European Journal of Obstetrics & Gynecology and Reproductive Biology, 48 (1993) 215-219 215

0 1993 Elsevier Scientific Publishers Ireland Ltd. All rights reserved. 0028-2243/93/%06.00

EUROBS 01497

Case Reports

Primary malignant lymphoma of the uterus: localization in a

cervical polyp
F.J. Broekmansa, J.M. Swartjes”, P. Van der Valkb and E.M.J. Schuttera

“Department of Obstetrics and Gynecology and bDepartment of Pathology, Free University Hospital, Amsterdam, The Netherlands

Accepted for publication 7 October 1992

Summary

Distinction between benign and malignant lymphoid lesions of the uterine cervix can be difftcult. Two patients show-
ing atypical lymphoid tissue confined to a uterine cervical polyp are presented. In one patient a non-Hodgkin lym-
phoma stage IE was diagnosed. Treatment consisted of combination chemotherapy. In a second patient the lesion was
classified as atypical lymphoid hyperplasia. No treatment was initiated. The presence of a non-Hodgkin lymphoma
in a cervical polyp is extremely rare. Distinction between benign and malignant lymphoid tissue within a cervical polyp
can be facilitated by immunohistochemical staining and application of the histological criteria for a reactive nature
of such lesions.

Malignant lymphoma; Cervical polyps

Intrctduetion GnRH (gonadotropin-releasing hormone) agonist. In

Primary localization of a malignant lymphoma in the
uterus is rare. Among women with a malignant lym-
phoma the prevalence ranges from 0.14 to 0.95% [l-3].
Although malignant changes confined to a uterine cer-
vical polyp do occur [4], the presence of this type of
malignant lymphoma has only been described twice
before [5,6].
Presented here are two cases in which histological
examination of a cervical polyp demonstrated the
presence of a malignant lymphoma in one and atypical
lymphoid tissue in the other.
Case reports
(A) A 45year old, nulligravid, premenopausal female
underwent myomectomy after pretreatment with a
Correspondence to: F.J. Broekmans, PO Box 7057, 1007 MB
Amsterdam, The Netherlands.
addition to leiomyomata, a mild form of endometriosis
was found at operation. Three months later the patient
presented with a history of slight postcoital bleeding.
Gynecological examination demonstrated a cervical
polyp with a diameter of 0.5 cm. A cytological smear of
the cervix showed normal endocervical and ectocervical
cells (class 1 Papanicolaou). In revision this conclusion
was confirmed. The polyp was removed by ring forceps
and fixed in formalin. Histological examination revealed
a dense, subepithelial infiltrate, composed almost entire-
ly of large, blastic cells, with large nuclei showing
predominantly central nucleoli and with relatively abun-
dant cytoplasm (Fig. 1). Immunohistochemically the
cytoplasma of the blastic cells was monotypic for Lamb-
da light chain (Fig. 2). A diagnosis of B-immunoblastic
lymphoma was made (Working Formulation: high
grade malignant). Computertomography of the ab-
domen, chest film, bone marrow biopsy and
hematological parameters showed no abnormalities. At
vaginal ultrasound examination, the uterus appeared
216

Fig. 1. Non-Hodgkin lymphoma, B-immunoblastic. The left panel is a low-power view showing the cohesive growth pattern of the
lymphoma (x 20). The right panel is a detail. Note the large, central nucleoli (x 520).

Fig. 2. Light chain staining of the tumour. The left panel shows lambda (positive), the right panel shows kappa (negative) staining
( x 320).

