolaou) 
are slight and sometimes difficult to differ- 
entiate from chronic inflammation for the 
untrained observer. In this last case cellu- 
lar alterations seem to concern most cells: 
nuclei look more irregular, the nuclear- 
cytoplasmic ration is more altered. Hyper- 
chromasia is different, more diffuse and 


Janis ara > ne rs 3 ey a] Cc 
nucleoli are generally absent (Fig. 9). 


All these morphological peculiarities of 
active leukoplakia can be taken into ac- 
count only in the absence of recent treat- 
ment (radium therapy or electrocoagula- 
tion). ‘They may last for long periods with 
no change. One of our cases has been fol- 
lowed since March 1958, and the last cyto- 
logical investigation was performed in June 
1959. It showed regression of the process. 
This case is an exception and generally the 
increase in severity is slow but continuous 
during one to two years, eventually leading 


to malignancy. 


Summary 

Special attention was given to the cyto- 
logical changes in leukoplakia of the oral 
cavity undergoing malignant changes. Defi- 
nite morphological alterations allowed one 
to foresee the outcome of malignancy. The 
cytological characters of this active leuko- 
plakia are given as compared to simple leu- 
koplakia or chronic inflammatory changes. 


11] 





Fic. 8. Keratinized, multinucleated cluster on the 


right. Parabasal malignant cells on the top. 
generated leukoplakia. 





Fic. 9. Chronic inflammation. 


De- 





112 SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


EMMERICH VON HAAM 


Columbus, Ohio, U.S.A. 


LEUKOPLAKIA of the cervix is a lesion 
whose importance has been greatly over- 
emphasized in previous years.! It repre- 
sents a more or less circumscribed area of 
epithelial thickening principally produced 
by increased thickness of the superficial 
keratinizing layer of epithelial cells which 
often make up two-thirds to three-fourths 
of the entire thickness of the mucosa. The 
lesion bears no relationship to that of hy- 
perkeratinization of the cervix seen in cases 
of severe uterine prolapse. The cause of 
leukoplakia of the cervix is still unknown. 
It may be an effect of local irritation or a 
local response to excessive follicular hor- 
mone stimulation. The smear from a leu- 
koplakic lesion may give a perfectly normal 
cytology, showing a high percentage of 
eosinophilic superficial cells. Sometimes 
anucleate yellow cornified debris may ap- 
pear, similar to that depicted by Smolka.? 
In a small number of cases we have obtained 
the picture of superficial cell dyskaryosis 
with large and often pyknotic nuclei and 
atypical and highly eosinophilic cytoplasm. 
These cells may arouse the suspicion of 
malignant cells and may be the cause of a 


false positive report. We are classifying the 
cell pattern from these lesions of dyskary- 
otic leukoplakia as Papanicolaou Class II 
unless we also find small, atypical basal or 
parabasal cells. with definitely altered nu- 
cleo-cytoplasmic ratio and hyperchromatic 
nuclei. In comparing the cytological pic- 
ture of cervical leukoplakia with the his- 
topathological picture of the biopsy, we 
have always been able to locate the dyskary- 
otic cells in the most superficial layer of 
the epithelial plaque and could demon- 
strate that they are not accompanied by 
increased proliferative activity of the basal 
cells. The simultaneous occurrence of leu- 
koplakia with carcinoma in situ is in our 
experience no more frequent than the ap- 
pearance of carcinoma in situ without 
leukoplakia, and for this reason we agree 
with those gynecologists who do not regard 
leukoplakia as a premalignant lesion. 


Bibliography 
1. Novak, E. and E. R. Novak: Gynecologic and 
Obstetric Pathology. Philadelphia, W. B. 
Saunders, 1958. 
2. Smolka, H. and. H. J. Seost: Grundriss und 
Atlas der Gynakologischen Cytodiagnostik. 
Stuttgart, Georg Thieme, 1956. 





Discussion 


Werner Bickenbach and Hans-Jiirgen Soost, Mu- 
nich, Germany: We have seen in leukoplakia the 
same cytological pictures described by Arrhigi and 
we agree with von Haam’s opinion that the signifi- 
cance of leukoplakia as a premalignant lesion has 
been overestimated in previous years. 

In addition, we do not think that the appearance 
of eosinophilic clumps, without nuclei, is proof of 
a high follicular hormonal effect. It would seem 
to us to be rather a local disturbance concerning the 
eosinophilic clumps, which might occur more fre- 
quently under hormonal influence in an epithelium 
which is already highly stratified. Eosinophilic 
clumps from a leukoplakia may be also found 
occasionally in an atrophic vaginal epithelium. 


Slight dyskaryosis in large polygonal, eosinophilic, 
superficial cells is generally not important. If one, 
however, finds isolated, enlarged, pyknotic nuclei 
in cells from the middle layers, we should be very 
careful in our judgment. There may be rare cases 
of very mature, invasive carcinoma behind these 
findings. 


Pierre Haour and Claud Conti, Lyon, Rhéne, 
France: Arrighi’s paper on leukoplakia of the cer- 
vix and also the study on smears of the oral cavity 
made by Dargent and Jacqueline Mouriquand are 
very interesting. 


The important point of the authors seems to us 
to be whether or not the presence or the absence 
of dyskaryotic cells is associated with anucleated 
squames. The intensity of dyskaryosis and also its 


t 
Acta Cytol 
Mar.-Apr. 1961 





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Volume 5 
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repartition among the different types of cells being 
related to the degree of evolution. 

In leukoplakia one may find in the smears clusters 
of anucleated squames, but anucleated squames by 
themselves are not specific for leukoplakia. They 
may be found in various conditions, either normal 
or pathologic: they are found in normal vaginal 
smears and also in smears from urinary sediment. 
Smears of infestation (Trichomonas) and irritative 
conditions (prolapse or pessary) also show anucle- 
ated squames. 

In ten cases of simple leukoplakia we found 
clusters of anucleated squames on all of the slides 
and also a large number of “dyseosinophilic” cells 
with occasional perinuclear halos, and also cells 
with an orangeophilic cytoplasm. Nuclear and 
cytoplasmic anomalies were infrequently noted: 
they were found in only three cases in all types of 
cells with positive cytology. In two cases carcinoma 
in situ were discovered. The third case became 
negative cytologically after several negative biopsies 
and the chemical lesion disappeared simultaneously. 
Thirty-two cases of basal leukoplakia and mosaic 
were also controlled by smears, at the Gynecological 
Clinic of Lyon. In 19 cases of basal leukoplakia, 
anucleated squames were noted in all cases. These 
cases were characterized by the presence of atypical 
cells in all of the smears. Atypical cells were of all 
types. Basal cells show principally an orangeophilic 
cytoplasm and often a large hyperchromatic nucleus. 
In orangeophilic cells, the dyskaryotic nuclei ap- 
peared intensively colored by Feulgen reaction and 
much more leaded with chromatin than when 
stained according to the Papanicolaou method. 
Seven of these 13 cases were positive by biopsy. In 
the 19 cases which were characterized as mosaics, 
clusters of anucleated squames were found; orange- 
ophilic basal cells were more frequently encountered 
than in simple leukoplakia but .cytoplasmic anom- 
alies and dyskaryosis were never as pronounced as 
in basal leukoplakia. Only three of these 19 cases 
were found to show carcinoma. 





Jacques Jenny and Alfred Wacek, Ziirich, Switzer- 
land: According to our experience there is no 
typical smear pattern for leukoplakia. This is not 
to be expected since under a leukoplakia a variety 
of histological pictures may be hidden. Moreover, 
the smear contains cells from the entire cervical 








TABLE 1. The Cytological Findings of 136 Cases 
of Colposcopical Leukoplakia 
Smear Histological finding 
Negative 108 
Suspicious 21 Atypical epithelium 10 
Positive 7 Atypical epithelium ] 
Carcinoma in situ 5 


Early invasive carci- 
noma 1 





SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


TABLE 2 





Histological 
findings: 


Cytological findings: 





total negative suspicious positive 





Hyperkeratosis 
and paraker: 
tosis 





348 305 39 | 
Hyperkeratosis, 

parakeratosis 

and atypical 

epithelium 56 16 29 11 
Hyperkeratosis, 

parakeratosis 

and carcinoma 

in situ 22 
Hyperkeratosis, 

parakeratosis 

and early inva- 

sive carcinoma 9 0 0 9 





Totals 135 $21 71 13 





surface and the leukoplakia embraces only a_por- 
tion of it. If the condition ynderlying a leuko- 
plakia is a hyper- or a_parakeratosis, then the 
cornifying cells in question will not stand out from 
the normal cells of the cervical surface. If one 
deals, however, with a premalignant or malignant 
epithelial alteration, then dyskaryotic and atypical 
ceils will be found as can also be seen in other 
colposcopic pictures. We have not taken smears 
strictly from areas of leukoplakia. 

We find ourselves in agreement with the state- 
ment of von Haam that the simultaneous occurrence 
of leukoplakia with surface carcinoma is not more 
frequent than is the incidence of carcinoma in 
situ. without leukoplakia. However, we do not 
believe that from this statement it can be concluded 
that leukoplakia is not a potentially premalignant 
lesion. On top of a cervix with a normal epithe- 
lium there is, at most, an occasional endocervical 
carcinoma (which is very rare in our opinion). In 
the case of a cervix with alterations described as 
“matrix areas” (leukoplakia, bases, mosaic) there 
is a much greater expectation of a pathological 
epithelial change. Therefore, we believe that the 
matrix areas as well as the other colposcopically 
suspicious findings (See ‘Topic: Colposcopy of Car- 
cinoma in Situ) have to be considered as suspicious 
and that we must act accordingly (See Topic: Man- 
agement of Leukoplakia). 


Jule Kovacic, Ljubljana, Yugoslavia: The histo- 
logical pattern of the epithelium that colposcopi- 
cally shows a leukoplakia varies considerably. Most 
important are the following changes: hypertrophy 
of the epithelium, hyperkeratosis, parakeratosis and 
conditions exhibiting an increased nuclear mass. 
Among the latter conditions, an atypical epithelium 





114 


and carcinoma in situ may be listed. As the 
histological pattern of colposcopical leukoplakia 
varies to a great extent, the cytological pattern 
cannot be expected to always be uniform and 
characteristic. The smears occasionally may be 
completely normal, but frequently one may find 
cells without nuclei, often in clusters. Such cells 
are most frequently detected in cases of histo- 
logical hyperkeratosis. In cases of leukoplakia mani- 
festing atypical epithelium, however, atypical cells 
may be detected. 

In 136 cases of colposcopical leukoplakia, a de- 
tailed examination of the corresponding smears has 
been performed. In 95 cases, eosinophilic cells 
without nuclei were found in large quantities; in 
57 cases they formed dense clusters. The results 
obtained with respect to suspicious or atypical cells 
are presented in Table 1. 

During the past two years, 435 cases of cither 
hyperkeratosis or parakeratosis have been found 
among our histological examinations. In addition 
to the above mentioned changes, we have observed 
56 cases of atypical epithelium, 22 cases of carci- 
noma in situ, and nine cases of early invasive car- 
cinoma. The results of the cytological examinations 
of these 435 cases are presented in Table 2. 

Our experiences show that the cytological exami- 
nation may be considered a fairly safe method for 
detecting a leukoplakia which is suspicious with 
respect to carcinoma and in which a biopsy is indi- 
cated. We agree with von Haam’s opinion that a 
comparatively frequent coincidence of leukoplakia 
and carcinoma in sifu does not necessarily prove 
leukoplakia to be a precancerous lesion. However, 
we think that this frequent simultaneous occur- 
rence of both changes does imply the necessity for 
a scrupulous examination of every leukoplakia in 
order not to miss a possible carcinoma. 


Marco Marcov, Stara-Zagora, Bulgaria: I believe 
that cervical leukoplakia must be regarded as a 
premalignant lesion of the cervix. In our experi- 
ence we have found an actual cervical carcinoma 
under a leukoplakia in nearly 6 per cent of the 
cas 





Furthermore, one year ago I observed a patient 
with leukoplakia who was kept under control with 


Closing Remarks 
Arturo A. Arrighi: We agree with the opinions 
of the discuisants, especially with the conclusions 
of Muth, in the sense that the presence of leuko- 
plakia requires further continuous colposcopic and 
cytologic controls. 


Jacqueline Mouriquand: Characteristic features 
typical of leukoplakia are anucleated squames and 


SYMPOSIUM ON PREMALIGNANT 


CERVICAL LESIONS—PART III 


Acta Cytol. 
Mar.-Apr. 1961 


the help of colposcopy and vaginal smears. Thus, 
I had the possibility of observing that after more 
than eight months of finding normal cells in the 
smears, signs of malignant degeneration finally 
appeared. The cancer was confirmed by _ biopsy. 

I believe that this cancer had existed under the 
abnormal hypertrophic superficial layer of the 
leukoplakia. ; 

In my opinion it is more useful to do an early 
biopsy in every case of leukoplakia instead of wait- 
ing until the malignant epithelium appears in the 
vaginal smears. 


Hector Munguia and Esther Franco, México, 
D.F., Mexico: In our experience we have found 
that leukoplakia may give normal cytological pat- 
terns in the smears. When altered patterns asso- 
ciated with leukoplakia are observed in the cyto- 
logical study, these are in agreement with the infor- 
mation obtained by histopathological studies. 

Seldom is there any difficulty in distinguishing 
benign inflammatory cellular alterations, when 
present, from carcinoma. However, this difficulty 
may occur and it is then necessary to look carefully 
for typical malignant cells. 

Based on our experience, we believe that at 
present no clear cut correlation between leuko- 
plakia and cancer may be drawn and, like von 
Haam, we do not consider leukoplakia a 
cancerous lesion. 


pre- 


Hans Muth, Munster i.w., Germany: Our results 
do not agree with those of von Haam, who did not 
find carcinomatous changes on the uterine cervix 
more frequently in those cases with leukoplakia 
than in those cases without leukoplakia. In agree- 
ment with the reports of Arrighi, we found, in a 
series of 289 cases of colposcopically atypical epi- 
thelium of the ectocervix, that 
the cases contained cytological cellular changes and 
10.7 per cent of the cases contained a so-called pre- 
clinical carcinoma. 

A carcinoma does not arise from every 
leukoplakia. However, a leukoplakia requires fur- 
ther continuous colposcopical and cytological con- 
trol, after having eliminated the possibility of a 
malignancy by biopsy. 


27.6 per cent ol 


case of 


cosinophilic clumps without nuclei or with nuclear 
remnants, intermediate and = parabasal cells with 
orangeophilic dyskeratotic cytoplasm and atypical 
nuclei. 


From the papers and the discussions, one may 
summarize the general opinion that if leukoplakia 
does not inevitably have a malignant evolution, it 
is an alarming condition deserving a very close 
follow up. 





