Adenocarcinoma in situ of the uterine cervix: a clinico-pathologic study of 36 cases

Exploring uterine involvement in hysterectomy samples following conization for adenocarcinoma in situ of the uterine cervix: Insights from a multicenter study by the FRANCOGYN group

BACKGROUND

Adenocarcinoma in situ (AIS) of the cervix can progress to invasive adenocarcinoma. While hysterectomy is standard, conservative management may be considered for women desiring future pregnancies. This study aimed to determine the prevalence of residual disease in hysterectomy specimens following excisional therapy with clear margins for AIS.

METHODS

A retrospective FRANCOGYN cohort study was conducted on patients who underwent a hysterectomy after conization with clear margins for AIS between 2008 and 2021. The primary goal was to assess the prevalence of residual disease in the hysterectomy specimens. Secondary objectives included identifying preoperative predictors of residual disease and comparing recurrence rates between patients with and without residual disease.

RESULTS

Of 53 hysterectomies performed after conization with negative margins for AIS, 20.8% (11/53) showed residual disease in the final histology. None of the patients had invasive cancer. In the residual disease group, 18% (2/11) had persistent CIN 3, and 82% (9/11) had persistent AIS. These patients tended to have higher BMI (27.5 kg/m² vs. 23.6 kg/m², p=0.04) and shorter endocervical margins (2mm vs. 5mm, p=0.01). No recurrences were observed during follow-up.

CONCLUSION

Despite clear margins on the initial conization for AIS, 20% of patients had residual disease in their hysterectomy samples, though no invasive cancer was found. A hysterectomy should be considered after completing childbearing, even if initial margins are clear.

Adenocarcinoma In Situ of the Uterine Cervix (AIS) Treated by Loop Electrosurgical Excision Procedure Strategy: An Observational Study

OBJECTIVES

Evaluation of the results of treatment of adenocarcinoma in situ by loop electrosurgical excision procedure and the safety of a conservative strategy.

METHODS

Identification of all cases of adenocarcinoma in situ treated by loop electrosurgical excision procedure at our institution and follow-up by a conservative strategy. Completeness of the identification of all cases was secured by data from the National Pathology Registry. The treatment strategy was based on cytologic follow-up performed by a general practitioner and, irrespective of margin status of the cone, only the results of the postoperative surveillance were indicative of further treatment.

RESULTS

A total of 224 patients were identified. The overall recurrence rate with a mean follow-up time of 87.8 months was 7.6% (17/224). The recurrence rate in patients with involved margins was significantly higher than in patients with uninvolved margins, 15.7% vs 5.2%, respectively. Six recurrences were diagnosed at first examination 6 months postconization in patients with involved margins. They were treated with hysterectomy in 4 cases and reconization in 1 case. If involvement of margins alone had been an indication of further therapy (hysterectomy or reconization) immediately after conization, the conservative management strategy prevented 46 surgical procedures. Two cases of invasive cancer were diagnosed during follow-up, 150 months and 196 months after primary treatment, and after normal follow-up examinations. These 2 cases must be considered de novo cases and cannot be considered treatment failures.

CONCLUSION

The conservative management strategy thus seems safe, and unnecessary surgical procedures were avoided.

Impact of cervical excisional dimensions on endocervical margins status in adenocarcinoma in situ of the uterine cervix: A multicenter study from the FRANCOGYN group

OBJECTIVE

Excisional procedures have a central role in the management of adenocarcinoma in situ of the cervix (AIS). We aimed to evaluate the relationship between the excisional specimen dimensions and the endocervical margin status.

METHODS

We conducted a multicentric retrospective study in seven French centers. All cases with proven AIS on a colposcopic biopsy and undergoing an excisional procedure afterwards were included in the analysis. We evaluated the impact of excision length, along with the lateral and anteroposterior diameters on the endocervical margin status. An additional subgroup analysis of the impact of maternal age on endocervical margin status was also conducted.