moderately enlarged, without evidence of leiomyomata.
The ovaries were normal. Examination under general
anaesthesia and fractional curettage showed no abnor-
malities.
Treatment was initiated as for a non-Hodgkin lym-
phoma stage IE (Ann Arbor). The patient received a
total of six courses of cyclophosphamide, doxorubicin,
vincristin, prednison and methotrexate (CHOP-MTX).
Three years after diagnosis she is well and alive.
(B) A 44-year-old, nulligravid, premenopausal female
presented with a 2-month history of recurrent postcoital
bleeding. On gynecological examination a cervical polyp
was found with a diameter of about 2 cm. A cytological
smear of the cervix showed normal cylindrical and
squamous epithelial cells without evidence of dysplasia
and was diagnosed as Papanicolaou class I. Revision in
retrospective confirmed this diagnosis. The polyp was
removed by ring forceps. Histological examination
revealed a lymphoid infiltrate in which at low-power
(Fig. 3) follicle centres were seen, containing many
mitotic figures, but only few tingible body macrophages.
A mantle zone was lacking around some of these cen-
tres. Immunohistochemical staining confirmed the
presence of compartimentahzation in the infiltrate (i.e.
both B- and T-cell areas). Both compartments showed
Fig. 3. :tiEve,atypical lymphoid hyperplasia in a cervical polyp. Low power view showing a follicular pattern. N’ote the paucity
of tingible body macrophages and the lack of mantle zones (X IO).
217
blast cells and mitotic figures, positive in the B-cell (L26
(CD20), Fig. 4) and T-cell (UCHLI (CD45R) and MT1
(CD43)) staining. The immunohistological staining on
the parafftn sections showed no monotypic immuno-
globulins. Since the follicle centres were somewhat
monomorphic, mantle zones were lacking around
several follicles and B-lymphoid blasts were also found
in the T-cell area, the process was suspect for malignant
lymphoma. However, the subepitbelial localization of
the infiltrate, the compartmentalization and the
presence of proliferating cells in both B- and T-cell com-
partments swayed the final diagnosis in favour of a reac-
tive process, although with reservation. Chest film and
CT scanning of the abdomen showed no abnormalities.
Consultation by experts on lymphoma of the Com-
prehensive Cancer Centre Amsterdam, led to the final
diagnosis ‘atypical lymphoid hyperplasia’. The possibili-
ty of a malignant lymphoma was rejected. No treatment
was initiated. Fourteen months of follow up revealed no
evidence of disease.
Discussion
The non-Hodgkin lymphoma confined to a cervical
polyp, as found in the first patient, is the third to be
218
Fig. 4. Reactive, atypical lymphoid hyperplasia, L26 (B-cell) staining. On the right side the edge of a follicle can be seen. Note the
presence of positive blastic cells in the non-staining (T-cell) area (X 520).
described in the literature [6]. The two other cases con-
cerned polypoid lesions of the cervix with diameters of
3 and 4 cm. In both cases surgical removal was followed
by radiation therapy [5,13].
According to the criteria for diagnosis of primary ex-
tranodal lymphoma, as described by Fox [7], the
localization within a cervical polyp must be considered
as a primary lymphoma of the uterine cervix. In recent
years, several cases have been published reporting the
presence of a primary lymphoma in the cervix [6,8-l 11.
These tumours frequently present by abnormal vaginal
bleeding or discharge [2,6,8], but may be asymptomatic
in 20% of cases. They often appear to be expansile le-
sions causing smooth enlargement of the cervix and
rendering it friable. Cytological smears may in some
cases direct to the diagnosis, but are generally normal
[ 11,121. Final diagnosis will usually depend on
histological examination of biopsy material.
Age distribution shows a median age well under 50
years. Eighty percent of the patients appear to be
premenopausal [6]. A tendency to occur in the younger
age groups when compared with the classical age
distribution for non-Hodgkin lymphomas has been
reported [&lo].
Primary malignant lymphomas of the uterine cervix
can be successfully treated by pelvic irradiation, alone or
in combination with radical surgery, even in locally ad-
vanced disease [2,6,13]. Surgical staging allows careful
assessment of lymphatic spread and the need for adju-
vant treatment. Recently, combination chemotherapy
has been shown to be an effective alternative in several
types of non-Hodgkin lymphomas, especially where
preservation of fertility is indicated [6,14]. Prognosis in
primary lymphoma of the cervix depends on the stage of
the disease. Whether survival rates are influenced by
histological type and treatment modality (surgery versus
radiation) remains obscure 181. The overall 5-year sur-
vival rate has been reported to be 77% 1131.Extranodal
uterine cervical or corporal lymphomas tend to have a
better prognosis than comparably staged nodal lym-
phomas [13].
Lymphoid lesions in the uterine cervix show a spec-
trum ranging from scanty infiltrates of lymphocytes and
plasma cells to full blown malignant lymphomas com-
posed of large, blastic cells. The two patients reported
here illustrate part of this spectrum. They also highlight
the problems in distinguishing between benign and
malignant lesions. Especially, follicular lymphoid le-