Volume 
Number 


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Volume 5 
Number 2 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IIT 


115 


Animal Experiments 


EMMERICH VON HAAM, DANTE G. SCARPELLI 


Columbus, Ohio 


AMONG our animal material which now 
exceeds over 1,000 mice and rats which we 
used for study of experimental carcinoma 
of the cervix, including evaluation of the 
factors which influence it,! +4 we had many 
opportunities to study the development of 
the malignant lesion from its earliest stages. 
In none of our animals, including those in 
which croton oil was used as a simple irri- 
tant, did we observe grossly or histolog- 
ically the picture which Novak’ defines as 
leukoplakia of the cervix. The inflamma- 
tory irritant was either too severe or the 
carcinogenic substance too active to permit 
the development of such a stage, provided 
such a lesion has its place in the develop- 
ment of cervical carcinoma as postulated 


by Hinselmann.® From our experimental 
experience we would like to agree there- 
fore with Novak that cervical leukoplakia 
is of no particular significance for the de- 
velopment of cervical carcinoma. 


Bibliography 

1. Von Haam, E. and D. G. Scarpelli: Cancer Re- 
search. 15: 449, 1955. 

2. Scarpelli, D. G. and E. von Haam: Am. J.. 
Path. 33: 1059, 1957. 

3. Scarpelli, D. G. and E. von Haam: Cancer Re- 
search. 17: 880, 1957. 

4. Scarpelli, D. G. and E. 
search. 18: 657, 1958. ‘ 

5. Novak, E. and E. R. Novak: Gynecologic and 
Obstetric Pathology. Philadelphia, W. B. 
Saunders, 1958. 


von Haam: Cancer Re- 


6. Hinselmann: quoted by Novak in Gynecologic 
and Obstetric Pathology. 





Colposcopy of Leukoplakia 


FRIEDRICH BAJARDI 


Graz 


LEUKOPLAKIA, as a rule, is characterized 
by the fact that it shows a clear-cut line 
when bordering the surrounding regions; 
moreover, in Schiller’s iodine test it does 
not stain or shows merely slight tints as 
compared to the dark-brown color of the 
normal mucous membrane. 

In contrast, however, to these regular 
signs, the proper colposcopical picture does 
not show any uniformity. It is understood 
that each leukoplakia becomes clearly vis- 
ible by reason of a white or whitish color- 
ing. On the other hand, besides uniformly 





, Austria 


transformed areas—termed leukoplakia in 
the proper sense of the word—other white 
spots can also be observed, differing from 
the basic form because of their finer struc- 
ture. These structures may be numerous 
red spots, regular or irregular in arrange- 
ment, or they may appear as a regular or 
irregular network. According to Hinsel- 
mann,3 to whom we owe the discovery of 
and further investigations into such 
changes, the red-dotted white spot is termed 
the base (of leukoplakia), while the area 
showing the network-like appearance is 








116 


Fic. 1. (Top) Pronounced leukoplakia of the 
cervix. Fic. 2. Base of leukoplakia and mosaic 
structure. 


called the mosaic structure. Leukoplakia, 
both the base and the mosaic structure, 
can be observed on some occasions singly, 
but they more often appear together. More- 
over, mixed forms can also occasionally be 
found. 

One example of leukoplakia is shown 
in Figure 1. This picture is particularly 
striking, making it possible to diagnose it 
even with the naked eye. The changed area 
rises slightly above the level of the sur- 
rounding mucous membrane, beside which 
the mother - of - pearl-like sheen of the 
changed area is most striking, pointing to a 
hyperkeratosis of the epithelium. 

It is, however, more often the case that 
leukoplakia can only be observed by means 


of colposcopy. Parakeratosis, or even a 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESTONS—PART III 





ee mh 
simple thickening of the epithelium or an 
increased nuclear density, can thus be held 
responsible for reduced transparency, there- 
fore accounting for the change to a white 
coloring. 

Figure 2 shows both the base (upper left 
side of the picture) and the mosaic struc- 
ture (in center). Both changes are rather 
pronounced. 

The base was originally observed by Hin- 
selmann$ in cases of leukoplakia in which 
the keratotic top layers had been scraped 
off. Actually, findings of the base of leuko- 
plakia can be reached even without kera- 
tosis or parakeratosis.1°6 This is based upon 
the fact that vessels, situated in the stroma 
papillae, approach very closely the surface 
of the epithelium, thus shining through the 
latter in the shape of red spots. The white 
or whitish basic color of the area is due to 
the same changes as in the case of the white 
coloring of a less pronounced leukoplakia. 

The network of red lines in the mosaic 
structure can likewise be attributed to ves- 
sels which approach the surface and which 
pass through stroma papillae, though dif- 
fering in arrangement compared with those 
in the base. Histologically we can _fre- 
quently observe epithelial buds entering 
the stroma, which thus create an increased 
thickness in the outlines of the epithelium. 
In the same way as in leukoplakia, and in 
the base, an increased nuclear density of 
the epithelium (e.g., in cases of carcinoma 
in situ) may also be solely responsible for 
the whitish coloring in the case of the 
mosaic structure. 

In applying 3 per cent acetic acid to the 
cervix, as recommended by Hinselmanné in 
the course of an “extended colposcopy,” the 
colposcopical picture of pronounced leuko- 
plakia, as shown in Figure 1, is hardly 
changed. Should, however, a keratotic layer 
be missing, as is frequently the case in less 
pronounced leukoplakia, both in the base 
and the mosaic structure, then the acetic 
acid is able to penetrate down to the lower 





Volume § 
Number - 


tissue 
prono 
due t 
spaces 
agains 
Th 
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elsew! 
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Cytol. 
. 1961 


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Volume 5 
Number 2 


tissue layers. The changes are of a more 
pronounced whiteness in coloring probably 
due to swellings within the intercellular 
spaces, thus standing out more clearly 
against the surrounding regions. 

The relations found between leuko- 
plakias and cervical cancer are dealt with 
elsewhere in this Symposium. Mention here 
can be made only of the fact that fine struc- 
tures in regard to the base and mosaic 
structure point with some probability to 
benignity, while coarse forms indicate ma- 
lignancy. Thus, in the case shown in Fig- 
ure 2, a carcinoma in situ was histologically 
diagnosed. 





SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 1t7 


Bibliography 


1. Ganse, R.: Kolpofotogramme. Berlin, Akad- 
emie Verlag, 1953. 


2. Glatthaar, E.: Seitz-Amreich, Biologie und 
Pathologie des Weibes. Urban & Schwarzen- 
berg, 1955. 


3. Hinselmann, H.: Die Kolposkopie. Wuppertal- 
Elberfeld, Girardet, 1954. 


1. Limburg, H.: Die Friihdiagnose des Uterus- 

karzinoms. Stuttgart, Georg Thieme, 1956. 
Mestwerdt, G.: Atlas der Kolposkopie. Jena, 
Gustav Fischer, 1953. 


7) 


Wespi, H. J.: Entstehung und Friitherfassung 
des Portiokarzinoms. Basel, Benno Schwabe 
& Co., 1946. 


Juxes-ANDRE BRET, FERNAND COUPEZ 


Paris, France 


THE TERM leukoplakia is a visual, clin- 
ical qualification which is expected to be 
precise. In effect: 

For the clinician, who performs an ex- 
amination with the naked eye this word 
applies to all thick, white formations which 
are resistant to wiping. 

For the pathologist, a diagnosis of leuko- 
plakia is not possible without the presence 
of keratosis or parakeratosis of the super- 
ficial layers. No prejudgment of the under- 
lying layers can be made. 

For the colposcopist, leukoplakia includes 
a set of patterns which could be advan- 
tageously dissociated from this too specific 
qualifying term. These pictures, indeed, 
depend on the following: the presence or 
absence of keratinization, the cellular den- 
sity of the mucosa, its thickness, the profile 
of its superficial layer, the profile of the 
basal membrane. 

The degree of keratinization, the cellular 
density, and the thickness of the mucosa 
influence the intensity of the visual repre- 
sentation. 


The profile of the superficial limit and 
that of the basal membrane influence the 
aspect of the lesion which takes three 
forms: the white spot without any regular 
arrangement on the surface, the mosaic, 
characterized by the presence of polygonal 
white fields, clustered against one another 
and separated by fine red stripes, the 
ground, on white surface dotted by red 
spots. 

If we keep the histological meaning of 
the term leukoplakia, we believe that its 
colposcopic diagnosis is very difficult when 
the keratinization is slight. When it is 
important, we think that leukoplakia can 
be recognized by mosaic or grounds. These 
pictures are not specific for a keratinizing 
process; they may be related to another 
pathological state: the dysplasia. 


Bibliography 


!. Bret, A. J. and F. Coupez: Colposcopie. Paris, 
Masson, 1960. 








118 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


Acta Cytol 
Mar.-Apr. 196] 


, 


WaArREN R. LANG* 


Philadelphia, Pennsylvania 


LEUKOPLAKIA, which literally means 
“white patch,” may be of three main 
varieties: clinical, histological and colpo- 
scopic. It is confusing and illogical not to 
differentiate one from the other. 

Clinical leukoplakia of the cervix is a 
white patch due usually to keratinization; 
on the vulva it may result from dermal 
thinning with hyalinized underlying 
stroma. The true nature of clinical leuko- 
plakia of the cervix is generally char- 
acterized by the pathologist as comprising 
hyperkeratosis, hypertrophy and_hyper- 
plasia of the prickle cells, hypertrophied 
and elongated rete pegs, and chronic in- 
flammatory changes together with edema 
and loss of elastic tissue in the stroma.! 

As detected by the colposcope, an instru- 
ment which views the cervix under stere- 
scopic magnification (10x or 20x) with a 
bright light, leukoplakia again refers to a 
“white patch” and is an indication of epi- 
thelial opacity. Three main factors may act 
alone or in combination to decrease the 
extent of the vascular stroma _ visible 
through the covering epithelium. These 
are: keratinization, epithelial thickening, 
and increased nuclear substance. 

Hinselmann, the founder of colposcopy, 
has described three classic types of colpo- 
scopic leukoplakia: 

(1) Simple leukoplakia (Leukoplakie) 
(Fig. 1). This is an area of whitening 
which may be often visible to the naked 
eye. The surface may be smooth, or ir- 
regular. Because it is avascular, it is easily 
distinguishable from the whitening of a 
nabothian cyst (Fig. 2). Keratinization and 
epithelial thickening are frequently pres- 
ent on histologic examination. 





*From the Department of Obstetrics and Gyne- 
cology, Jefferson Medical College, Philadelphia 7, 
Pennsylvania, U.S.A. 





Fic. 1. Note simple leukoplakia at approximately | 
ten o'clock of area of columnar epithelium and 
transformation zone of anterior lip. Papanicolaou 
smear Class I. Biopsy showed keratinization. 


(2) Mosaic leukoplakia 
(Fig. 3). This consists of a yellow-white 
area with a mosaic pattern. Histologically, 
connective tissue septa extend high into the 


‘ 





Fic. 2. 
cervical lip. Note blood vessels on surface; these 
serve to distinguish the whitish areas from leuko- 
plakia. 


Large nabothian cysts on the posterio1 





) 
(Felderung) 





Volume 
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Volume 5 
Number 2 


epithelial layer. Keratinization may be 
present. A form of mosaic leukoplakia can 
also arise from the close 
many glands with thickened, dense leuko- 


plakic rims.? 


association of 


(3) Ground leukoplakia (Leukoplakie- 
erund) (Fig. 3). This is characterized by a 
yellow-white area with a red, stippled effect 
(in fact, Wespi calls it Punktierung). ‘The 
histologic explanation resembles that of 
mosaic leukoplakia but in our experience, 
keratinization is less apt to be present histo- 
logically. 

Gently wiping the cervix with a cotton 
sponge moistened with three per cent acetic 
acid is of definite value not only in ridding 
the portio of mucus and secretions, but also 
in delineating the types of leukoplakia 
present. In our opinion an accurate diag- 
nosis of the specific type of colposcopic 
leukoplakia is not possible without the 
use of acetic acid. All types of leukoplakia 
fail to take the stain after the use of aque- 
ous iodine solution, e.g., Lugol’s solution. 
A green light also has merit in detecting 
areas of leukoplakia. 

Closely allied to leukoplakia is an iodine 
nonstaining area of squamous epithelium 
(Fig. 4). Such squamous epithelium may 
be grossly and normal. 
lodine nonstaining areas of normal appear- 
ing squamous epithelium specifically indi- 


colposcopically 


cate glycogen lack and may result from 
estrogen deficiency, or may be present with 
degeneration, regeneration (e.g., following 
biopsy) or minor histologic atypias. Per- 
haps, in some instances these areas are, in 
a sense, preleukoplakic. 

The significance of colposcopic leuko- 
plakia warrants comment. In general, the 
various forms indicate some abnormality of 
growth but not necessarily the presence of 
carcinoma as is so often incorrectly assumed 
by those unacquainted with the intricacies 
The various forms of a 
colposcopic leukoplakia are often found at 


of colposcopy. 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 





119 





Fic. 3. Posterior lip of cervix showing ground 
icukoplakia on the viewer's right; mosaic leuko- 
plakia on the left. Papanicolaou smear Class ITI. 
Biopsy showed early invasive squamous cell carci- 
noma. 


the edge of grossly evident carcinoma and 
may be the only findings with an in situ 
lesion. Their seriousness is roughly pro- 
portional to their quality and quantity, 





Fic. 4. Cervix of woman previously diagnosed as 
having carcinoma in situ; extensive coning biopsy 
performed four months previously. The cervix 
took iodine stain (Lugol’s solution) well except for 
area at eleven-thirty o’clock where normal appear- 
ing squamous epithelium did not. Papanicolaou 
smear Class I. Biopsy of nonstaining area showed 
normal squamous epithelium with moderate in- 
flammation. 








120 


i.c., the more pronounced and more ex- 
tensive the leukoplakia the more apt is 
malignancy to be present.s Biopsy, of 
course, gives the final answer. Colposcopy 
may serve as a means of detecting pre- 
invasive or invasive cancer when the 
cytologic smear is negative. The interre- 
lationships of cytology and colposcopy have 
been reviewed elsewhere.® 7 Colposcopic 
leukoplakia may be both reversible and 
recurrent.8-10 


Bibliography 

l. Herbut, P. A.: 

Pathology. 
1953. 


Gynecological and Obstetrical 
Philadelphia, Lea and Febiger, 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


Acta Cytol, 
Mar.-Apr. 196] 


2. Hinselmann, H.: Colposcopy: With Contribu- 
tion on Colpophotography by A. Schmitt 
(trans. by W. Lang). Wuppertal-Elberfeld, 
Germany, W. Girardet, 1955. 

3. Wespe, H.: Early Carcinoma of the Uterine Cer- 
vix, Pathogenesis and Detection 
Schiller, M.). 
1949. 

1. Lang, W. R.: Proc. Third 

Conference, 620, 1957. 

Limburg, H.: Acta Union Internationale Con- 
tre le Cancer. 14: 321, 1958. 

6. Lang, W. R. and A. E. Rakoff: Ob. and Gyn. 

8: 312, 1956. 

