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Stilbestrol

Diethylstilbestrol (DES) is a drug, a synthetic estrogen that was developed to supplement a woman's natural estrogen production. First prescribed by physicians in 1938 for women who experienced miscarriages or premature deliveries, DES was originally considered effective and safe for both the pregnant woman and the developing baby. A double-blind study was not done until DES had been on the market for more than a decade (Dieckmann, 1953). Even though it found that pregnant women given DES had just as many miscarriages and premature deliveries as the control group, DES continued to be aggressively marketed and routinely prescribed. more...

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In the United States, an estimated 5-10 million persons were exposed to DES during 1938-1971, including women who were prescribed DES while pregnant and the female and male children born of these pregnancies. In 1971, the Food and Drug Administration (FDA) issued a Drug Bulletin advising physicians to stop prescribing DES to pregnant women because it was linked to a rare vaginal cancer in female offspring.

More than 30 years of research have confirmed that health risks are associated with DES exposure. However, not all exposed persons will experience the following DES-related health problems.

Women prescribed DES while pregnant are at a modestly increased risk for breast cancer.

Women exposed to DES before birth (in the womb), known as DES Daughters, are at an increased risk for clear cell adenocarcinoma (CCA) of the vagina and cervix, reproductive tract structural differences, pregnancy complications, and infertility. Although DES Daughters appear to be at highest risk for clear cell cancer in their teens and early 20s, cases have been reported in DES Daughters in their 30s and 40s (Hatch, 1998).

Men exposed to DES before birth (in the womb), known as DES Sons, are at an increased risk for non-cancerous epididymal cysts.

Researchers are still following the health of persons exposed to DES to determine whether other health problems occur as they grow older.

Current research also looks at DES Third Generation. Third Generation refers to the offspring of DES Sons and Daughters. There is not yet much information available because the Third Generation are at an age where they can start to be physiologically affected by the DES exposure of his or her parent(s).

Third generation injuries are associated with preterm labor or deliveries resulting in premature birth and cerebral palsy, blindess or other neurological deficits or death of a child. One DES Daughter had a child who, at the age of four years, had such a severe case of cerebral palsy that the child was unable to turn himself over; the cerebral palsy was linked to the DES exposure of the mother.

Another study (J Pediatr Hematol Oncol 2003; 25:635-636.) found DES to be transgenerational, meaning that the maternal grandmother had taken DES while pregnant but the mother did not experience any health associated with the DES exposure. This was realized when a rare tumor was discovered on a 15 year old girl.

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Protocol for the examination of specimens from patients with carcinoma of the vagina
From Archives of Pathology & Laboratory Medicine, 1/1/99 by Scully, Robert E

This protocol is intended to assist pathologists in providing clinically useful and relevant information as a result of the examination of surgical specimens. Use of this protocol is intended to be entirely voluntary. If equally valid protocols or similar documents are applicable, the pathologist is, of course, free to follow those authorities. Indeed, the ultimate judgment regarding the propriety of any specific procedure must be made by a specific patient or specimen.

It should be understood that adherence to this protocol will not guarantee a successful result. Nevertheless, pathologists are urged to familiarize themselves with this document. Should a physician choose to deviate from the protocol owing to the circumstances of a particular patient or specimen, the physician is advised to make a contemporaneous written notation of the reason for the procedure followed.

EXPLANATORY NOTES

A: Prenatal Diethylstilbestrol Exposure.-Prenatal exposure to diethylstilbestrol or related synthetic drugs was relatively common in the United States and other countries until 1971, when its relation to clear cell adenocarcinomas of the vagina and cervix led to proscription of these drugs by the Food and Drug Administration. A history of this type of prenatal drug exposure should alert the pathologist to the possible presence of those tumors and associated lesions.l-3

B: Prior Tumors and Operations.-A history of dysplasia, carcinoma in situ, or invasive carcinoma of the cervix, as well as knowledge of its microscopic features may be essential in the determination of whether a subsequent vaginal tumor is a recurrent or new tumor. Also, a history of a carcinoma even higher in the female genital tract may influence the interpretation of a neoplasm that is detected in a specimen of the vagina. Prior pathology slides and reports should be obtained and reviewed if a review is deemed essential by the clinician or pathologist for optimal pathologic evaluation of the present specimen.

