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Squamous metaplasia occurring in the squamo-columnar junction (transformation zone) of the cervix begins as a patchy process, the foci of squamous metaplasia enlarging and eventually fusing. The metaplasia involves both the surface epithelium and underlying crypts.
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Metaplasias elsewhere in the female genital tract are relatively very rare and can be transitional and mucinous metaplasia of the fallopian tube.6 The abdominal and pelvic peritoneum, as part of the secondary Mullerian system, may undergo metaplasia into various Mullerian epithelia. Nonneoplastic secondary mullerian lesions, which are in many cases a form of metaplasia, comprise endometriosis, endosalpingiosis and endocervicosis. When occurring in combination, they have been termed as mullerianosis. It is recognized that probably most cases of abdominal and pelvic endometriosis are not truly metaplastic but are the result of retrograde menstruation.
Morules differ from mature squamous metaplasia in that they lack keratinisation and intercellular bridges. Morules and foci of mature squamous elements, metaplasia often co-exist. An endometrial lesion in which squamous elements, usually in the form of morules, are extremely common and prominent is an atypical polypoid adenomyoma. Extensive squamous metaplasia of the endometrium also occur in association with pyometra, endometritis, cervical stenosis or an intra-uterine device. Endometrial squamous metaplasia occurs secondary to progestogen therapy.
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MUCINOUS METAPLASIA
This is a rarer form of endometrial metaplasia. The diagnosis should be reserved for cases in which the endometrial epithelial cells are replaced by cells with abundant mucincontaining cytoplasm, which resemble endocervical cells. Rarely, intestinal metaplasia has been described in the endometrium, in which the mucinous epithelium contains goblet cells. This is also the case in the cervix. As with other types of endometrial metaplasia, mucinous metaplasia can co-exist with endometrial hyperplasia. As mucinous metaplasia of the endometrium can have a complex growth pattern, it can be difficult to distinguish between mucinous metaplasia and well-differentiated adenocarcinoma, especially in endometrial biopsy tissue.
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In biopsy tissue, a diagnosis of mucinous adenocarcinoma should be considered in a lesion resembling cervical microglandular hyperplasia in a postmenopausal patient, although cervical microglandular hyperplasia rarely occurs in this age group.
Vimentin staining may be of use: adenocarcinoma usually stains positively and microglandular hyperplasia is negative. Rarely, mucinous metaplasia in the endometrium is accompanied by mucinous lesions elsewhere in the female genital system.
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ARIAS-STELLA CHANGE
Seen In pregnancy or trophoblastic disease, and occasionally with hormone therapy: rarely, there is no association.
Histologically, there may be cellular stratification, secretory activity and enlargement of the epithelial cell nuclei and cytoplasm.
Nuclei show considerable atypia and occasional mitotic figure may be present.
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In addition, the Arias-Stella change involves pre-existing endometrial glands and there is no evidence of stromal infiltration.
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The most important differential diagnosis of papillary syncytial metaplasia is papillary adenocarcinoma of endometriod or serous type. The changes of papillary syncytial metaplasia are limited to the surface and are often associated with signs of breakdown.
A lesion recently described in detail by Lehman and Hart which is most frequently seen in endometrial polyps is characterised by papillary proliferations with fibrovascular cores. This lesion is like papillary syncytial metaplasia, it has a papillary appearance and so could be misdiagnosed as papillary endometrial carcinoma.
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Ichthyosis uteri
Another rare entity that appears to be declining in incidence,
ichthyosis uteri is a benign process in which the endometrial lining has been replaced by a cytologically benign stratified proliferation of cells with squamous differentiation. It has been associated with chronic endometritis and with heat ablation of the endometrium.
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Ichthyosis uteri
Ichthyosis Uteri
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Other features favoring clear cell metaplasia over clear cell carcinoma include focality of lesion, absence of visible tumor on hysterectomy, absence of stromal invasion and presence of estrogen receptor positivity.
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Conti..
3]Glial metaplasia- Glial tissue is rare and the chief D/D is a teratoma. It is presumed to a consequence of previous abortion.
4] Adipose metaplasia- Adipose tissue may be rarely seen in the stroma of endometrial polyp. It is found in an endometrial biopsy or curretage specimen, so perforation must be suspected.Other explanation of adipose tissue presence include lipoma, lipoleiomyoma,rare uterine hamartogenous like lesions.
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Conti.
5]Extramedullary hematopoiesis- Extramedullary hematopoiesis, recognized by the presence of megakaryocytes, erythroid and myeloid precursors, is occasionally seen.
If extramedullary hematopoiesis is identified in the endometrium in the absence of other tissues, and underlying hematological disorder should be considered and investigated.