7. Schmitt, A.: Ob. and Gyn. 13: 665, 1959. 

8. Lang, W. R., A. E. Rakoff, F. de Narvaez and 
G. Tatarian: Am. J. Ob. & Gyn. 74: 1000, 1957. 

9. Dietel, H. and A. Focken: Geburtsh. u. Frauenh. 
15: 593, 1955. 

G.: Zentralbl. Gyniik. 71: 222, 


(trans. by 
New York, Lea and Febiger, 


National Cancer 


co 


10. Rossler, 1949. 


WOLFGANG WALZ 


Heidenheim/Brenz, Germany 


GENERALLY speaking, I would like to 
point out that the term “leukoplakia” 
means nothing but “white spot.” It is an 
optical diagnosis with no meaning what- 
soever concerning the histological structure 
of the particular lesion. The “white spot” 
originates optically through the fact that 
the incoming light does not reach the 
blood vessel-containing connective tissue. 
This can be the case only in the following 
histological changes which 
colposcopically as leukoplakia: 

(1) Benign cornified squamous _ epi- 
thelium (i.e., at prolapse, as the cornified 
layer does not reflect the light) (Fig. 1). 

(2) Abnormal, highly proliferated squa- 
mous epithelium without  cornification 
which does reflect the incoming light be- 
fore reaching the subcutaneous connective 
tissue (i.e., papilloma with cervical glands 
filled with squamous epithelium) (Fig. 2). 

(3) Necroses on true erosion (Fig. 3) 
and on carcinoma also are not translucent, 
so they appear as leukoplakia. 


can appear 


(4) Squamous _ epithelium _ particularly 
rich in cells, i.e., carcinoma in situ, reflect 
the incoming light very strongly, because 
of their abundance of nuclei, so that if the 
epithelium is high enough optically a 
leukoplakia can appear. 

(5) Cornified carcinoma and carcinoma 
in situ. For the colposcopical diagnosis 
we have the problem of whether we can 
differentiate the listed histological changes 
apt to cause leukoplakia, in regard to being 
benign or malignant. For being malignant 
we have, according to our experience, the 
following criteria: The higher and the 
more squamous a leukoplakia is, the more 
a malignant change must be expected. For 
differential diagnosis the following test can 
be used: Stain the leukoplakia with one 
per cent toluidine-blue solution. If the par- 
ticular spot becomes darker than its sur- 
rounding we have an epithelium rich in 
cells, always suspicious for a malignant 
change. If the spot stays white or stains 


but little we have a real cornification. In 


i 
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Volume 5 
Number 2 


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Volume 5 SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


Number 2 

general it occurs very rarely that a malig- 
nant process has but one leukoplakia. Usu- 
ally we find in its immediate surrounding 
characteristic changes of the blood vessels 
and the mucous membranes, as “ground” 
and “mosaics.” Most difficulties are found 
in a combination of true erosion and 
leukoplakia, as the accompanying inflam- 
mation dilates the blood vessels or a velvet- 
like redness appears. Necroses, which ap- 
pear as leukoplakia, usually stick tightly 
to their basis and have a yellowish appear- 
ance which strengthens the suspicion of 
malignancy. 

Originally Hinselmann recognized each 
leukoplakia either as malignant or at least 
as a matrix-area for a possible origination 
of carcinoma, which doubtless brought an 
over-estimation of the diagnosis “‘leuko- 
plakia.” Particularly it was always put in 
connection with cornification. For this 
problem I should like to list some of our 
cases, which we have examined between 
1951-1956 (see Table 1). 

These cases listed above show that the 
majority of leukoplakias were benign 
changes. However, I would like to add 
that as shown above a number of leuko- 
plakias were found at the edge of carci- 
noma and carcinoma in situ (in the lowest 
column of Table 1 listed under “leuko- 
plakias as additional findings’). However, 
they were found in a similar percentage 
at the edge of the other benign changes of 
the cervix, which had histologically no 
connection with these lesions. We found 








TABLE | 

‘Total patients Invasive 

examined Carcinoma Carcinoma 

1951-1956 I-IV in situ 

3,204 88 27 

Leukoplakias as 

main findings 99 3 1 
Leukoplakias as 

additional 

findings 108 4 3 





12 





] 





Fic. 1. Prolapse-leukoplakia at the anterior lip 
of cervix. This and the other pictures are colpo- 
photos taken with the colposcope of Zeiss. 


Fic. 2. Circular ectopy. Papilloma 
Histologically _without cornification. 
same patient the colpomicroscopical 
where in this symposium.) 





at 2 o'clock. 


(From 


the 


finding else- 





Fic. 3. True erosion with surface necrosis appear- 


ing as leukoplakia. External os can 
upper part of picture. 


be seen 


in 





122 
locally cornified epithelium 
areas, which, according to our opinion, 
must be regarded as the reaction of the 
squamous epithelium against a detrimental 
influence on its surface. The diagnosis 
“leukoplakia” appears as a kind of guiding 
symptom for the existence of possible 
malignant lesions, itself usually not being 
part of the malignant lesions. However, we 
observed leukoplakias in a similar _per- 
centage in connection with benign as with 
malignant lesions. I would also like to 
point out that histologically only compara- 
tively few cornified squamous epithelium 
carcinomas are found (about 12-15 per cent 
of all cervical carcinomas), which indicates 
that cornification is not responsible for a 
possible development of carcinoma as it 
has frequently been thought to be. 


squamous 


Discussion 

Jean Berger, Basel, Switzerland: The colposcopic 
pictures of leukoplakic changes on the cervix uteri 
are characteristic and have been well defined by 
the discoverer of colposcopy and his first disciples, 
Mestwerdt and Wespi, et al. We encounter the 
charactevistic pictures, such as “base” and “mosaic,” 
as they have been described above by Lang and 
Bajardi. These are areas on which, under all 
circumstances, a biopsy has to be performed. Fur- 
thermore, the leukoplakia is an elevated, sharply 
defined small area, which is characterized by its 
marked keratinization. ‘This picture may also 
be appreciated macroscopically, as described by 
Franque, many years before the introduction of 
colposcopy. 

Of more significance to us is another form of 
leukoplakic change, namely the “beginning leuko- 
plakia,” also called “leukoplakic areas,” which ap- 
pears as a well demarcated iodine negative area 
and in which neither base nor mosaic is to be 
seen. These areas are the most significant since 
they cannot be determined by the naked eye and 
may be mistaken for a beginning regeneration. In 
all of these cases a biopsy should be done. 

In regard to the Malignancy Index of such 
changes, one might say that malignant changes are 
not as frequently encountered as was_ initially 
assumed by the founders of colposcopy. Among 
749 cases of leukoplakia we have found 716 cases 
of histologically proven abnormal epithelium, 28 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


Acta Cytol 
Mar.-Apr. 196] 


In conclusion we can establish that it is 
possible, with the required experience, to 
detect all suspicious leukoplakias by the 
aid of colposcopy and to bring them to a 
histological examination. 


Bibliography 


1. Hinselmann, H.: Handbuch der Gyniikologie 
« (Veit-Stéckel). Vol. IV: 854. 
2. Hinselmann, H.: Z. Geburtsch. 101: 604. 


3. Lahm: Handbuch Gyniikologie Halban-Seitz 
Vol. IV: 769. 

4. Limburg, H.: Die Fruhdiagnose des Uterus- 
karzinoms. Stuttgart, Georg. Theime, 1956. 


5. Meyer, R.: Handbuch 
barsch. Vol. VII. 

6. ‘Treite: Die Fruhdiagnose des Plattenepithel- 
karzinoms am Collum Uteri. Stuttgart, Fer- 
dinand Enke, 1944. 

Walz, W.: Z.f. Geburtsh. 139: 198, 1953. 

8. Wespi, H. J.: 

karzinoms. 


Pathologie Henke-Lu- 


Portio- 
Schwabe, 1946 


Die Fruherfassung des 
Basel, Benno u. 


cases of “increased atypias” and in five cases a 
squamous cell carcinoma. that 33 
cases (4.5 per cent) a malignant alteration was 
encountered. In 797 cases with the colposcopical 
finding of a “base” the Malignancy Index was 3.1 


This means in 


and in 1603 cases with colposcopic “mosaic” the 
Index of Malignancy was 0.9. Of much more 


importance to us is the inconspicuous, sharply out- 
lined iodine-negative area which is not detected 
by the acetic acid test but appears only after appli- 
cation of iodine. In this type of change we found, 
among 1,835 2.9 per cent 
atypia or a beginning carcinoma. 


cases, in an increased 


This 
the most important since it is frequently overlooked. 


group is 


The same holds true for the so-called “atypical 
transformation zone” which may be confused with 
marked inflammations and which has a Malignancy 
Index of between 15 and 20. 

Herbert Janisch, Vienna, Austria: We agree with 
the four main speakers in regard to the various col- 
poscopical pictures of “leukoplakia.” What the 
evaluation these areas concerned with 
have discussed elsewhere in this Symposium. Cer- 
tainly the significance “matrix 
areas” has rhe 
the 
per 


of is we 
the so-called 
overestimated in the past. 
incidence of these areas in the material of 
various authors ranges between and 15 
cent. The application of the Schiller test and the 
inclusion of iodine negative areas certainly con- 
tributes to these results. According to our experi- 


of 
been 


95 





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Volume 5 
Number 2 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART 


PABLE | 





Invasive carcinoma 


Early invasive Carcinoma 





Stages I-IV carcinoma in situ 
Number of cases of carcinoma 
(total 173) 86 20 67 
Simple leukoplakia 0 0 7 
Leukoplakia with additional alterations 28. 15 15 





ence the “Malignancy Index” of these matrix areas 
is small, ranging between 2 and 4 per cent. 

To Walz we would like to say that in addition 
to the pure forms of leukoplakia there are also 
leukoplakia-like pictures. Here we deal, in most 
cases, with cellular condensations of regenerative 
epithelium, which is frequently found in undiffer- 
entiated metaplasia. The undifferentiated regen- 
erative epithelium is also frequently found in the 
“unusual” transformation zones. We have learned 
from colpomicroscopy that these metaplastic areas 
stain dark blue with |! per cent toluidine-blue 
solution, i.c., differently from the parakeratotic 
cornified epithelia of the various forms of leuko- 
plakia. In addition to this, we quite acci- 
dentally noticed that there are other factors, 
eg. vascular atypias which facilitate the colposcop- 
ical evaluation. 


Marija Stucin, Ljubljana, Yugoslavia: During the 
period from 1957 to 1959 we have colposcopically 
examined 9,978 patients. Among these, 173 cases 
of carcinoma have been found. The coincidence of 
simple leukoplakia, as well as both of its variations, 


eg., ground leukoplakia and mosaic, with  car- 
cinoma is shown in Table 1. 
As can be seen, in 95 of the 173 (54 per cent) 


carcinomas, leukoplakia has been found colposcop- 
ically. In 67 of 87 preclinical carcinomas (77 per 
cent) leukoplakia could be observed by colposcopy. 
The high proportion of leukoplakias detected in 
preclinical carcinomas led us to the conclusion 
that these changes may fairly safely be considered 
as a reliable indicator in following early forms of 
cervical carcinoma by means of colposcopy. 

In our use of colposcopy we have so far achieved 
sufficient experience so as to be able to discern 
the difference between suspicious and nonsuspicious 
leukoplakias and accordingly to reduce the number 
of biopsies. Leukoplakias which we consider col- 
poscopically nonsuspicious, however, undergo bi- 
opsy when the result of the cytological examina- 
tion is positive or inconclusive. 

Differing in this respect from Walz, we have 
found in most of our cases of carcinoma, a leuko- 
plakia by means of colposcopy. Accordingly, we 
consider leukoplakia an important indicator in 
the search for carcinoma. 


Enrique Vasquez Ferro, Buenos Aires, Argentina: 
he descriptions given by Bajardi, Bret and Coupez, 


Lang and Walz are excellent, especially the re- 
marks that leukoplakia may vary according to 
the point of view of a clinician, a pathologist or 
a colposcopist. 

For the clinician, leukoplakia is only a white 
spot visible by the naked eye. For the pathologist, 
leukoplakia represents a perfectly defined _histo- 
logical pattern with keratosis and/or parakeratosis; 
while for the colposcopist, the idea of leukoplakia 
is more extended, corresponding to a_ series of 
modifications of the squamous epithelium going 
from the single opacity or thickness of the epi- 
thelium to the hyperkeratotic leukoplakia. 

Some leukoplakias can be discovered by the naked 
eye or by the Schiller Test. The value of col- 
poscopy is to determine the extent of the abnormal 
epithelium and to establish suspition of malignancy. 
An experienced colposcopist knows that there are 
leukoplakias where a malignancy is suspected; in 
such cases if a simple biopsy is negative repeated 
biopsies or conization or amputation for serial 
study of the cervix should be recommended. 

In some cases there are frequently observed zones 
of thickness and opacity of the epithelium around 
an ectopy, which histologically corresponds to a 
hyperactive or aglucogenic epithelium. 

The other variations of leukoplakia such as 
“base” (Grund) or “mosaic” (Felderung) are only 
visible through the colposcope. A_ well trained 
colposcopist will be able to appreciate the suspicion 
of malignancy of these lesions. 

Two facts should be emphasized: colposcopy con- 
tributes to the detection of abnormal changes of 
the epithelium and permits more accuracy when 
performing biopsies. 


Hans Iselin Wyss, Zurich, Switzerland: We also 
believe that the morphological changes as described 
by Bret and Coupez create the picture of the 
matrix area (leukoplakia, base and mosaic). First 





Walz Ziirich 





Number of cases with 
carcinoma in silu 27 79 

Matrix area as the main 
finding 1 (3.7%) 45 (56.9%) 

Matrix area as additional 
finding 


3(11.1%) 4 (6.1%) 








124 


of all keratinization, or a non-cornified but thick- 
ened epithelium and possibly an increased number 
of nuclei in an epithelium of normal thickness, 
seems to us to be responsible for a matrix area. 
The relationship between epithelium and con- 
nective tissue plays a further role in the additional 
subdivision into leukoplakia, base and mosaic. 

In regard to the relationship between the matrix 
area and the corresponding histological picture, see 
our discussion in this Symposium under the topic: 
“Interrelationship: Leukoplakia and Cervical Car- 
cinoma.” Because of these results we tend to 
believe that each leukoplakia has to be examined 
histologically. If the colposcopic picture changes 
during further control examinations, then each 
time an additional histological examination is 


Closing Remarks 

Jules-André Bret: The completely benign pat- 
terns require only cytological control. It seems to 
us that, except for inflammatory reactions, leuko- 
plakias, “mosaic” or “base” (being colposcopically 
suspicious lesions), always display definite visual 
features and are visible even without administra- 
tion of acetic acid. They are surrounded by a 
typical “red zone,” ranging from the simple conges- 
tion to true ulceration, and they are also character- 
ized always by an abnormal hypervascularization. 


Warren R. Lang: Although the majority of col- 
poscopic leukoplakias are not indicative of car- 
cinoma in situ or invasive carcinoma, we agree with 
Stucin that it is better to biopsy such areas since 
there must be some histologic explanation for the 
colposcopic appearance. It is difficult to be certain 
colposcopically that a serious lesion is not present. 
In our experience, as that of Wyss, early carcinoma 
usually demonstrates some form of colposcopic 
leukoplakia. Unlike the experience of Berger, 





SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


Acta Cytol, 
Mar.-Apr. 196] 


necessary. We believe the coaise mosaic and _ the 
irregular base are especially suspicious. In pure 
leukoplakias a highly pathological epithelium is 
expected only rarely. In our opinion the epithelial 
thickness and the degree of cornification do not 
give any evidence concerning malignancy. 