RESULTS

Of the 101 cases of AIS diagnosed on initial biopsy, 95 underwent a primary excisional procedure, among which 80% (n = 76/95) had uninvolved endocervical margins and 20% (n = 19/95) had positive endocervical margins. The excisional specimen length was not significantly related to the endocervical margin status. Conversely, both lateral and antero-posterior diameters were significantly correlated with the negative endocervical margins status: OR = 1,19, 95% CI [1.03, 1.40], p = 0.025, for the lateral diameter and OR = 1.34, 95% CI [1.14, 1.64], p = 0.001 for the antero-posterior diameter. The median lateral diameter was 20 mm, IQR (18, 24) in case of endocervical negative margins vs. 18 mm IQR (15, 24) in case of positive endocervical margins (p = 0.039), and the median anteroposterior diameter was 17 mm IQR (15, 20) in case of negative endocervical margins vs 14 mm IQR (11, 15) in case of positive endocervical margins (p = 0.004), respectively.  Additionally, in patients over 45 years old, endocervical margin were more likely to be positive despite similar excisional dimensions (7/17 (41%) of positive endocercival margins before 45 years old vs 12/78 (15%) after, p = 0.039) CONCLUSIONS: Endocervical margin statues were significantly related to the transverse diameters (lateral and anteroposterior diameters), but not to the excision specimen length. Reducing the excised length may lead to fewer post-procedure complications but would still allow to obtain a large proportion of negative endocervical margins.

Cytology and curetting diagnosis of endocervical adenocarcinoma

INTRODUCTION

Papanicolaou testing is effective in identifying squamous intraepithelial lesions of the cervix. Endocervical adenocarcinoma (EAC) and adenocarcinoma in situ (AIS) are far less commonly identified. Endocervical curettings (ECCs) are usually obtained after colposcopic biopsy, sample the endocervical canal, and aid in the detection of endocervical glandular lesions. Here, we examine the utility of Papanicolaou testing and endocervical curetting for detecting AIS and EAC.

MATERIALS AND METHODS

Cases from 2007 to 2019 with a histologically confirmed diagnosis of AIS and EAC were identified and the clinical data and diagnostic material, including the cytology and surgical specimens, obtained.

RESULTS

A total of 108 cases of AIS and EAC were identified, Papanicolaou tests were performed in 97 of these cases, and ECC in 87. AIS or EAC were detected in 46.4% of Papanicolaou tests; 41.4% of ECC showed AIS or EAC. A total of 92.7% of cases were positive for high-risk human papillomavirus (HPV) and concurrent squamous intraepithelial lesion was present in 53.3% of cases. AIS or EAC were more commonly identified in cases without concurrent squamous intraepithelial lesions.

CONCLUSIONS

Papanicolaou testing and endocervical curettings have a low detection rate for AIS and EAC. The majority of AIS and EAC cases test positive for high-risk HPV. Papanicolaou test and ECC show different detection rates and are complementary tools in patients with AIS and EAC. In some settings, an ECC can increase the diagnostic sensitivity and specificity of the pathologic diagnosis.

[Use of HPV virologic test for atypical glandular cells in Alsace between 2014 and 2016]

OBJECTIVES

The new recommendations by the National Institute of Cancer (January 2017) recommend the use of a complementary human papillomavirus (HPV) virologic test during the diagnosis of atypical glandular cells in pap smear. The aim of this study was the performance analysis of the HPV virologic test for the detection of significant histological cervical abnormalities (CIN2 or more) in case of atypical glandular cells before the new recommendations were published.

METHODS

We performed a descriptive and retrospective cohort study in Alsace between January 2014 and December 2016. We have included, from the EVE-association database, the patients with atypical glandular cells in pap smear.

RESULTS

In total, 1074 patients had a pap smear with atypical glandular cells ; 0.18% of total pap smears. This study included 152 patients who had a HPV test. We observed 6 cases of CIN2 (3.9%) and 12 cases of CIN3 (7.9%). No in situ adenocarcinoma nor invasive carcinoma were detected. The sensitivity of the HPV test was 88.9% (95% CI: [0.65; 0.99]), the specificity was 65.9% (95% CI: [0.55; 0.76]), the positive predictive value was 34% (95% CI: [0.21; 0.49]) and the negative predictive value was 96.8% (95% CI: [0.89; 0.99]).

CONCLUSION

The detection of HPV in atypical glandular cells seems to be powerful with an excellent negative predictive value but, because of moderate sensitivity and due to the risk of histologic lesion progression, the current recommendations should to be applied with care.

Oncological results and recurrent risk factors following abdominal radical trachelectomy: an updated series of 333 patients

OBJECTIVE

To update the oncological results and identify recurrent risk factors in young patients with early stage cervical cancers following abdominal radical trachelectomy (ART).