sions may present problems, as was shown in the second
patient.
Usually, cervical polyps and biopsies are immediately
fixed in formalin before being sent to the pathology
department. Under these circumstances, demonstration
of monotypic immunoglobulin at the surface of the
tumour cells, which is considered as the definite proof of
malignant lymphoid disease, is virtually impossible. On
the other hand, follicular lymphomas are rare in ex-
tranodal localizations. Eventually, a solid conclusion
will be reached by application of the histological criteria
for a reactive nature of such follicular lesions [ 151.These
criteria include the presence of pleomorphism of the ger-
minal centre, the presence of tingible body
macrophages, of high numbers of mitotic figures and of
well-defined mantle zones around the follicles.
Another problem may be distinguishing between lym-
phoma and carcinoma. Cervical lymphomas are very
often high grade malignant and may exhibit cohesive
growth, thereby simulating carcinoma. The differential
diagnosis, however, will be easily settled by im-
munohistochemistry with appropriate markers (keratin
antibodies, leucocyte common antigen). These anti-
bodies can be successfully applied to formalin fixed
tissue.
In summary, two patients are presented showing lym-
phoid lesions within a cervical polyp. One appeared to
be malignant, the other showed reactive changes. This
unusual presentation focuses attention to the spectrum
of lymphoid infiltrates in the cervix and stresses the need
for removal and subsequent histological and, in selected
cases, immunohistological evaluation of cervical polyps.
References
1 Freeman C, Berg JW, Cutler SJ. Occurrence and progno-
sis of extranodal lymphomas. Cancer 1972;29:252-260.
219
2 Komaki R, Cox JD, Hansen RM, Gunn WG, Greenberg
M. Malignant lymphoma of the uterine cervix. Cancer
1984;54:1699-1704.
3 Chorlton I, Kamei RF, King FM, Norris HJ. Primary
malignant reticuloendothelial disease involving the
vagina, cervix and corpus uteri. Obstet Gynecol
1974;44:735-748.
4 Aaro LA, Jacobson LJ, Some EH. Endocervical polyps.
Obstet Gynecol 1963;21:659-665.
5 Wright CJE. Solitary malignant lymphoma of the uterus.
Am J Obstet Gynecol 1973;117:114-120.
6 Muntz HG, Ferry JA, Flynn D, Fuller AF, Tarraza HM.
Stage IE primary malignant lymphomas of the uterine cer-
vix. Cancer 1991; 68:2023-2032.
7 Fox H, More JRS. Primary malignant lymphoma of the
uterus. J Clin Path01 1965;18:723-728.
8 Mann R, Roberts WS, Gunasakeran S, Tralins A.
Primary lymphoma of the uterine cervix. Gynecol Oncol
1987;26:127-134.
9 Sandvei R, Lote K, Svendsen E, Thunold S. Successful
pregnancy following treatment of primary malignant
lymphoma of the uterine cervix. Gynecol Oncol
1990;38:128-131.
10 Johnston C, Senekjian EK, Ratain MJ, Talerman A. Con-
servative management of primary cervical lymphoma
using combination chemotherapy: a case report. Gynecol
Oncol 1989;35:391-394.
1I Taki I, Aozasa K, Kurokawa K. Malignant lymphoma of
the uterine cervix. Acta Cytol 1985;29:607-611.
12 Krumerman MS, Chung A. Solitary reticulum cell sar-
coma of the uterine cervix with initial cytodiagnosis. Acta
Cytol 1978;22:46-50.
13 Harris NL, Scully RE. Malignant lymphoma and
granulocytic sarcoma of the uterus and vagina. A clinico-
pathologic analysis of 27 cases. Cancer 1984;53:
2530-2545.
14 Coleman M. Chemotherapy for large-cell lymphoma: op-
timism and caution. Ann Intern Med 1985;103:140-142.
15 van der Valk P, Meyer CJLM. The histology of reactive
lymf nodes. Am J Surg Pathol 1987;11:868-882.