Contrary to Walz, in our hospital we found sig. 
nificantly more leukoplakias in cases of carcinoma 
in situ. 

We agree with Walz, however, that the majority 
of the matrix areas do not yield pathological epi- 
thelium in the histological examination. In 6 per 
cent of all matrix areas we have found a highly 
pathological epithelium (0.5 per cent invasive car- 
cinomas, 3.5 per cent carcinoma in situ, 2 per cent 
“unquiet” epithelium). 


Janisch and Ferro, our studies do not indicate 
iodine-nonstaining portio areas of normal-appearing 
squamous epithelium as being highly significant. 

We fully concur with the statement of Ferro, 
“colposcopy contributes to the detection of abnor- 
mal changes of the epithelium and permits more 
accuracy when performing biopsies.” 


Wolfgang Walz: To Stucin and Wyss: Appar- 
ently both these authors obtained results, in regard 
to the occurrence of leukoplakias in carcinoma in 
situ, which differ considerably from the ones | 
have found. Unfortunately, both of them have 
misunderstood me. As I gather from their Tables, 
they have included not only leukoplakia, but also 
all the other matrix areas, whereas I, in my paper, 
have considered only leukoplakia, as was required 
by the title of this section of the Symposium. If 
I add the remaining matrix areas, then in my 
material, 52 per cent of the carcinomas in situ 
have so-called “matrix areas,” which is in accord- 
ance with the figures of Wyss and Stucin. 

I agree fully with Berger and Janisch. 





Volume 
Number 


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—_—~------ 
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Volume 5 
Number 2 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


125 


Colpomicroscopy of Leukoplakia 


Tassi.o ANTOINE, KurT BRANDL, VIKTOR GRUNBERGER, 


EKKEHARD KOFLER, HANS KREMER 


Vienna, Austria 


In cases of leukoplakia the colpomicro- 
scope merely shows a more or less unstained 
homogeneous area, with recognizable 
clumps around the edge. Careful examina- 


tion should be given to the edge of the 
leukoplakia in order not to overlook a 
carcinoma in situ hidden by the leuko- 
plakia. 


WOLFGANG WALZ 


Heidenheim/Brenz, Germany 


CoRRESPONDING to the different histologi- 
cal findings which might appear clinically 
as leukoplakia, the following findings were 
established by colpomicroscopy: 

(1) The benign cornified squamous epi- 
thelium. On the epithelium surface are 
situated only cells without nuclei, the cyto- 
plasm of which stains little, if at all (Fig. 
1). In order to decide if there might be a 
carcinoma in situ under the cornified layer, 
the latter may be scraped off with a sharp- 
ened spoon. This part is stained once more 
by toluidine blue. Then the underlying 
epithelium can be recognized without dif- 
ficulties (Fig. 2). It is very important to 
examine the boundaries of such a cornified 
area. If there is a normal squamous epi- 
thelium, recognizable by the large polyg- 
onal superficial cells, then the probability 
of a carcinoma under the cornified stratum 
is rather low, particularly if there are only 
small cornified areas (Fig. 3). Frequently 
in the surrounding of a normal squamous 
epithelium there are islands of small corni- 
fied areas, which usually are not sharp- 
edged towards the noncornified epithelium. 


, 

(2) Benign papillomas without corni- 
fication as well as abnormally high squa- 
mous epithelium (as in the case of filled 
cervical glands) have their 
normal squamous cells. The papillomas, 
however, frequently tend toward cornifica- 
tion and possess fine papillae on their sur- 
face (Fig. 4). In the case illustrated there 
is a beginning parakeratosis on the surface 
recognizable by vanishing cell boundaries 
and pyknotic nuclei. 


on surface 


(3) Necrosis, as on a true erosion, which 
clinically appears as leukoplakia, is rather 
difficult to judge colpomicroscopically. 
There usually is to be found a structure- 
less homogeneously blue-stained surface, 
occasionally dotted with leukocytes and 
lymphocytes. Also in this case one can 
try to remove the necrosis and to restain 
the particular part. If large hemorrhages 
advisable to anti-inflam- 
matory treatment and to check the findings 
after a number of days, because of possible 


occur it is use 


carcinoma hidden under the necrosis. 
(4) Noncornified carcinoma in situ and 
invasive carcinoma of the cervix which 











Fic. 1 
benign cornified epithelium. This and the other 


(Top). 


Colpomicroscopical finding of a 


figures stained by Toluidine blue (from x180). 


Fic. 2. The same case as Fig. 1 after scraping off 
the cornified stratum. 


clinically appear as a leukoplakia are, by 
the colpomicroscope, identifiable without 
difficulty by their atypical epithelial sur- 
face. 

(5) Carcinoma in situ with cornification 
can be easily diagnosed colpomicroscopi- 
cally as it is practically never covered by 
a continuous cornified layer. Between the 
cornified areas there are places with cor- 
respondingly changed cells on the surface 
(Fig. 5). Strikingly, such carcinomas usu- 
ally have larger nuclei than the noncorni- 
fied species. Also chromatin structure can 
be seen clearly. Such nuclei usually do not 
stain as intensively as in noncornified 


carcinomas. Frequently cell boundaries 


still exist. As a whole such cells have char- 
acteristics 
cells. 


corresponding to dyskaryotic 





SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 





Acta Cytol 
Mar.-Apr. 196] 


Fic. 3 (Top). Border between the normal squa- 
mous epithelium (above) and a cornified area. 
Fic. 4. Surface of a papilloma without cornification. 


Invasive carcinomas correspond on the 
surface to carcinoma in situ. It is well 
known that we cannot recognize by the 
colpomicroscope an invasion into the lower 
connective tissue. The more irregular the 





Fic. 5. 
fied area (the lower part of picture). Spindle cells 
are recognizable in the upper part of picture. 


Surface of a carcinoma in situ with corni- 





y 





Volume 
Numbe 


surfa 
sible 
on 
necr 
diffic 
Sinc 
reco 


Fra 
of 

if « 
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Mc 
po: 





\cta Cytol, 
-Apr. 196] 


squa- 
area, 
cation. 


1 the 
well 
the 
ower 
> the 











Volume 5 
Number 2 
surface the more we must suspect a pos- 
sible Occasionally leukoplakias 
on advanced carcinoma are caused by 
necrosis. In that case diagnosis can be very 
difficult (just as it would be with cytology). 
Since this pertains mostly to clinically 


invasion. 


recognizable carcinomas, however, it is of 
lesser importance. 

In conclusion, we can state that with the 
exception of the listed limitations, all leuko- 


Discussion 

Marcel Dargent and Pierre Haour, Lyon, Rhone, 
France: The observations of Antoine's group and 
of Walz on leukoplakia are interesting, principally 
if one compares these with the study of exfoliative 
cytology of leukoplakia (Arrighi, Dargent and 
Mouriquand) made in another part of this Sym- 
posium. With microcolposcopy it is probably pos- 


Closing Remarks 


T. Antoine, V. Griinberger, E. Kofler and H. 
Kremer: ‘The morphological finding in leukoplakia 
is the superficial cornification. Under this vari- 
ous types of epithelial changes may lie. When, 
however, the cornified layers are removed, the 
underlying epithelial changes are supposed to be 
at least partly disturbed. Therefore, it would be 
better to call attention during the colpomicroscopic 
examination to the edges of the leukoplakia. A 
large leukoplakia should be biopsied in any case 
in order to study the underlying epithelial changes 
histomorphologically. 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 





127 


plakias can be diagnosed correctly by aid 
of the colpomicroscope and will agree with 
the corresponding histological findings. 


Bibliography 
1. Antoine, T. and V. Griinberger: Atlas der 
Kolpomikroskopie. Stuttgart, Georg Thieme, 
1956. 


2. Walz, W.: Z. Geburtsh. 136: 225, 


1952. 


3. Walz, W.: Z. Geburtsh. 144: 117, 1955. 


sible to make a diagnosis of simple or aggravated 
leukoplakia and, therefore, to follow the evolution 
of a cornified lesion. From Walz’s statements it 
appears that dyskaryotic cells are found mostly 
under the cornified epithelium rather than around 
the edges of the lesion, and the technical details 
which consist of removing the cornified superficial 


layers are important. 
° 


Wolfgand Walz: I am delighted to see that the 
discussants have had the same experience with the 
colpomicroscope that we have had. I should like 
to make a little correction in my statements on 
the occurrence of dyskaryotic cells. I refer only 
to those carcinomas in situ which tend towards 
cornification. Otherwise, I encountered in 
most of the carcinomas in situ, especially in the 
marginal regions of the lesion, an accumulation 
of dyskaryotic cells. Regarding this, I may refer 
to my contribution in Acta Cytologica, 2: 17, 1958. 


have 














Clinical Viewpiont on the Management 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 





Acta Cytol, 
Mar.-Apr. 1961] 


of Leukoplakia 


TAssiLo ANTOINE 


Vienna, Austria 


AS LEUKOPLAKIA is a_ facultative pre- 
cancerous lesion, we must first clear up 
whether it is already a pre-invasive cancer 
or not. If repeated examinations (cytology, 


colposcopy or colpomicroscopy) show that 
there is no sign of malignancy, electro- 
coagulation is the method of choice. Other- 
wise, a biopsy has to be done. 





Discussion 

Jacques Jenny and Alfred Wacek, Ziirich, Switzer- 
land: We agree with Antoine that leukoplakia may 
be a precancerous lesion in a general, as well as in 
a specific sense, as long as the other conditions 
designated by Hinselmann as matrix areas are 
also included (base and mosaic). Particularly sus- 
picious, in our opinion, are the so-called coarse 
mosaic and coarse base. The clarification of the 
diagnosis is done in our hospital by cytology, col- 
poscopy and Schiller’s surface biopsy with subse- 
quent histological examination. [f premalignant 
or malignant epithelium can be excluded by this 
procedure, then, in our opinion, a yearly check-up 
is sufficient control. If this is not possible for some 
external reason or if the patient is not reliable, 
electrocoagulation of the cervix is recommended. 


Maria Kawecka and Janina Vorbrodt, Gliwice, 
Poland: Our management of ectocervical leuko- 
plakia consists both of electroexcision and electro- 
coagulation, but only after carcinoma in situ has 
been histologically excluded, inasmuch as the fre- 
quent coexistence of leukoplakia and carcinoma 
in situ has to be taken into consideration. 

We have observed two young patients with ex- 
tremely extensive leukoplakia who present some 
diagnostic and therapeutic difficulties. In these 
patients the lesion was found to be widely spread, 
including the ectocervix, the vaginal vaults, the 
labial mucosa and dyskeratosis was even found in 
the perineal and perianal regions. Several biopsies 
performed on the ectocervix, vaginal walls and 
vulva revealed leukoplakia in “carcinoma in situ 
vertens.” 

The question of how to treat patients with ex- 
tensive leukoplakia remains to be solved. 

The control examination of two further patients 
performed several months after a hysterectomy was 
done because of a cervical carcinoma in situ, showed 
leukoplakia of the vaginal wall. 


In several patients treated by means of electro- 
conization for both cervical carcinoma in situ and 
leukoplakia, recurrence of the leukoplakia devel- 
oped several months after treatment. 

One other patient was examined one year after 
radium therapy for an early invasive cervical car- 
cinoma. In this case a leukoplakia in “carcinoma 
in situ vertens” of the vaginal vault was found in 
the previously irradiated region. 

The etiology of leukoplakia still remains un- 
known and local treatment cannot be considered 
as causal. Thus, none of the usual therapeutic 
procedures: local excision, hysterectomy associated 
with removal of the vaginal vaults and radium 
therapy can be considered as a certain procedure 
to remove leukoplakia or prevent its recurrence. 

We are of the opinion that the treatment of 
leukoplakia should be individualized, depending 
upon localization and degree of extension. Control 
examination should be obligatory, thus enabling 
one to discover an early recurrence of the leuko- 
plakia. 


Jule Kovacic and Marija Stucin, Ljubljana, Yugo- 
slavia: According to our experiences in as many 
as 10 per cent of all colposcopical leukoplakias the 
detection of early invasive or in situ carcinoma may 
be expected. This fact makes it a necessity to 
first of all exclude, in every case of leukoplakia, 
the possible existence of a malignant lesion. The 
best method in our opinion is a scrupulous colpo- 
scopic examination, a cytological evaluation, and 
finally a biopsy. If the existence of a malignant 
lesion can be excluded by biopsy or if the leuko- 
plakia is colposcopically and cytologically nonsuspi- 
cious, we consider it best to periodically repeat 
the examination, using both methods. 

In many instances of colposcopical leukoplakia 
we often found these alterations to be recurrent 
after electrocoagulation, as well as to be spontane- 
ously reversible without treatment. 





Volum 
Numbe 


We 
havin 
since 


Er! 
agree 
plaki 

4 It is 
theli 
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cta Cytol, 
Apr. 196] 


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1 car- 
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- 


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Volume 5 
Number 2 


We perform electrocoagulation only in cases 
having a widespread ectopy or epidermization, 
since these patients have constant difficulties. 


Ernst-Helmut Kriiger, Halle/Saale, Germany: We 
agree with Antoine that the recognition of leuko- 
plakia does not offer any colposcopical difficulties. 
It is the only form of colposcopically atypical epi- 
thelium where the behavior of the vessels does not 
play a role in evaluation. 

Colposcopically one may differentiate the fol- 
lowing among the leukoplakias: 


1. The prolapse leukoplakias are distinguished 
by their indistinct borders with the normal epi- 
thelium. These are, in most cases, harmless epi- 
thelial changes. 

2. The parakeratotic squamoid epithelial changes 
present themselves colposcopically not as_ bright 
whitish areas, but as more yellowish areas. They 
are also somewhat raised above the normal surface. 

3. The plaque-like leukoplakia is, in our opinion, 
often overestimated as to its malignant tendency. 

Certainly a definite evaluation of leukoplakia is 
only possible by means of histology. In cases of so- 
called surface carcinoma, leukoplakia can almost 
always be encountered. Attempts to distinguish 
colposcopically between benign and malignant leu- 


Closing Remarks 


Tassilo Antoine: Like Jenny and Wacek, I be- 
lieve that the leukoplakia is especially suspect 


when occurring with the so-called “base” and 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 





129 


koplakias are, in our opinion, not feasible. That 
type of elevated leukoplakia which stains yellowish 
after painting with iodine is generally bound to be 


examined histologically. A possible connection 
between leukoplakia and carcinoma has _ been 
established. 


Marco Marcov, Stara-Zagora, Bulgaria: Antoine 
is correct. The management of leukoplakia depends 
upon whether or not we have signs of malignancy. 
Electro-diathermo-coagulation is the method of 
choice, but only after repeated cytological or colpo- 
scopical examinations. 

If no opportunity exists to use the above methods, 
a biopsy must be done in every case of leukoplakia. 


