KCP-786 KCP-786 서울대학교 병원 전공의 백해운

History 59 세 (Gravida5, Para2) 2007 년 HPV18(+) 이후 자궁질 도말검사를 수 차례 받음 Op Hx : 2011 년 담낭결석, 2010 년 복압 요실금 기타 특이사항 없음 2012 년 9 월 경부터 간헐적으로 질출혈 2013 년 2 월 질출혈이 심해져서 내원 자궁경부에서 용종이 관찰되었고, 주변부는 딱딱하게 만져졌음 MRI: 자궁경부에 불규칙한 모양을 보이는 1.7 x 2.0cm 크기의 병변 자궁경부에서 자궁질 도말검사 및 펀치생검을 시행

BackgroundNecrotic (tumor diathesis) Cellularity Moderate to highly cellular ArchitectureCluster of overlapping small cells Nest, rosette, microacini pattern Not honeycomb pattern CellProminent nuclear molding CytoplasmScant High N/C ratio Ill-defined border NucleusHyperchromatic, finely granular Stippled (Salt-and-pepper) chromatin Inconspicuous nucleoli Cytologic features

Differential diagnosis Small cell carcinoma with glandular or squamous differentiation Poorly differentiated adenocarcinoma Poorly differentiated squamous cell carcinoma Helpful features Helpful features in detecting neuroendocrine carcinoma Nuclear molding Indistinct nucleoli Scanty cytoplasm

Small cell carcinoma Endocervical adenocarcinoma Squamous cell carcinoma GeneralVery rare Young to middle- aged women Symptomatic cervical mass Some are associated with squamous, glandular or adenosquamous differentiation Uncommon In conventional smears:  Fewer and smaller abnormal cells  Small nuclei  Less atypia  Less hyperchromasia Most common Vaginal bleeding Tumor diathesis Usually seen  Necrotic debris and bloody background Present when invasive  Heavy blood with abundant glandular epithelium Present  Fibrin, necrotic debris, blood & leukocytes

Small cell carcinoma Endocervical adenocarcinoma Squamous cell carcinoma Appearance Single or groups of small cells or gland- like aggregates Usually in nests; syncytial aggregates Nuclear molding, crush artifact, and smearing Crowded pseudosyncytial clusters with many isolated cells Papillary fragments Usually columnar, rosettes, very tight sheets with holes vs. balls, molded groups Many groups of dyskaryotic cells Small single keratinized cells in the background HPV infection Associated with HPV 18 Associated with HPV 16/18 Associated

Small cell carcinoma Endocervical adenocarcinoma Squamous cell carcinoma Cell shape & size Small cells Tiny cells packed in very tight sheets Round plump cells Bizarrely shaped dyskaryotic squamous cells  including ‘fiber cells’ and ‘tadpole’ cells Nuclei Round or oval Mildly pleomorphic Enlarged Pleomorphism Variation in size and shape Nucleoli IndistinctMacronucleoli Small and single  occasionally large and multiple Marked variation Macronucleoli Sometimes irregular Chromatin Hyperchromatic Evenly distributed Salt-and-pepper Usually hyperchromatic Coarsely granular Clearing Clumped chromatin Abnormal clumping with coarse aggregation Coarsely granular chromatin Cytoplasm Scanty High N/C ratio Ill-defined border Granular Finely vacuolated Variable mucin Fluffy cytoplasm High N/C ratios Cytoplasmic keratinization

Cytologic diagnosis MICRO (1 HE) Cervicovaginal smear: Neuroendocrine small cell carcinoma with glandular differentiation OR Neuroendocrine small cell carcinoma associated with endocervical adenocarcinoma