DESIGN

Retrospective study.

SETTING

A university-based cancer hospital.

POPULATION

Three hundred and thirty-three patients.

METHODS

We conducted a retrospective analysis from a prospectively maintained database of patients undergoing ART from April 2004 to December 2017.

MAIN OUTCOME MEASURES

Survival rate, clinicopathological factors related to recurrences.

RESULTS

Two hundred and seventy-one patients had squamous carcinomas (SCC), 51 had pure adenocarcinomas (AC), and 11 had adenosquamous carcinomas (AS). One hundred thirty-two women (39.6%) had tumours ≥2 cm. With a median follow up of 56 months (range, 6-169), 11 patients (3.3%) had recurrence, and five patients (1.5%) died. The cumulative 5-year recurrence-free survival and overall survival rates were 96.3 and 98.6%, respectively. The recurrence rate in women with tumours ≥2 cm was comparable to that in patients with tumours <2 cm (5.3 versus 2.0%, respectively, P = NS). However, the recurrence rate was significantly higher in patients with AS histology than those with AC and SCC histology (18.2, 3.9, and 2.6%, respectively, P < 0.05). All of the recurrent patients with AS histology had tumours ≥2 cm. Multivariate analysis showed that the only independent risk factor for recurrence was histology type.

CONCLUSIONS

This updated series showed a favourable survival rate following ART. These results further supported that ART was a safe option for well-selected patients with stage IB1 cervical cancers ≥2 cm. However, if patients with tumours ≥2 cm have AS histology, they should be advised with great caution when contemplating ART.

TWEETABLE ABSTRACT

Abdominal radical trachelectomy could be a safe, fertility-sparing option for strictly selected patients with stage IA1-IB1 cervical cancers ≤4 cm.

Oncological and reproductive outcomes of adenocarcinoma in situ of the cervix managed with the loop electrosurgical excision procedure

Background

The standard treatment for cervical adenocarcinoma in situ (AIS) is hysterectomy, which is a more aggressive treatment than that used for squamous intraepithelial lesions. Several previous studies have primarily demonstrated that the loop electrosurgical excision procedure (LEEP) is as safe and effective as cold knife cone (CKC) biopsy when AIS is unexpectedly found in a loop excision. This study evaluated the safety of LEEP as the initial treatment for patients with AIS who were strictly selected and evaluated before and after loop resection.

Methods

The oncological and reproductive outcomes of a series of AIS patients who underwent LEEP as the initial treatment between February 2006 and December 2016 were retrospectively evaluated.

Results

A total of 44 women were eligible for analysis. The mean age at diagnosis was 36.1 years, and 14 patients were nulliparous. Multiple lesions were identified in 4 (9.1%) patients. Either hysterectomy (6 patients) or repeat cone biopsies (3 patients) were performed in 8 of the 10 patients who presented positive or not evaluable surgical resection margins (SMs) on the initial LEEP specimens. Residual disease was detected in two patients. All patients were closely followed for a mean of 36.9 months via human papillomavirus testing, PAP smears, colposcopy, and endocervical curettage when necessary. No recurrences were detected. Of the 16 patients who desired to become pregnant, 8 (50%) successfully conceived, and the full-term live birth rate was 83.3% among this subgroup.

Conclusions

LEEP with negative SMs was a safe and feasible fertility-sparing surgical procedure for patients with AIS, and the obstetric outcome was satisfactory. However, long-term follow-up is mandatory.

Surgical treatment and outcome of early invasive adenocarcinoma of the uterine cervix (FIGO stage IA1)

AIM

To investigate the surgical outcome of FIGO stage IA1 cervical adenocarcinoma.

METHODS

Between 2005 and 2011, 12 patients from Kyushu University Hospital had cervical adenocarcinoma, with a tumor depth of less than 3 mm and a horizontal width of less than 7 mm (FIGO stage IA1), diagnosed by cervical conization. All patients underwent simple hysterectomy or simple trachelectomy with pelvic lymphadenectomy.

RESULTS

The mean patient age was 34 years (range, 26-70 years). The median follow-up period was 70.5 months (range, 26-99 months). No pelvic lymph-node metastasis was seen, and no patient experienced disease recurrence.