Hans-Klaus Zinser, Cologne, Germany: Applica- 
tion of colposcopy has taught us that leukoplakia 
occurs more often than suspected by macroscopic 
inspection alone. While in former days we believed 
that each one of these alterations had to be removed 
and histologically examined, today we know that 
underneath this alteration an epithelium is not - 
always atypical. Indication for removal of the 
leukoplakia depends, in our viewpoint, upon the 
result of the cytological smear. With positive cytol- 
ogy we perform conization. With negative cytology 
the case is put under observatipn. 


“mosaic.” It has not been our experience that 
leukoplakias frequently recur after electrocoagula- 
tion. In some patients, however, there may be a 
tendency of the epithelium towards hyperkeratosis 
so that new leukoplakias evolve beside the old ones. 





Interrelationship: Leukoplakia and Cervical Carcinoma 


FRIEDRICH BAJARDI 


Graz, Austria 


Tasie | shows the results achieved by 
histological examinations of 100 cases of 
leukoplakia. 

The first guided punch biopsy yielded in 
two cases, early invasive carcinoma and in 
three cases, carcinoma in situ. In addition 
to these five “preclinical carcinomas” 
(Navratil), we could trace five cases of 


“atypical epithelium,” which, however, is 
rather closely connected with carcinoma in 
situ. In nine cases we found “unquiet” 


epithelium and in the remaining 81 cases 
“abnormal epithelium.” (The morphology 
and the prognoses of these changes are dis- 
cussed later in this issue.) 

The results of the further “prethera- 





130 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


Acta Cytol, 
Mar.-Apr. 1961 


TABLE 1. Histological Findings in 100 “Pure” Leukoplakias 





Primary histo- 
logical diagnosis 


Final histo- 
logical diagnosis 





Early invasive carcinoma 
Carcinoma in situ 
Atypical epithelium 
“Unquiet” epithelium 


Abnormal epithelium 


{ 5Y, 





peutical histological examination” (Nav- 
ratil) are based on step serial sections’ of 
conizations, which were regularly _ per- 
formed after a primary diagnosis of a car- 
cinoma in situ or an atypical epithelium, 
but also in some cases of “unquiet” epi- 
thelium. In two cases the diagnosis of 
“atypical epithelium” was extended to that 
of “carcinoma in situ.” In a_ primarily 
diagnosed carcinoma in situ, as well as in 
one case of atypical epithelium, the evalu- 
ation of the step serial sections of the cone 
finally resulted in an early invasive car- 
cinoma. Thus, among 100 cases of leuko- 
plakia eight preclinical carcinomas could 
be found. 

One hundred additional cases are given 
in detail in Table 2. 

By means of colposcopy we could trace 
delicate structures within the sharp-edged, 


white areas of the cervix, either as red 
spots or reticularly ramified lines. These 
changes, called base of leukoplakia or 
mosaic structures, seldom appeared singly 
but more frequently in combination. In a 
considerable number of the cases we also 
leuko- 
plakias, that is, white spots deprived of any 
pattern, according to the changes of the 
first group. 


found a combination with “pure” 


Usually also a more extensive area of 
the ectocervix was affected by this simul- 
taneous existence of different patterns. In 
opposition to the first group we have there- 
fore to suppose a more progressed stage 
of change, which, however, can only be 
traced and delimited 
colposcopy. 


with accuracy by 
Accordingly, also the malignancy index 


of these cases is a higher one. Thus four 


PABLE 2. Histological Findings in 100 Cases of Predominantly Combined 
Colposcopic Findings (Leukoplakia, Base, Mosaic Structure) 





Primary histological 


Final histological 





diagnosis diagnosis 
Gross invasive carcinoma 1 5 
Early invasive carcinoma 3 9% 7 20% 
Carcinoma in situ 5 8 
Atypical epithelium 4 6 
“Unquiet” epithelium 8 5 
Abnormal epithelium 66 66 
Undifferentiated regenerating 3 3 


epithelium 





~_— 





~ 





_ 





Volume 
Number 
invas! 
vance 
carcil 
biops 
with 
“unq 
abno 
cases 
resul 
ating 
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nosis 
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Cytol, 
. 1961 


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Volume 5 
Number 2 
invasive carcinomas (including one ad- 
vanced invasive case) as well as five surface 
carcinomas could be traced by the first 
biopsy. Furthermore we found 14 cases 
with atypical epithelium, eight cases with 
“unquiet” epithelium and 66 cases with 
abnormal squamous epithelium. In three 
cases the histological examination finally 
resulted in an undifferentiated regener- 
ating epithelium. 

Here, too, the primary histological diag- 
nosis had to be enlarged in a few cases. 
Thus in one case of primarily-stated, early 
invasion, an already advanced stage of in- 
vasion was found in the specimen obtained 
by operation. In the pre-therapeutic pro- 
cedure we could trace, by conizations with 
step serial sections, invasive tumors in three 
further cases. In two of them the primary 


histological diagnosis was “carcinoma in 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 13] 


situ” and in one case “atypical epithelium.” 
Furthermore, one carcinoma in situ and 
four cases with atypical epithelium pro- 
gressed to early invasive carcinomas, four 
cases with atypical epithelium and two 
cases with “unquiet” epithelium progressed 
to surface carcinomas, while one case with 
“unquiet” epithelium finally had to be 
classified as atypical epithelium. 

Compared with the primary malignancy 
index of 9 per cent, we, therefore, are con- 
fronted in this group of examinations with 
a final malignancy index of 20 per cent. 


Bibliography 


1. Navratil, E.: In Biologie und Pathologie des 
Weibes, IV Seitz-Amreich, Berlin, Urban & 
Schwarzenberg, 1955. 

2. Navratil, E.: La prophylaxie en gynecologie et 
obstetrique, tome I. Geneve, 1954, Confer- 
ences et rapports du Congres international 
de gynecologie et d’obstetrique. 

. 





Discussion 

Jule Kovacic and Marija Stucin, Ljubljana, Yugo- 
slavia: We have found leukoplakia to be present 
in 609 of 9,978 patients examined colposcopically. 
In this number we included only cases with the 
colposcopical diagnosis of either “simple leuko- 
plakia” or “ground leukoplakia.” Cases of “mo- 
saic,” the third variation of these changes, were 
counted only if they appeared in combination with 
either simple or ground leukoplakia. A histological 
examination was performed in 445 cases. Only 
those cases with marked leukoplakias especially 
those prominent with respect to the surrounding 
mucosa were selected for biopsy. In cases of non- 
suspicious leukoplakia, biopsy was omitted, for, in 
such conditions the probability of the existence of a 
carcinoma is negligible, according to our experience. 


The histological findings of the 445 cases chosen 
for biopsy from the 609 colposcopically detected 
leukoplakias, compared with the results arrived at 
by colposcopy are given in Table 1. 

The malignancy index of the above colposcopical 
leukoplakias, computed only for preclinical car- 
cinomas, amounts to 11.9 per cent. 

In addition, to the above results we have 435 
histological examinations of hyperkeratosis, kera- 
tosis and parakeratosis. Among these cases, 22 car- 
cinomas in situ and nine early invasive carcinomas 
were found. This total of 31 out of 435 cases, gives 
a malignancy index of 7.1 per cent. 

As leukoplakia shows a comparatively high pro- 
portion of preclinical carcinomas, we consider that 
it is a valuable and important indicator in the fol- 
lowing of preclinical carcinoma. 


‘TABLE | 





Colposcopical Findings 





Leukoplakia with 





Simple leukoplakia additional changes Total 
Number of cases 71 538 609 
Number biopsied 56 389 445 
Benign alterations 49 328 - $77 
Atypical epithelium 0 15 15 
Carcinoma in situ 7 1 35 \ 42 iT 

12.5 11.8% i 11.9% 

Early invasive carcinoma 0 f 11 f 11 











132 


Hans Iselin Wyss and Jacques Jenny, Zurich, 
Switzerland: At our hospital we have compiled all 
cases that during the last two years have received 
a scraping according to the Schiller technic. The 
following colposcopic pictures are considered an 
indication for a scraping: (1) Tumor; (2) Unusual 
transformation zone; (3) Matrix areas (leukoplakia, 
base, mosaic); (4) Uncharacteristic, sharply defined 
iodine-negative areas, including the sharply defined 
transformation zone; (5) Ulcerations and granula- 
tions; (6) True erosion, and (7) Bleeding ectopy 
and transformation zone. 

These findings are listed according to their index 
of malignancy, i.e... number one is the most sus- 
picious and number seven the least suspicious. 

In 1955 and 1956 in 3,243 patients a Schiller’s 
scraping was done for one of the above listed indi- 
cations. Among these 3,243 patients, 1,404 (43.3 
per cent) displayed a matrix area, frequently in 
connection with other findings. In the course of 
further work-up these 1,404 cases revealed the 
following histological findings: 





No. of 


Histological Findings patients Percentage 





Normal squamous epithelium 
and normal cylindrical 
epithelium 8 0.46 


Inflammatory squamous 
epithelium and inflammatory 


cylindrical epithelium 2 2 
Abnormal cervical epithelium 1,310 93.2 
“Unquiet” cervical epithelium at 626 
Non-invasive atypical cervical 

epithelium (carcinoma in 49 3.5 +} 6.0%, 

situ) 

Invasive carcinoma 7* 05 





* Among these is one sarcoma. 


Our figures are considerably under those given by 
Bajardi for the pathological alterations of the 
matrix areas. Although we have combined leuko- 
plakia, mosaic and base, we find only 3.5 per cent 
surface carcinomas and 0.5 per cent invasive car- 
cinomas, as compared to 8 per cent carcinomas in 
situ and 12 per cent invasive carcinomas in Bajardi’s 
material. The difference may possibly be that in 
our statistics unselected material has been evaluated. 

In our discussion in another topic of this sym- 
posium, “Colposcopy of Carcinoma in Situ,” we have 
listed the colposcopic findings in carcinoma in situ. 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART III 


Acta Cytol 
Mar.-Apr. 196] 7 


The compiling of the main findings was done 
according to the most striking visual impression, 
In another paper we have plotted the most malig. 
nant finding as the main finding, not considering ' 
its extent. From this point of view the following 
results emerged: 








' 

Matrix areas 56.9% | 
Atypical transformation zones 20.39, 
Uncharacteristic, sharply-defined iodine- | 

negative areas 15.2% 
Bleeding ectopy, bleeding transformation 

zone - 

ew a0 
Remaining groups 1-3% 

From our investigations it may be concluded that 
the carcinoma in situ frequently appears as a matrix | 


area. When we furthermore consider that 6 pei 
cent of all leukoplakias are found with a severe 
pathological alteration 


(invasive carcinoma, car- 











cinoma in situ, “unquiet” epithelium) then the ’ 
conception seems justified: that every matrix area 
has to be clarified histologically. 

Below is an excerpt from the Table given in our 
discussion of “Colposcopy of Carcinoma in Situ” ' 
in this Symposium. 

. : — 
Fotal Col poscopic 
colposcopic main 
findings finding 
Matrix areas 12 30 
Atypical transformation zone 39 25 
Uncharacteristic, sharply 

defined, iodine-negative 

area, including sharply 

defined transformation 5 

zone 64 27 
Bleeding ectopy, bleeding 

transformation zone 18 10 
oe ' 
Tumor 1 l 
Ulcerations and granulations 3 l 
True erosions 6 8 

> 
Polyps 2 
Unsuspicious atrophic 

cervix I I 
Unsuspicious ectopy and j 

transformation zone 2 2 





Closing Remarks 


Friedrich Bajardi: To Wyss and Jenny: Our own 
statistical data are also based upon unselected ma- 


terial. The over-all 200 cases have been counted 
merely according to their chronological sequence. | 
Are there perhaps regional differences as to the 
incidence among the population? 





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IV. Reserve Cell Hyperplasia, Basal Cell Hyperplasia and Dysplasia 


Histomorphology of Reserve Cell Hyperplasia, 


Basal Cell Hyperplasia and Dysplasia 


FRIEDRICH BAJARDI 


Graz, Austria 


IN OUR study group, we mean by the term 
“dysplasia” a faulty tissue differentiation 
in respect to a given site. As a result of such 
a misdifferentiation in the special case of 
the epithelium of the cervix uteri, all the 
variations which do not correspond to a 
normal pattern of the cervical epithelium 
have to be listed. In addition, the ectopy 
of the ectocervix and the normal squamous 
epithelium, if occurring in the endocervix, 
has to be included. In accordance with the 
topic, the following discussion of the histo- 
morphology shall be limited to those forms 
of the pathological squamous epithelium 
which have significance as premalignant 
modifications. These are disregarding the 
carcinoma in situ, the ““unquiet epithelium” 
and the “atypical epithelium” (according to 
the nomenclature of Glatthaar and Muel- 
ler). In these formations we deal with 
faultily differentiated epithelium, the en- 
tire thickness of the epithelium being homo- 
geneously altered, without abrupt change of 
differentiation within it. 

Opposed to these types of formations are 
those pictures in which, in a very marked 
line parallel to the surface, two morpho- 
logically different types of epithelium touch 
each other. The superficial pre-existent 


layer may be composed of cylindrical epi- 


533 


thelium or squamous epithelium. The cells 
close to the base display a more or less pro- 
nounced regeneration (hyperplasia) and 
are mainly undifferentiated or show a low 
degree of differentiation. We designate 
them as subcylindrical or reserve cells (re- 
serve cell hyperplasia) if they are existent 
underneath a layer of pre-existent cylin- 
drical cells. If they grow under pre-existent 
squamous epithelium we call them basal 
cells (basal cell hyperplasia). 

Principally we are confronted with the 
very same process in reserve cell hyper- 
plasia and basal cell hyperplasia as well, 
i.e., a sudden process of epithelial regener- 
ation without subsequent differentiation of 
the newly formed cells. Thus, in this stage, 
basal cell hyperplasia and reserve cell hy- 
perplasia as well, may very well be included 
in the designation “undifferentiated regen- 
erative epithelium” as proposed by Glatt- 
haar. In which direction and in what way 
regenerating epithelium will later on dif- 
ferentiate, cannot be predicted in the indi- 
vidual case. ‘The result seems always to be 
an epithelium that discloses‘a lower degree 
of differentiation than the pre-existent tis- 
sue, that is, it will be pathological for a 


given site or “dysplastic.” In basal cell 





134 


Fic. 1 (Top). 


Reserve cell hyperplasia in the 
form of one to two rows of subcylindrical cells and 
a solid plug of cells in the connective tissue. Fic. 2. 
Reserve cell hyperplasia in the form of three to 


five layers of subcylindrical 


cells with tendency 
towards differentiation. 


hyperplasia and reserve cell hyperplasia we 
see, therefore, the precursors of dysplasia. 

The histomorphology of the types of 
dysplasias in question here, namely the 
“unquiet epithelium” and the “atypical 
epithelium,” will be dealt with in a future 
issue. The figures shown there represent 
typical patterns, variations of which, of 
course, are possible. 