C: Clinical Findings and Diethylstilbestrol Exposure.-Naked-eye examination, colposcopy and iodine staining of the cervix and vagina may disclose a variety of changes highly suspicious of prenatal diethylstilbestrol exposure, such as cervical hypoplasia, pseudopolyp, coxcomb deformity, and vaginal adenosis or ridge, any of which should alert the pathologist to examine carefully for diethylstilbestrol changes.

D: Bethesda Classification System of Cervical/Vaginal Cytology.-For consistency in reporting, the cytologic classification proposed in the Bethesda System is recommended.4 This protocol does not preclude the use of other systems of classification; the Papanicolaou class designation system, however, is not recommended.

G: Other Prognostic Factors.-The architectural pattern of clear cell adenocarcinoma may have prognostic significance. Too few DNA ploidy studies and molecular genetic studies have been done to establish their prognostic value in cases of vaginal cancer.

H: Other Lesions.-Squamous dysplasia or carcinoma in situ, adenocarcinoma in situ, or atypical adenosis, particularly if such changes are at the resection margin, may increase the frequency of recurrent tumor.

I: Staining of Mucosal Surface.-Schiller's and Lugol's solutions stain glyco*enated epithelium brown. Therefore, they stain glycogenated squamous epithelium and wellglycogenated tumors. The stains are useful in identifying sites of nonstaining vaginal adenosis or immature squamous metaplasia of adenosis in patients exposed to diethylstilbestrol that may not be detectable before staining.

K: Cervical Abnormalities.-Ectropion (erosion, eversion) of the cervix, which is characterized by the appearance of glandular (columnar) epithelium outside the external os of the cervix, is seen in approximately 90% of women exposed to diethylstilbestrol in utero (but is often seen in nonexposed women as well). Approximately one third of patients exposed to diethystilbestrol have one or more gross structural abnormalities of the cervix (note C).

L: Fallopian Tubes.-The fallopian tubes are abnormal in some women exposed to diethylstilbestrol in the form of hypoplasia or defects demonstrated on hysterosalpingographic examination.3

Contributors: the College of American Pathologists Cancer Committee; Arthur L. Herbst, MD; and Robert J. Kurman, MD.

References

1. Herbst AL, Ulfelder H, Poskanzer DC. Adenocarcinoma of the vagina: association of maternal stilbestrol therapy with tumor appearance in young women. N Engl J Med. 1971;284:878-881.

2. Herbst AL, Bern H. Developmental Effects of DES Pregnancy. New York, NY: Thieme-Stratton, Inc; 1981:chap 3, 4, 6, 7. 3. Kaufman RH, Noller K, Adam E, et al. Upper genital tract abnormalities and pregnancy outcome in diethylstilbestrol-exposure progeny. Am J Obstet Gynecol. 1984;148:973-984.

4. Kurman RI, Solomon D. The Bethesda System for Reporting Cervical/Vaginal Cytologic Diagnoses: Definitions, Criteria, and Explanatory Notes for Terminology and Specimen Adequacy New York, NY: Springer-Verlag; 1994.

5. Scully RE, Bonfiglio TA, Kurman RJ, Silverberg SG, Wilkinson WJ. Histological typing of female genital tract tumours. In: World Health Organization: International Histological Classification of Tumours. New York, NY: Springer-Verlag; 1994.

6. Pettersson F. International Federation of Gynecology and Obstetrics Report. Stockholm, Sweden: International Federation of Gynecology and Obstetrics; 1988.

7. Fleming ID, Cooper JS, Henson DE, et al, eds. AICC Manual for Staging of Cancer. 5th ed. Philadelphia, Pa: Lippincott Raven; 1997.

Bibliography

Kurman RJ, Norris HJ, Wilkinson E. Tumors of the Cervix, Vagina, and Vulva. Washington, DC: Armed Forces Institute of Pathology; 1992. Atlas of Tumor Pathology; 3rd series, fascicle 4.

Kurman RJ. Blaustein's Pathology of the Female Genital Tract 4th ed. New York, NY: Springer-Verlag; 1994.

Robert E. Scully, MD, for the Members of the Cancer Committee, College of American Pathologists

Accepted for publication August 26, 1998. From the Department of Pathology, Massachusetts General Hospital, Boston.

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