CONCLUSION

Early invasive cervical adenocarcinoma with a depth of invasion of 3 mm or less and a horizontal spread of 7 mm or less has little potential for nodal metastasis or recurrence. Therefore, simple hysterectomy or trachelectomy, without lymphadenectomy, might be an alternative treatment option for stage IA1 cervical adenocarcinoma.

Risk of persistent and recurrent cervical neoplasia following incidentally detected adenocarcinoma in situ

BACKGROUND

Adenocarcinoma in situ of the uterine cervix is a precursor to cervical adenocarcinoma and may coexist with both adenocarcinoma and high-grade squamous dysplasia (cervical intraepithelial neoplasia 2 and 3). Up to 60% of adenocarcinoma in situ lesions are detected incidentally following excisional biopsies performed for the treatment of cervical intraepithelial neoplasia 2/3. To date there are no data regarding risk factors for persisting or progressive cervical neoplasia in these patients.

OBJECTIVE

We sought to investigate patient outcomes following incidentally detected cervical adenocarcinoma in situ after loop electrosurgical excision procedure or cold knife cone biopsy performed for the treatment of high-grade cervical intraepithelial neoplasia.

STUDY DESIGN

We conducted a retrospective, population-based cohort study of Western Australian patients with an incidental diagnosis of adenocarcinoma in situ from 2001 through 2012. Primary outcomes were persistent or recurrent cervical intraepithelial neoplasia 2/3 and or adenocarcinoma in situ, and invasive adenocarcinoma during follow-up (<12 months) and surveillance (≥12 months) periods.

RESULTS

The cohort comprised 298 patients, with 228 (76.5%) treated initially by loop electrosurgical excision procedure and 70 (23.5%) treated by cold knife cone biopsy. The mean age was 31.2 (range 18-68) years and the median length of follow-up was 2.4 (range 0.3-12.2) years. Overall, 11 (3.7%) patients had cervical intraepithelial neoplasia 2/3, 23 (7.7%) had adenocarcinoma in situ, and 3 (1.0%) had adenocarcinoma diagnosed during the follow-up and surveillance periods. Age >30 years, pure adenocarcinoma in situ lesions, and larger lesions (>8 mm) were associated with a greater risk of disease persistence or recurrence.

CONCLUSION

Following the incidental detection of adenocarcinoma in situ, age >30 years, pure adenocarcinoma in situ lesions, and lesions >8 mm were significantly associated with disease persistence/recurrence. In younger women, incidentally detected adenocarcinoma in situ that coexists with cervical intraepithelial neoplasia 2/3 and is <8 mm extent with clear margins may not require reexcision.

The effect of coexisting squamous cell lesions on prognosis in patients with cervical adenocarcinoma in situ

OBJECTIVE

The aim of this study was to assess the relative incidences of cervical adenocarcinoma in situ (AIS) and squamous cell carcinoma in situ (sCIS) and to determine the effect of coexisting squamous cell lesions on prognosis in patients with cervical AIS.

STUDY DESIGN

We performed a retrospective review of patients diagnosed with AIS or sCIS who underwent cervical conization at a University hospital between 2000 and 2011.

RESULTS

A total of 1184 patients with cervical carcinoma in situ were included. The ratio of sCIS to AIS was 16:1. Among 71 patients with AIS, AIS with coexisting squamous cell lesions and AIS alone were detected in 41 patients (58%) and 30 patients (42%), respectively. During the median follow-up of 57.1 months, 5 episodes of AIS recurrences and one episode of invasive recurrence occurred. The recurrence rate was significantly higher in patients with AIS alone than in patients with AIS and coexisting squamous cell lesions (17% versus 2%; P=0.043).

CONCLUSION

These results suggest that patients with cervical AIS and coexisting squamous cell lesions have a more favorable prognosis than patients with AIS alone.

The spectrum of cervical glandular neoplasia and issues in differential diagnosis

CONTEXT

Premalignant and malignant glandular lesions of the cervix are known to often cause diagnostic problems with a variety of benign (more common) as well as other malignant mimics, the latter setting often being represented by secondary involvement by endometrioid endometrial carcinoma especially in small samplings.