Characteristic for both of these altera- 
tions is the increase in the number of cells. 
The “unquiet epithelium” is characterized 
by a moderate polymorphia and _ polychro- 
masia in the nuclei. Mitoses are increased 
and can be seen up to the middle third of 
the epithelium. Stratum basale, stratum 
spinosum and stratum superficiale can be 
differentiated from each other. In contrast, 
the nuclear and cellular polymorphism is 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 





Acta Cytol 
Mar.-Apr. 196] 


? 
much more pronounced in the atypical epi- | 


thelium. Often mitoses may be found up | 
to the top layer of the epithelium. Cellular | 
borders are frequently blurred. A slight 
tendency towards the maturation of the 
epithelium can always be demonstrated; 4 
however, it is usually not as pronounced as 
in the microphotograph shown. The sub- 
ject of carcinoma in situ, which cannot } 
completely be separated from the subject 
“dysplasia,” will be discussed and its mor- 
phological aspects described in a future 
issue under the topic entitled: Histomor- 
phology of Carcinoma in Situ. 


Examples of reserve cell hyperplasia are } 


demonstrated in Figures 1 to 3. In Figure | | 
the pre-existent cells are elevated from their | 
base by one to two rows of subcylindrical 

cells. Within the connective tissue we find 
a plug of the same undifferentiated reserve 


Fic. 3. 
cells underneath degenerated cervical cells. Fic. 4. 
Small cell carcinoma in situ. Similar cell type as 
in the reserve cell hyperplasia of Fig. 3. 


(Top) Very active proliferation of reserve 


Volume 
Number 
cells, 
cery if 
2 are 
of e 
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lium 
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cells 
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pr. 196] 
il epi- 
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Volume 5 
Number 2 
cells, apparently lying in the lumen of a 
cervical gland. ‘The reserve cells in Figure 
2 are situated in three to five layers on top 
of each other. The prevailing impression 
is of a beginning maturation of the epithe- 
lium. In Figure 3 one finally recognizes, 
under the faint, degenerated cylindrical 
cells, extremely actively proliferated, small 
undifferentiated cells with hyperchromatic 
nuclei. The cytomorphological similarity 
with the small cellular carcinoma in situ 


All 


changes shown in Figures | through 4 are 


shown in Figure 4 is remarkable. 
from the endocervix. 

Figures 5 through 7 are examples of basal 
cell hyperplasia. Always the superficial 
third of the epithelium is more highly dif- 
ferentiated than the deeper epithelial parts. 
Many are The 
superficial part of the epithelium may cor- 


combinations possible. 


lic. 5 (Top). Basal cell hyperplasia: Marked nu- 
clear “restlessness” in the hyperplastic part of the 


epithelium. Fic. 6. Basal cell hyperplasia: pro- 
nounced nuclear atypias of the hyperplastic part 
of the epithelium. 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 








zy, 


Basal cell hyperplasia: the two lower 
the 


Fic. 7. 
thirds of the epithelium look malignant. At 
left, normal epithelium. 


respond to a normal or to an “abnormal” 
epithelium (Fig. 5); however, it may even. 
contain marked nuclear atypias (Fig. 6, 7). 
The cells from the deeper layers in Figure 
5 display an at least somewhat disturbed 
picture, whereas in Figures 6 and 7 they 
already appear malignant. 

The transitions from the hyperplasia to 
dysplasia and also to carcinoma in situ are 
vague and sometimes it is hard to decide 
whether one still deals with a hyperplasia, 
an atypical epithelium, or with a carcinoma 
in situ. Frequently all these aberrations 
may be found side by side in the same case. 
Thus, the importance of hyperplasia and 
carcinogenesis is beyond 


dysplasia for 


doubt. For practical diagnostic purposes 
it is necessary to rule out a co-existing car- 
cinoma when histologically one of those 
premalignant pictures has been demon- 
strated. Subsequently the case has to be 
checked at regular intervals in order to 
catch, as early as possible, a carcinoma 
which may develop from a hyperplasia or 


a dysplasia. 


Bibliography 
1. Glatthaar, E.: In Seitz-Amreich, Biologie und 
Pathologie des Weibes. Berlin, Urban & 
Schwarzenberg, 1955. 
2. Younge, P. A., A. T. Hertig and D. Armstrong: 
Am. J. Obst. Gyn. 58: 867, 1949. 








SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 


Acta Cytol. 
Mar.-Apr. 1961 


JEAN A. DE Brux, J. Durré-FROMENT 


Paris, France 


THE HYPERPLASIA of the reserve cells and 
that of the basal layers are closely related; 
they appear as two successive phenomena 
whose starting point is a process of meta- 
plasia with excessive proliferation of the 
replacement cells. Secondarily, if there are 
anomalies of stratification or maturation, 
modifications of dysplastic nature may ap- 
pear, complicating the original aspect. 

For an adequate study of these problems, 
we must first examine the normal mecha- 
nism of metaplasia: 

The term “metaplasia,” which originated 
with Virchow, was formerly defined by 
Lubarsch and Schridde as a process of re- 
generation arising from the proliferation 
of the germinal cells, but which, owing to 
their plasticity, ends in a differentiation 
which is morphologically and functionally 
altogether different from that of the pre- 
existing tissue. 

In the genital tract, these phenomena 
take the form of a substitution of the col- 
umnar epithelium of the endocervical canal 
by a squamous cell epithelium—a_ process 
of reaction or cicatrization following irri- 
tation or inflammation of the mucosa—and 
they occur with extreme frequency on the 
borders of ectropions and _ exteriorized 
polyps, by reason of their abnormal situa- 
tion at the external orifice of the cervix, 
whose biology is widely different from that 
of the vagina. 

The reserve cells are very small, flat, and 
situated at the foot of the cylindrical cells. 
Their multiplication first transforms their 
primitive interrupted layer into a continu- 
ous row; the proliferation continuing, sev- 
eral superimposed layers then form, covered 
over at first by the pre-existing columnar 
elements. Upon the exfoliation of the lat- 
ter, there remains a “metaplastic” epithe- 
lium composed of four or five layers of 
cells called ‘“‘parabasal” cells because of 


their resemblance to the deep-lying cells 
of a normal epithelium; they are round or 
oval, with large, round centrally placed 
and hyperplastic nuclei; the cells appear 
contiguous, distinctly outlined, and there 
are no intercellular bridges, the stratifica- 
tion being still imperfect. 

Later, the epithelium becomes organized 
into architecturally regular strata, with de- 
velopment of cellular layers of an inter- 
mediate and superficial type, as in any 
squamous cell 
newly-formed 


epithelium; this 


squamous 


finally, 
cell epithelium 
becomes functional, and the presence of 
glycogen may then be noted. 

Hyperplasia of the reserve cells is a meta- 
plasia, but one whose hyperactivity leads 
to an excessive multiplication ef the nuclei, 
which pile up in poorly-stratified superim- 
posed layers; as a result of the crowding of 
the cells, the nuclei become elongated and 
placed perpendicularly to the surface. The 
cytoplasmic limits, however, are still visible, 
with sometimes even a sketching-in of inter- 
cellular bridges. The nuclei have excep- 
tionally active chromatin, whose seedy but 
regular aspect differs from the finely speck- 
led appearance of the normal metaplastic 
cells. The cellular membrane the 
nucleolus are sharply defined. There is 
noted a slight polymorphism, some of the 
nuclei still being round, others more elon- 
gated; there is also a slight anisonucleosis: 
certain of the nuclei are clear, punctuated 
by minute vacuoles regularly distributed 
among the grains of chromatin (Fig. 1). 

This incomplete, immature and relatively 
monomorphous epithelium conserves _ its 
original undifferentiated aspect throughout 
its evolution; neither differentiation nor 
maturation occus subsequently. And it is 
perhaps the intense activity and the imma- 
ture character of the cells that determine 
this absence of “aging” of the epithelium. 


and 


| 


me 


~~ 


Volume - 
Number 


FIG. 
perpla 
chyma 


We 
plas: 
met: 


the 
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in § 
the 


Nuc 
m 


Cyt 
Mo 
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Cytol, 
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cells 
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any 

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— 


— 





Volume 5 
Number 2 

Fic. 1. Reserve cell hy- 
perplasia. Active mesen- 


chymatous metaplasia. 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 








We have chosen to call this type of meta- 
plasia: “active undifferentiated, immature, 
metaplasia” (A.U.I.M.). 

In any case, the real problem created by 
the hyperplasia of the reserve cells is pre- 
cisely that of its distinction from carcinoma 
in situ. The following Table summarizes 
the principal criteria of differentiation: 


Hyperplasia of 
Reserve Cells 
numerous, with 
packing. 


Nuclei 
moderate 


Cytoplasmic borders vis- 
ible. 

Moderate spread of the 
cytoplasm. 

Absence of intercellular 
bridges. 

Absence of — stratifica- 
tion. 

Slight nuclear polymor- 
phism (some elon- 
gated, most rounded). 


Slight anisonucleosis. 


Chromatin seedy, but 
nucleus relatively pale 
or only slightly dark. 

Nuclear membrane and 
nucleolus distinct. 

Mitoses relatively 
and normal. 


rare 


Carcinoma 

in Situ 
Nuclei 
with 
ing. 


very numerous, 
excessive pack- 


Cytosplasmic borders in- 
visible. 


Cytoplasm narrow, tight. 


Absence of intercellular 
bridges. 


Absence of stratification. 


Nuclear monomorphism 
(nearly all elongated). 


Nuclei practically equal 
in size. 

Chromatin very grainy 
and dense, nucleus 
very dark. 

Nuclear membrane and 
nucleolus indistinct. 


Mitoses numerous, often 
abnormal amitoses, oc- 
curring high in the 
epithelium. 


Whereas the hyperplasia of the reserve 
cells corresponds to an active metaplasia 
remaining undifferentiated and immature, 
the hyperplasia of the basal dayers originates 
from the same phenomenon, but with a 
different character: for here the epithelium 
tends toward its differentiation and matura- 
tion into “adult” squamous cell epithelium. 
The deeper layers are covered by cellular 
strata more numerous than normal. How- 
ever, modifications may intervene to 
change, more or less completely, the archi- 
tecture and cellular morphology, bringing 
about lesional aspects of dysplastic nature. 

The different modalities will depend on 
the differentiation of the cellular strata, 
and especially on the character of their 
maturation. One of two contingencies will 
occur: 


1. the differentiation is normal, and the 
architectural stratification is retarded; or 

2. the differentiation is uncertain and 
the stratification is very retarded or absent. 
The cellular layers, sometimes very active, 
remain without tendency towards matura- 
tion, for two-thirds or even three-fourths of 
the epithelium. 

But there will follow a remodeling of 
this hyperplasia of the basal cells by the 
maturation of the elements, or, more pre- 





cisely, by disturbances of their maturation, 
that will give to the new epithelium a new 
and special character, transforming it into 
a dysplasia. The maturation will be one of 
the following: incomplete, precocious, ex- 
cessive, erratic or disharmonious. 


2 


are 


Differentiation normal, stratification 


more or less retarded: 


a. The basal cells present a picture of 
very great activity and a hyperplasia 
of the nuclei, whose chromatin specks 

accentuated, 


and in which mitoses 


are more numerous than normal. There 







SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 





Acta Cytol 
Mar.-Apr. 196) | 


| 

Fic. 2. Histological sec- 
tion of a “regular dys- 
plasia” (dyskaryosis). The 
differentiation is normal 
the stratification variable 


and the maturation is in- 
complete. 


————— 


is little or no glycogen in the upper 
layers. 


b. The basal cells form layers more nu- | 
merous than normal, rising in the epi- 
thelium at the expense of the mone | 
layers, unless the epithelium is markedly } 
thickened. Usually, moreover, the as-! 
pect is normal, except that glycogen, 
evidence of regular functional activity, 
is absent. 


c. Disturbances of the maturation: 


(1) On certain epithelia the matura- 
; 


Fic. 3. Detail from the 
previous picture: Fast 
growth and_ incomplete 
maturation 


(dyskaryosis). | 





Volun 
Numb 


Fi 
tion 
the 
hype 


ti 
p' 


Acta Cytol, 


-Apr. 196} 
) 





gical sec. 
ar dys. 
sis). The 
normal, 
variable 
on is in- 


| 


; 
upper 


ore nu: 
he wel 
upper 
arkedly } 
the as: | 
ycogen, 
ctivity, 


on: 


latura- 
? 


‘om the | 
Fast 
omplete 
aryosis). 


Volume 5 
Number 2 


Fic. 4. 


tion of 


the basal layer, basal cell 
hyperplasia. 


Fic. 5. Histological sec- 


tion of 
plasia. 





SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 139 


Histological sec- 
a hyperplasia of 


tion is excessive; there is a rapid 
cornification of the intermediate 
cells, as well as the formation of a 
leukoplastic layer of keratin display- 
ing eleidin or of parakeratosis with 
persistence of pyknotic nuclei. 

(2) Maturation begins, but remains 
incomplete; the voluminous “obese” 
nuclei shrink but do not become 
very opaque. As a result, in the 
middle and superficial layers there 
persist large nuclei of polymorphic 
aspect, from the blown-up, rounded 





an irregular dys- 





nuclei, to those with notches and 
even festoons. Such an ensemble 
constitutes a dyskaryosis. ‘The corni- 
fied cytoplasm often, if not always, 
shows a perinuclear halo due to the 
shrinkage (Figs. 2 and 3). 

(3) Maturation is sometimes irregu- 
lar, with pyknotic cells having corni- 
fied cytoplasm throughout the lower 
half of the epithelium. 


These aspects constitute the majority of 
the simple epithelial atypias correspond- 
ing to Groups I and II, a, b and c of Hinsel- 






140 SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV, Acta Crt | Numb 
Mar.-Apr. 196] . 
> 


Fic. 6. Detail from the 

previous picture. Note 
the clear distinction of 
two definite layers: im- Fi 
mature and _— superficial tion 
nuclear layer and mature plasi 
irregular nuclear — layer dlysk 
with stratification — line 
and easily visible  inter- 
cellular bridges. 

f 

: 





























mann, or “regular dysplasias” (de Brux- come irregularly and sometimes exces- 
Palmer). sively cornified. ‘The cells assume the 

, — ‘ sna aspect of parabasal, fibroid, or, some- 
2. Differentiation uncertain, stratification — of pat abasal, fibroid i nia 
seein’ on siucat: times, of intermediate ceHs. ‘This is the 
= ; . . aspect of the very irregular dysplasia, 
a. The cells, packed in the epithelium, | ; 7 "I 
are hyperplastic; they are turned per- 
pendicularly to the surface, and there 
are numerous anomalies. In the lower 


with disturbed architecture and cellular 
atypias sufficiently marked to raise the 
question of their evolutive potential 


part, the shrinkage takes place rapidly (Fig. 4). 

but poorly: the nuclei are irregular, b. But besides this form, other aspects 
angular, chromatic, and become densely of irregular dysplasia arise from dis- i 
opaque. Their cytoplasm tends to be- turbances of maturation of the cells: 


Fic. 7. Histological sec- 
tion of an irregular dys- 
plasia. 








cta Cytol, 
Apr. 196] 


‘om the 
Note 
tion of 
rs: im- 
perficial 
mature 
layer 
n line 
inter- 


eXces- 
ie the 
some- 
is the 
dlasia, 
lular 
e the 
ential 


spects 
1 dis- 


Is: 


al sec- 
r dys- 








— 





Volume 5 


} Number 2 


Fic. 8. Histological sec- 
tion of a basal cell hyper- 
plasia with abnormal and 
dyskaryotic maturation, 


(1) Maturation is precocious and be- 
gins abnormally low in the epithe- 
lium, starting from the intermediate 
layers. ‘The cytoplasms, at first poly- 
chromatophilic, further up become 
decidedly eosinophilic, whereas the 
voluminous nuclei appear pre-pyk- 
notic or even pyknotic (Figs. 5, 6). 
(2) Maturation is excessive, occur- 
ring at a normal level, but “over- 
shooting the mark,” and ends in the 
production of parakeratosis or of 
keratin, as in the regular dysplasias 
(Fig. 7). 