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To differentiate Immature Sq.metaplasia from CIN. Presence of uniform population of cells with scanty cytoplasm and nuclei which lack significant pleomorphism . The nuclei are not hyperchromatic and abnormal mitosis may not be seen. The presence of mucin on the surface of cells may be useful . A minor degree of nuclear atypia is acceptable in immature Sq. metaplasia. When grading of CIN is difficult, a diagnosis CIN unclassified should be made with a statement on whether this is likely to be low gd(CIN 1) or high (CIN 2-3). Koilocytosis may also involve Immature metaplastic Sq. epithelium and result in atypical changes. Using HPV typing with careful follow-up, have shown that some cases of atypical immature sq. metaplasia are probably a variant of high gd CIN.
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This lesion involves the surface epithelium and underlying endocervical crypts and is characterized by a multilayered epithelium resembling CIN.
Stratified mucinous intra-epithelial lesion is associated with more extreme pleomorphism and hyperchromasia and higher proliferation index, demonstrable by MIB1 staining, than immature sq. metaplasia.
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In addition, stratified mucinous intra-epithelial lesion is almost always associated with CIN or CGIN and commonly with an invasive carcinoma which may be squamous ,glandular or adenosquamous in type.
It has been considered that stratified mucinous intra-epithelial lesion is a form of reserve cell neoplasia and a marker of phenotypic instability
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Transitional Metaplasia
Trasitional cell metaplasia of the cervix is uncommon and is usually an incidental finding in postmenopausal women. It may involve both the surface epithelium and underlying Endocervical glands and is more common on the ectocervix. Histologically it may show cells with pale, uniform ,ovoid to spindle-shaped nuclei which may contain grooves. A useful Diagnostic feature , not always present, is that in the deeper layers of the epithelium the nuclei are usually oriented at right angles to the basement membrane whereas superficially they are parallel to it. The main problem in diagnosis is the superficial resemblance to CIN 3,especially in those cases with tightly packed nuclei and low N:C ratio.
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But recently a ciliated variant of CGIN has been described (designated AdenoCA in situ of tubal type). A panel of IHC stains comprising of MIB1,bcl2 and p16 may be of value.
MIB1 Tubo-endo metaplasia Endometriosis Microglandular hyperplasia High gr CGIN Negative or low Neg or low Intermediate or high Bcl2 diffuse Diffuse Negative Negative p16 Neg or focal Neg or focal Negative Diffuse 50
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2 basal Endocervical microglandular Microglandular associated Figure with hyperplasia associate with basal hyperplasia (HE, ob. 6) hyperplasia
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Intestinal metaplasia
Intestinal metaplasia involving endocervical crypts has rarely been seen. It is characterized by the presence of goblet cells and sometimes Paneth cells. Co-existent appendiceal neoplasms were present and differential cytokeratin staining (CK7 and CK20) suggested metastasis from appendix by a transtubal route.
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Intestinal metaplasia
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Oxyphilic metaplasia
Oxyphilic metaplasia is characterized by replacement of the endocervical cryptal epithelium by cuboidal cells with eosinophilic cytoplasm. Often there is a degree of nuclear atypia and this lesion was originally designated atypical oxyphilic metaplasia . Its only significance is that it is mistaken as CGIN.
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Oxyphilic metaplasia
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1] Endosalpingiosis is characterized by the presence of nonneoplastic glands lined by ciliated tubal type epithelium. It usually involves the peritoneum and the subperitoneal tissues including the surface of the ovaries. Endosalpingiosis is usually an incidental finding on microscope , but rarely may form cystic mass referred to as florid cystic endosalpingiosis. Psammoma bodies are often present in glandular lumina or the surrounding stroma. Endosalpingiosis is especially likely to be found in patients with ovarian serous neoplasms which may benign ,borderline and malignant. Occasionally, foci of endosalpingiosis have multilayering with papillary formation and mild cytological atypia.
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2] Endocervicosis is characterized histologically by the presence of non-neoplastic mucinous glands resembling endocervical glands. This is much less common then endometriosis or endosalpingiosis. Involved sites have included the peritoneum, pelvic lymph nodes, the urinary bladder, the uterine serosa, the cervix, and the vagina.
Especially when florid and involving the wall of the bladder cervix, a diagnosis of well differentiated mucinous adenocarcinoma , including cervical minimal deviation adenocarcinoma of mucinous type, may be considered.
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3] Another rare metaplastic lesion to arise from the secondary Mullerian system is diffused peritoneal leiomyomatosis. This condition is characterised by multiple small nodules of bland smooth muscle cells involving the peritoneum and omentum and is often associated with pregnancy or exogenous hormones
Diffuse peritoneal leiomyomatosis often shows positive immunohistochemical staining with progesterone receptor and persistent cases have been successfully treated with gonadotropin-releasing hormone agonists.
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THANKS
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