OBJECTIVE

To highlight key histologic features and immunohistochemical markers that may be helpful in the distinction of in situ endocervical carcinoma from benign glandular proliferations, and those that separate different subtypes of invasive endocervical carcinoma, as well as invasive carcinoma from other carcinomas secondarily involving the cervix and nonneoplastic proliferations of the cervix.

CONCLUSIONS

Clinical and morphologic features as well as immunohistochemistry results should be used in conjunction in the differential diagnosis of glandular proliferations of the cervix, as correct interpretation has major clinical consequences for the patient in most instances (especially benign versus malignant). Immunohistochemical markers should be used as part of a panel of antibodies, as exceptions may occur to the usual pattern of staining, and if used singly, they may mislead the pathologist to establish a wrong diagnosis.

Cervical conization of adenocarcinoma in situ: a predicting model of residual disease

OBJECTIVE

To determine factors associated with the presence of residual disease in women who have undergone cervical conization for adenocarcinoma in situ (ACIS) of the cervix.

STUDY DESIGN

We identified women who underwent a cervical conization for a diagnosis of ACIS followed by repeat conization or hysterectomy between Jan. 1, 1995, and April 30, 2010. Data were summarized using standard descriptive statistics.

RESULTS

Seventy-eight patients met study criteria. The presence of ACIS at the internal conization margin or in the postconization endocervical curettage (ECC) correlated with residual ACIS (P < .001). A margin positive for ACIS was associated with residual glandular neoplasia in 68% of cases. An endocervical curettage positive for ACIS was associated with residual ACIS in 95% of cases. If both the margins and the endocervical curettage were positive for the presence of ACIS, 8% did not have residual disease, 77% had residual ACIS, and 15% had invasive adenocarcinoma. If both the internal conization margin and the postconization ECC were negative for the presence of ACIS, 14% of the final specimens had residual ACIS and none had invasive cancer.

CONCLUSION

The addition of postconization ECC to cone biopsy for ACIS of the cervix provides valuable prognostic information regarding the risk of residual ACIS. Women with ACIS who have both a negative postconization ECC and a negative conization margin have a 14% risk for residual ACIS and can be treated conservatively if desiring fertility. A positive postconization ECC or internal margin incurs significant risk of residual disease and 12-17% will have cancer.

Intestinal-type endocervical adenocarcinoma in situ: an immunophenotypically distinct subset of AIS affecting older women

Conventional endocervical adenocarcinoma in situ (cAIS) is typically strongly and diffusely positive for p16 with a high Ki67 index consistent with its frequent association with high-risk human papillomavirus (HPV) infection. The intestinal variant (iAIS) is less common, and its relationship to HPV infection has not been thoroughly examined. This study compares the clinicopathologic features, frequency of HPV infection, and expression of CDX2 and surrogate biomarkers of HPV infection (p16, Ki67) in cAIS with those of iAIS. A total of 86 cases with a diagnosis of AIS (49 iAIS, 37 cAIS) were identified from our multi-institutional files. Of these, 13 iAIS and 20 cAIS cases had slides and tissue available for histopathologic review, immunohistochemical analysis, and molecular tests. All 86 cases were used to evaluate clinical parameters; however, HPV DNA analysis and immunohistochemical analysis for p16, MIB-1, CDX2, and p53 were performed only on those cases with available slides or paraffin blocks. The average age at diagnosis was significantly higher in iAIS compared with that in cAIS (44.5 vs. 32.6 y) (P=0.0001). All 20 cAIS cases showed moderate to strong and diffuse p16 staining; however, only 9/13 iAIS cases showed this degree of p16 staining, whereas 4/13 (31%) iAIS cases showed weak and patchy distribution (P<0.02). Only 6/9 (67%) iAIS cases were positive for either HPV type 18 (5) or 33 (1), in contrast to 11/11 conventional cAIS (P=0.04). Similarly, 12/14 cAIS, but only 5/13 iAIS, cases showed a high Ki67 proliferative index. CDX2 was positive in all iAIS cases, whereas p53 was negative. Most iAIS cases are positive for high-risk HPV and show moderate to strong and diffuse p16 staining; however, a subset of iAIS shows variable staining with p16 and Ki67, is not associated with HPV, and occurs in a distinctly older age group suggesting an alternative pathogenesis. Awareness that iAIS can show variable staining for p16 and Ki67 is important when resolving problematic endocervical lesions, particularly in small biopsies with unusual p16 staining patterns.