(3) Maturation is erratic, beginning 
in the deep-lying layers, in which 
the cells are irregularly affected. 
Here and there appears a basal cell 
with eosinophilic cytoplasm and with 
the nucleus chromatic, pre-pyknotic 
still 
shrunk, such cells retaining their 
character without developing to the 
intermediate cell stage, throughout 
their rise in the epithelium. 


or sometimes incompletely 


(4) There is a disharmony in the 
This 
is manifested by the presence, in all 
the levels of the epithelium, of cells 


nucleo-plasmatic maturation. 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 


141] 





with eosinophilic cytoplasm and still 


immature nuclei, or of cells with 
cyanophilic cytoplasm and pyknotic 
or pre-pyknotic nuclei. 

‘These two later anomalies (3 and 4) are 
often intermingled and are sometimes so 
accentuated that they may give a certain 
appearance of anarchy in the disposition of 
the cells of the epithelium (Fig. 5). These 
aggravated lesions, which in essence con- 
stitute the transition between the regular 
simple dysplasias and the irregular dyspla- 
sias, may be termed regular dysplasias (be- 
cause the architecture is conserved) with 
irregular nuclei (Fig. 4, 5). 


Summary and Conclusion 

The metaplastic process is the very base 
of the epidermoid epithelial atypias en- 
countered the The “primum 
movens” of these anomalies of the epidermi- 
zation is still unknown, but its histogenesis 
is beginning to come to light. It may be 
schematically represented as follows: 


on cervix. 


The reserve cells destined to form the ger- 
minal cells, instead of assuming the basal 
character, remain undifferentiated and im- 
mature as far as the upper part of the epi- 
thelium. Thus the difficulty arises encoun- 
tered in differentiating the hyperplasia of 


142 


the reserve ceil from the carcinoma, which 
differs from the former only by a few 
nuances of nuclear detail. 

The hyperplasia of the basal cells differs 
at the outset from the hyperplasia of the 
reserve cells, for there is already a differen- 
tiation. Here the nuclear and cytoplasmic 
morphology of the internal basal cell is 
already recognizable. But the features that 
will determine the lesional aspects are: (a) 
the piling up of the basal layer and the 
height at which the cellular differentiation 
will take place; and (b) the disturbances in 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 


Acta Cytol. 
Mar.-Apr. 196] 


, er) 
the maturation of the cells of this epithe- 


lium. 
There will thus be found different as- 


pects, arising from the pullulation of the | 


undifferentiated reserve cells; of which: (a) 
some resemble normal epithelium. by reason 
of the normal or paranormal differentia- 
tion and maturation; and (b) others, on 
the contrary, because of the absence of, or 
disturbances in, the differentiation and 
maturation, resemble a carcinoma. These 
lesions, however, do not have a truly malig- 
nant character. 





Discussion 


F. A. Langley, Manchester, England, U.K.: ‘These 
two papers are very interesting and valuable. Never- 
theless, one is left wondering whether the distinc- 
tions made by de Brux are not too fine to be of 
general use, the interpretation of the changes in 
any given case being very subjective. Nevertheless, 
I think that the sorts of distinctions he makes are 


ones we should all try to make hoping that, in due 
course, a simpler and more objective classification 
of this type of abnormal epithelium will emerge. 


Rudolf Ulm, Vienna, Austria: I agree entirely 
with the very precise descriptions given by the main 
authors regarding the histomorphological patterns 
of the epithelial changes in question. There re- 
mains nothing to add to the descriptions given. 





Exfoliative Cytology of Reserve Cell Hyperplasia, 
Basal Cell Hyperplasia and Dysplasia 


JEAN DE Brux, J. Dupré-FROMENT 


Paris, France 


THE CYTOLOGY of these different lesions 
is more subtle and less sharply defined than 
their histological aspects. 

In the differential diagnosis between 
hyperplasia of the reserve cells and car- 
cinoma in situ, their cytology is better 
adapted to bring into relief the differential 
characters of nuclear density and volume 
of the chromatin grains. However, as this 
method gives no indication as to architec- 
tural anomalies, it does not furnish the 
means of distinguishing so many varieties 
of lesions or of analyzing each lesion as 
thoroughly as does the biopsy, which con- 


tains both the architectural and the cyto- 
logical characters. 

Furthermore, the cytologist should never 
lose sight of what cytology represents in 
relation to histology: for the smear, unless 
it has been strictly limited to a single ab- 
normal zone, histologically indicated in ad- 
vance with great precision, is in most cases 
the expression of an ensemble of lesions 
sometimes very diverse, some being. still 
benign, others perhaps already malignant. 
There is too often a tendency to consider 
all the cellular elements of a smear as repre- 
senting a single variety of lesion, like that 





Volume 5 
Number 2 


—— 


Cells fre 
carcino! 
in situ 


Invasiv 
immati 
epithel 
oma ce 


Trans 
forme 
endoc 
ical ce 


Meta 
plast 
cells 


Imi 
anc 
fere 
me 
cel 

(re 
cel 
pl: 





ta Cytol, 
pr. 196} 


pithe. 


nt as- 
f the 
1: (a) 
eason 
entia- 
S, on 
of, or 
and 
“hese 
lalig- 


1 due 
ation 
lerpe, 
tirely 
main 
terns 
e re- 


'to- 


ver 
in 
SS 
ib- 
id- 
eS 
ns 














Volume § SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 143 
TABLE | 
Staining Cytological Nuclear- 
Form Size reaction grouping cytoplasmic Nucleus Chromatin 
of pattern ratio 
cytoplasm 
Cellsfrom Round,of Equal to Cyano- Isolated Inverted Round, Coarsely granu- 
carcinoma __ basal cell an inner philic cells with centrally lated chromatin, 
in situ type basal cell clear located, the nuclear mem- 
cellular usually brane is more or 
borders cyanophilic less embedded in 
nuclei all the nuclear sub- 
of same stance, marked 
size thickening of the 
nuclear mem- 
brane 
Invasive Round, of | Equal to Cyano- Isolated Inverted Round, Coarsely granu- 
immature __ basal cell inner and __ philic cells with centrally lated, unevenly 
epitheli- type outer basal clear cellu- located, distributed chro- 
oma cells cells lar borders regular or matin, transpar- 
or clumps irregularly ent scattered 
of “junc- outlined, vacuolized; mul- 
tion cells” very cyano- tiple nuclear 
philic,in- fragments or 
tensely opaque chro- 
staining or matin without 
transpar- —_, Structure 
ent, aniso- 
nucleosis 
Trans- Cylindrical Larger Cyano- Tissue Normal Round, Finely granu- 
formed with one thana philic with fragments, centrally lated, fine 
endocerv- end cylindrical tendency cell groups, located, nuclear mem- 
ical cells rounded cell towards clear cyto- purplish, brane, slightly 
polichro- plasmic the nuclei marked; nucleolus 
masia border are of even 
size 
Meta- Oval Equal to Cyano- Cells Normal Roundor Accentuated 
plastic shaped or larger philic, crowded in oval, nuclear 
cells cells with than an most often, clusters centrally membrane, 
stretched outer basal however, with over- located, nucleolus 
cytoplasm cell clear poli- lapping of purplish, 
or round chromasia _ the cells, all nuclei 
cells of cellular of same size 
outer basal borders 
cell type clearer or 
or cells of cells 
navicular arranged in 
type like bands like 
junction “junction 
cells cells” (often 
vacuolized 
cytoplasm) 
Immature Ovalcells Equal to Cyano- Clusters Normalor Roundor Coarsely granu- 
and undif- with or larger philic or strips slightly oval, lated, marked 
ferentiated stretch than an of junction inverted centrally nuclear mem- 
metaplastic cytoplasm outer cells located, brane, prominent 
cells of outer basal cell regular nucleol or scant 
(reserve or inner cyano- vacuolized chro- 
cell hyper- basal type philic or matin with few 
plasia) transpar- evenly distributed 
ent, aniso- granules 
nucleosis 











144 


Acta Cytol | 


Mar.-Apr. 196] 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 


Volume 5 
Number 2 





FIG. | 

plastic 
Fic. 1. Clump of hyper- | pare v 
plastic basal cells. cinoma 

empty 

of the biopsy, which is strictly localized in cells, isolated or in patches. In their forn, isola 
scope. The cytologist must therefore be they resemble large external basal cells. pate 
able to interpret the polymorphism of a = Their cytoplasm is rounded or somewhat | @PP' 
smear by taking the census of the different elongated, cyanophilic, and finely reticu- plas 
types of cells and of chromatin. Examples lated. The nucleus of each ‘cell is central o' 
of this complexity are furnished by a study — and more voluminous than in the normal ages 
of the hyperplasias of the reserve cells and _ nuclear-cytoplasmic ratio. The chromatin fort 
those of the basal layers. is rich, forming a thick but very regularly int 
‘ ; distributed network, with chromatin clumps }| “ec 

A. Hyperplasia of the Reserve Cells : ao ; | ' 
“s aie al ; - of equal size. The nucleolus is moderately me 
ar pes oO 7 Ss ~harac ae S E ¢ oa 

- = type cells, Characterize this enlarged, and the nuclear membrane is at wes 
. . ° . g 
esion: no point thickened. : 
1. One type consists of the hyperplastic 2. Certain elements appear much more ele 

e . e . a ° yt 

elements having the aspect of metaplastic | modified and suspect. They may be either wn 

' 
? 

pl 

ea 

t as 

Fic. 2. Clump of hyper- ce 

plastic reserve cells. n 

a 

tl 








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pr. 196] 


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| 


SYMPOSIUM ON PREMALIGNANT 


Volume 5 
Number 2 


Fic. 3. Clump of hyper- 
plastic reserve cells. Com- 
pare with immature car- 
cinomatous cells displaying 
empty nucleus. 


isolated, grouped, or mingled in’ with 
patches of cells of the preceding type. They 
appear denser, with very cyanophilic cyto- 
plasm and a nucleus which tends markedly 
to inverse the normal nuclear-cytoplasmic 
ratio, with anisonucleosis. The chromatin 
forms grains of varying sizes, bulkier than 
in the preceding form, and the nucleolus is 


decidedly more prominent. The nuclear 
membrane is thick and shows zones of 
reinforcement. 


3. Finally, there are noted patches of 
elements whose nucleus is voluminous but 
whose chromatin is rarefied, with a few 


Fic. 4. Clump of hyper- 
plastic reserve cells. It is 
easy to recognize the two 
aspects of this type of 
cell (Fig. 2,3). See also 
next picture which shows 
a histological section of 
the lesion from which the 
above shown cells are de- 
rived. 


ae ee 


CERVICAL LESIONS—PART IV 





* 





a an 
bulky clumps; the nuclear membrane is 
very slightly marked. 

The diversity of the aspects thus encoun- 
tered is due, not to the presence of different 
elements, but to differences in the evolution 
of the reserve cells: 

a. The cell of metaplastic type 
(1) is the native element, undiffer- 
entiated and hyperplastic, still pre- 
served without appreciable modi- 
fication. 


b. The cell whose chromatin be- 
comes -dense, with thickening of 








146 





the nuclear membrane (2), may be 
considered as a benign process of 
aging, with nuclear contraction 
and densification of the chromatin. 
c. The clear, grainy aspect of 
the cell (described in type 3) is a 
sign of the degeneration of the nu- 
cleus emptied of its substance. 

These cells are therefore difficult to dis- 
tinguish from those of malignant lesions. 
Here, the cytological context is often as 
important as the cellular morphology itself. 
In fact, in the undifferentiated and imma- 





SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 


Acta Cytol. 
Mar.-Apr. 1961 


Fic. 5. Histological sec- 
tion of the lesion from 
which the clumps of hy- 
perplastic reserve cells 
shown in Fig. 4 were ex- 
foliated. 


ture hyperplasia, one never finds dysplastic 
and eosinophilic parabasal or fibroid ele- 
ments, and the cytoplasm is entirely cyano- 
philic or at least polychromatophilic. 

Hence, the problem of a differential diag- 
nosis is particularly great between this 
hyperplasia of the reserve cells and the im- 
mature squamoid carcinoma—much more 
so than with the carcinoma in situ, which 
always shows a certain degree of poly- 
morphism, with the presence of mature and 
dysplastic elements. 


Fic. 6. Clump of cells 
from a carcinoma in situ. 


é 
5 
i 
: 
j 


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| 





Volume ; 
Number 


Fic. 
from < 


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are | 
shov 
whi 
anis 
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or, 

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Th 
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‘a Cytol, 
pr. 196] 


‘al sec- 

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SYMPOSIUM 


Volume 5 
Number 2 


Fic. 7. Clump of cells 
from a carcinoma in silu. 


Certain immature carcinomas, in fact, 
are devoid of anomalies and on the smear 
show patches of a monomorphous aspect 
which, at first sight, have only a slight 
anisonucleosis and a hyperactive chromatin 
whose dots may be accentuated and dense, 
or, on the contrary, sparsely scattered. 

It is, therefore, very difficult to establish 
the line that distinguishes the benign hyper- 
plastic lesion from the malignant lesion. 
The chromatin must be examined under 
high magnification: A regularity of distri- 


Fic. 8. Transformed 
columnar cell. Nuclear 
hyperplasia with dispersed 
chromatin and prominent | 
nucleus. 


ON PREMALIGNANT CERVICAL LESIONS—PART IV 





147 


, 


bution of the chromatin grains, as well as 
of their size and form pleads in favor of 
benignity, whereas an anisomorphism of the 
chromatin clumps, anarchically distributed 
within the nucleus, indicates probable 
malignancy. 

It should be admitted, however, that in 
certain cases it is impossible to differentiate, 
the structural details on which to base a 
sound interpretation being too subtle; in 
these cases the only possible answer is “Class 
III,” with a request for further smears. 











B. Hyperplasia of the Basal Cells 
and Dysplasias 

Either: This may show no cytological 
evidence, the hyperplastic immature layers 
being surmounted by cellular layers nor- 
mally differentiated and undergoing a 
strictly normal maturation, with, at the 
most, the presence of a few cells with nuclei 
somewhat voluminous but with perfectly 
regular contours. 

Or: It is manifested by a frankly abnor- 
mal cytological picture that may be either 
dyskaryotic or dysplastic: 








SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 





a 
¢ 





Mar.-Apr 


has become opaque, 


structure. 


1. The dyskaryosis, or incom- 
plete nuclear maturation, is char- 
acterized by the presence of nuclei 
regular but “blown up,” or increas- 
ingly irregular as they shrink, with 
the membrane at first simply fes- 
tooned, then becoming lumpy 
when knots appear in the chroma- 
tin. In spite of this disquieting 
aspect, the chromatin remains 
clear, regular, sometimes slightly 
opaque, in patches forming poly- 
gons. 


Fic. 10. Reserve 


nuclear membrane. 






Acta Cytol. 


Fic. 9. Hyperplastic 
basal cell. Large cell with 
round and_ voluminous 
nucleus. The chromatin 


clear nuclear chromatin 


Large nucleus with grainy 
and evenly — distributed 
chromatin, a jarge nucle- 
olus and a finely defined 





Volume 
Number 


Fic. 
cinom 
cult 
type 
plasti 
can 
the © 


a Cytol. 
pr. 196] Volume 5 SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 149 


? 


} Number 2 





plastic 
! with Fic. 11. Cell from a car- 
1inous cinoma in situ. It is diffi- 
matin / cult to differentiate this 
e, no type of cell from a hyper- 
matin plastic reserve cell. This 
can be done only from 
the context. 
| 
\ 
2. The dysplasia is due to dis- This is the so-called “irregular” dysplasia, 
turbances in the mechanism olf with architectural disturbance. 
the maturation, and brings to- M 
ee) : 8 7 Here, again, the cytological context plays 
gether on a single smear “‘dys- . ‘ : : 
ae ; : a very important role in the diagnosis. 
plastic” elements having mature, 
irregular and hyperchromatic nu- In order to better define the morphologi- 
clei and of often eosinophilic cyto- cal characters permitting a differential diag- 
plasm and immature cells hav- nosis, we have assembled, photographed 
ing hyperactive chromatin, coming under immersion, the most representative 
from the deep layers which are in- elements of the various lesions of difficult 
creased in number. diagnosis. 
> 
{ 
Fic. 12. Immature and 
} invasive squamoid carci- 
‘ell. noma; a: Two large dark 
any } Staining nuclei with a 
ited | reticular structure chro- 
cle- matin, clumps of chro- 
ned matin and nucleoli, b: 


clear nucleus with scarce 
chromatin; there are ir- 
regular patches of chro- 
} matin and the _ nuclear 
membrane is thick. 





SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART 





IV Acta Cytol. 


Mar.-Apr. 1961 } 


RutHo M. GraHAM 
Buffalo, New York, U.S.A. 


I HAVE never encountered a distinct cyto- 
logic picture which I could correlate with 
basal cell hyperplasia. My understanding 
of basal cell hyperplasia is that the basal 
layer of the epithelium extends much 
higher than would be encountered normally 
and that the cells themselves are somewhat 
abnormal. However, these hyperplastic 
basal cells are covered by mature benign 
intermediate and superficial cells. Since 
the unusual growth of the basal layer is 
completely covered by normal benign cells, 
I can see no reason why we should expect 
to encounter any unusual cellular pattern 
if only desquamated cells are examined. 
Since the material in my laboratory con- 
sists of vaginal aspirations, I would not 
expect to see any unusual feature in basal 
cell hyperplasia, and I have seen none. 
This might not be true if scrapings were 
used, since in that instance some of these 
deeper cells might be seen. This is one 
reason I prefer examination of exfoliated 
cells to that of scrapings. I do not see how, 
from a cervical scraping, one can be certain 
whether the cells encountered are from the 
surface or are fairly deep in the epithelium. 
The significance of such cells at the surface 
is much greater. Basal cell hyperplasia is 
not a clinical entity. It is a histologic pic- 
ture. I would be interested in knowing if 
any of the discussants have definite ideas 
concerning the importance and subsequent 
behavior of this histologic picture. 

Neither have I seen any definite cytologic 
picture which could be correlated with re- 


serve cell hyperplasia. This may be ac- 


counted for again by the fact that we are 
dealing with desquamated cells. This is a 
diagnosis that has been made infrequently 
in the pathological laboratories with which 
I have been associated. Again one may ask 
—does this histologic picture actually cor- 


relate with any subsequent event in the 
patient who is carefully followed? 

Though the histologic definition of dys- 
plasia has been. commented on in this Sym- 
posium, I, at this writing, have not had the 
opportunity of seeing the definitions. Be- 
cause I suspect that there will be some di- 
vergence of opinion, and for the purpose of 
clarity, I would like to describe briefly my 
understanding of the term. Dysplasia is a 
histologic picture in which abnormal nuclei 
are present throughout the entire thickness 
of the epithelium including the superficial 
layer. The abnormal nuclei in the upper 
layers of the epithelium are surrounded by 
adequate cytoplasm and there is no “crowd- 
ing” of the nuclei. The maturation of the 
cytoplasm of these cells is proceeding fairly 
normally, but there is little or no matura- 
tion of the nuclei and they are distinctly 
abnormal. 

This histologic picture is reflected in the 
cytologic pattern seen in these cases. Cells 
are encountered whose nuclei are identical 
with true malignant cells with marked 
irregularity of the chromatin pattern. They 
differ markedly from the usual malignant 
cell because the nucleus is surrounded by 
an adequate amount of cytoplasm. We arbi- 
trarily define the cytoplasm as “adequate” 
if the distance from the nuclear border to 
the cellular border is greater than the maxi- 
mum diameter of the nucleus. Such cells 
with adequate cytoplasm but malignant 
nuclei we consider to be dyskaryotic. We 
do not actually measure such cells with a 
micrometer but judge visually whether or 
not adequate cytoplasm is present. Such 
cells are present in dysplasia, and we have 
come to associate the presence of cells ex- 
hibiting dyskaryosis with dysplasia, if no 
other abnormal forms are present. 





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Volume 
Number 


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Volume 5 
Number 2 


SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 


EMMERICH VON HAAM 
Columbus, Ohio, U.S.A. 


THE EXFOLIATIVE cytology of these lesions 
has been described too many times for any 
new and important observations to be con- 
tributed. The group of lesions represents 
borderline cases of carcinoma in situ, and 
their cytological picture is usually classified 
by us as Papanicolaou Class III with the 
request for a repeat smear. The following 
criteria should be followed to differentiate 
this group from that of carcinoma in situ 
on the one hand and from benign inflamma- 
tory dyskaryosis on the other hand: (1) The 
cellular changes do not only affect the inter- 
mediate or superficial cells but are espe- 
cially prominent in the basal and parabasal 
cells. (2) The latter are found in definitely 
increased number, as in the case of a cervi- 
cal erosion, but are not accompanied by 
spider cells or the atrophic keratinized cells 
of vaginal atrophy. (3) The basal and 
parabasal cells are not only increased in 
number but also show a certain degree of 
atypia. The cytoplasm usually stains darker 
and more cyanophilic, resembling in some 
aspects the SR cells described by Graham.! 
Sometimes vacuoles are present, sometimes 
keratohyaline inclusions can be found. The 
nuclear-cytoplasmic ratio is not altered, and 
cells with larger nuclei also possess more 
cytoplasm. The nuclei appear swollen, 
slightly vesicular and are usually not hyper- 
chromatic. They do not contain bulky 
clumps of chromatin or many or atypical 


Discussion 


Arturo Angel Arrighi, Buenos Aires, Argentina: 
We think that these three pathological conditions 
(reserve cell hyperplasia, basal cell hyperplasia and 
dysplasia) do not have a pathognomonic cytological 
picture and that by the examination of smears ob- 
tained either by aspiration or by scraping of the 
cervix we are not sufficiently informed to make the 
diagnosis of any of these histological images. Neither 
have we been able to recognize and classify in the 
smears a single cell as a reserve cell. 


nucleoli. The latter may be prominent but 
appear round and not bizarre. Mitotic 
figures, which always are prominent in the 
cervical biopsy of these lesions, are only 
rare and never of the atypical types de- 
scribed by Scarpelli and von Haam? for 
carcinoma in situ. 

We feel that the lesion probably still is 
reversible but may develop into, or be 
found together with, carcinoma in situ. It 
is quite frequently observed during preg- 
nancy, and patients showing this type of 
lesion should always remain under further 
cytological observation. If the smear from © 
this lesion also shows an abnormal bacterial 
flora, and especially a heavy Trichomonas 
infestation, efforts should be made to clear 
the infection. If the smear Shows cytological 
evidence of hormonal deficiency, the patient 
should be treated briefly with adequate hor- 
mone therapy and followed cytologically. 
In order to differentiate these cells from 
those characteristic of carcinoma in situ, 
emphasis must be placed upon an unaltered 
nuclear-cytoplasmic ratio, the infrequency 
of nuclear pyknosis, the comparatively nor- 
mal or prominent nucleoli, and the absence 
of atypical mitoses. 


Bibliography 
1. Graham, R. M. and J. B. 
6: 215, 1953. 
2. Scarpelli, D. G. and E. von Haam: Cancer Re- 
search. 17: 880, 1957. 


Graham: Cancer. 


Usually the smears obtained in these conditions 
show Class III (Papanicolaou) cells with changes 
especially evident in the parabasal cells. We agree 
with von Haam in emphasizing the importance of 
the preservation of the nuclear-cytoplasmic ratio 
and the absence of atypical types of mitosis in the 
differential diagnosis of carcinoma of the cervix. 


Werner Bickenbach and Hans-Jiirgen Soost, 
Munich, Germany: We only want to state on this 
question that in reserve cell hyperplasia and in 
basal cell hyperplasia, and similarly in dysplasia, 





152 SYMPOSIUM ON PREMALIGNANT CERVICAL LESIONS—PART IV 


we have seen cytological smears which compelled 
us to judge them as Class III, in rare cases as 
Class IV, after Papanicolaou. (We take the smears 
directly from the ectocervix by cotton swab or 
by wooden spatula.) In our experience cell changes 
in reserve cell hyperplasia and in basal cell hy- 
perplasia, as described by de Brux, lead us to 
think even of an invasive carcinoma. We believe 
that a differentiation of the various forms in these 
histological changes only by the cytological picture 
is an over-estimation of the method and actually 
impossible. 


Marcel Gaudefroy, Lille, Nord, France: When 
I saw “exfoliative cytology of reserve cell hyper- 
plasia, basal cell hyperplasia and dysplasia” in the 
preliminary program of this volume, I asked to be 
a discussant because I thought that these so-called 
hyperplasias were, above all, histological lesions, 
without any clear cytological pattern by themselves. 
I see that I am not alone in this opinion, and I do 
not want to repeat the considerations extensively 
explained by Ruth Graham, with whom I agree 
completely. I am wondering at the scrupulously 
detailed study of de Brux and Dupré-Froment, who, 
however, write, “it is difficult to differentiate this 
type . . . This can be done only from the context 
(Fig. 11),” and “It should be admitted that in cer- 
tain cases it is impossible to differentiate,” (the end 
of Topic A in his outline). I would like to ask 
de Brux, (1) if the described cytological patterns are 
not more theoretical than practical, and (2) if the 
cytological context alone, without histological con- 
trol, is not often insufficient to make a differential 
diagnosis with premalignant or malignant cells? 


Hannes Kremer, Vienna, Austria: I agree with 
Ruth Graham when she states that only normal 
superficial cells can be found in the cytological 
smear in cases of reserve cell hyperplasia or in 
cases of basal cell hyperplasia. Both epithelial 
formations have, in their upper parts, normal 
mature cells. However, through some _ influence 
(either thermal, chemical, mechanical, inflamma- 
tory), should the hyperplastic epithelial areas be 
completely or partially denuded, then the cells, de- 
scribed by de Brux and Dupré-Froment, will appear 
in the smear. Of course, the cytologist is unable to 
decide with certainty whether or not these normal 
basal cells are cells of a hyperplastic epithelium. 

Determining whether or not a single cell is de- 
rived from a dysplasia seems far more complicated 
to me. Also, when the details of a so-called “dys- 
karyotic” cell are observed accurately, we have 
repeatedly noticed the fact that they cannot be 
differentiated from cells of a carcinoma in situ or 
of an invasive carcinoma by differences in cell 
structure. Also, in this case, the nuclear-cytoplasmic 
ratio is only slightly altered. This, in fact, points 
to the benign character of the epithelium. The 
Jack of any other differentiated and undifferenti- 
ated atypical, i.e., suspicious, cells in the smear 
encourages the cytologist in his diagnosis. I should 
like to add that such abnormal ceils could originate 
from a dysplastic epithelium in which the dys- 
karyotic changes vary from case to case. Histo- 


Acta Cytol, 
Mar.-Apr. 1961 


logically, these could range from simple to highly 
developed atypias, which have not, as yet, reached 
the full extent of a malignant growth. Cytologi- 
cally, however, the different grades of a dysplastic 
epithelium cannot, in my opinion, be differentiated. 


Alexander Meisels, Mexico, D. F., Mexico: There 
is little to add to the excellent presentation made 
by the main authors on this topic. Although reserve 
cell hyperplasia, basal cell hyperplasia and dysplasia 
usually disappear in relatively short periods of time, 
we also classify them in Class ITI, because we have 
followed an occasional case that later developed 
into a carcinoma in situ. Why do some cases evolve 
towards a carcinoma while others return to Class I? 


Violette M. Nuovo, Paris, France: I have the same 
opinion as Ruth Graham. I have hardly ever en- 
countered such cells as described by de Brux in 
cases of hyperplasia, and when I did it was in a 
case of hyperplasia associated with deep ulceration 
and an intense inflammatory reaction. 

I diagnose dysplasia on the basis of the same 
criteria that Ruth Graham uses. 


Closing Remarks 


Jean A. de Brux: If a majority makes the law, 
then I am certainly in the wrong.. Nevertheless, I 
wish to strongly reaffirm my position, not in order 
to convince the discussants and perhaps also the 
main authors, but in order to oblige them to ex- 
amine more closely and compare the cytological 
images with the pathological specimens, at least 
concerning the hyperplasia of the reserve cells. 
This is an active, undifferentiated and immature 
metaplasia formed of undifferentiated elements (nei- 
ther squamous nor columnar), hyperplastic, often 
mitotic, which undergoes no maturation (reduc- 
tion in nuclear size). They exfoliate in the form 
of large elements with bulky, regular nuclei with 
very fine nuclear membranes, and regular and 
finely distributed chromatin. The cytoplasm is 
large and pale. These cells exfoliate in shreds. At 
the surface, certain of these cells undergo a slight 
nuclear retraction. The contrast between the Class 
If aspect of such smears, and the extremely sus- 
picious appearance of the biopsies, has led us to 
seek the cause for these discrepancies. We believe 
at present that this type of cell is pathognomonic 
of a hyperplasia of the basal cells, and that this 
latter lesion is strictly benign. Its evolution will 
certainly be in the direction of differentiation, more 
or less delayed stratification, and maturation. We 
request our discussants to make a very careful study 
of their smears and the corresponding biopsies, to 
verify our assertions. 


Ruth M. Graham: There appears to be general 
agreement that it is not possible to recognize reserve 
cell hyperplasia and basal cell hyperplasia on the 
basis of the cytologic pattern. It is important that 
we recognize the limitations of the cytologic method 
and do not attempt to extend the method to diag- 
noses which are clearly in the province of histology 
not cytology. 















ytol. 
1961 










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