[Adenocarcinoma of the uterine cervix: particularities in diagnosis and treatment]

INTRODUCTION

The adenocarcinoma of the uterine cervix accounts for 10 to 20% of the premalignant and malignant lesions and is different from the cervical intraepithelial neoplasia and invasive squamous cell carcinoma.

MATERIALS AND METHODS

Recent literature review (from 1985 to 2012) based on the literature available.

RESULTS AND DISCUSSION

Adenocarcinoma in situ is an induced HPV lesion (role of HPV 18) of the glandular epithelium: its preferential endocervical situation explains the difficulties in the diagnosis and follow-up after conservative treatment. If the hysterectomy remains the gold standard for treatment, the conservative treatments (resection in sano of the lesions with margins of more than 1cm, meticulous study of the operative specimen, compliance with the follow-up) are possible in the young patients who desire to preserve their fertility. The invasive adenocarcinoma is characterized by a more difficult diagnosis because of its endocervical development, and a prognosis less favorable when compared to squamous cell carcinoma with a greater frequency of the lymphatic node involvement and metastatic diffusion. Its treatment must take into account the particular gravity of the factors of worse prognosis (FIGO stage, tumor size, lymphatic node spreading, adenosquamous histological subtype) in particular in the advanced stages and includes beside the surgery, radiotherapy and chemotherapy.

Neoplastic Lesions of the Cervix

This review presents a discussion of the gross and microscopic features, diagnosis, differential diagnosis, and prognosis of neoplastic lesions of the cervix. Biomarkers are discussed for each entity presented - cervical intraepithelial neoplasia, squamous carcinoma, glandular neoplasms, adenocarcinoma in situ, adenosquamous carcinoma, and others.

Carbonic anhydrase IX (CA-IX) and high-risk human papillomavirus (H-HPV) as diagnostic biomarkers of cervical dysplasia/neoplasia in Japanese women with a cytologic diagnosis of atypical glandular cells (AGC): a Gynecologic Oncology Group (GOG) Study

Background:

High-risk human papillomavirus (H-HPV) infection is linked to cervical neoplasia but its role in detecting cervical glandular lesions (GLs) is unclear. Carbonic anhydrase IX (CA-IX) is a hypoxic biomarker that is highly expressed in neoplastic cervical GLs. The diagnostic utility of these biomarkers was evaluated by the Gynecologic Oncology Group in Japanese women with a cytological diagnosis of atypical glandular cells.

Methods:

Immunostaining was used to detect CA-IX in a conventional Pap smear. Immunoreactivity of CA-IX was interpreted by a panel of pathologists blinded to the histological diagnosis. Polymerase chain reaction was used to detect H-HPV in a liquid-based cytology specimen.

Results:

Significant cervical lesions (SCLs), defined as cervical intraepithelial neoplasia (CIN2, CIN3), adenocarcinoma in situ or invasive carcinoma, were observed in 37/88 (42%) of women. CA-IX testing alone (n=88) had a sensitivity of 89, 100 or 73% for SCLs, GLs or significant squamous lesions (SLs), respectively, with a false negative rate (FNR) of 14%. Testing for H-HPV (n=84) had a sensitivity of 65, 53 or 80% for SCLs, GLs or SLs, respectively, with a FNR of 22%. The combination of CA-IX and H-HPV testing had a sensitivity of 97, 100 or 93% for SCLs, GLs or SLs, respectively, with a FNR of 5%. Among eight H-HPV-negative GLs, six (75%) had a diagnosis of lobular endocervical glandular hyperplasia (LEGH).

Conclusion:

The combination of CA-IX and HPV testing improved the diagnostic accuracy. The low rate of H-HPV positivity in the GLs was associated with coexisting LEGH independent of H-HPV.

Carbonic anhydrase IX and human papillomavirus as diagnostic biomarkers of cervical dysplasia/neoplasia in women with a cytologic diagnosis of atypical glandular cells: a Gynecologic Oncology Group study in United States

High-risk human papillomavirus (H-HPV) infection is strongly linked to cervical neoplasia, but its role in detecting glandular lesions (GLs) is unclear. In the cervix, carbonic anhydrase IX (CA-IX) is expressed in cervical neoplasia, but rarely in the benign cervix. The diagnostic utility of these biomarkers was evaluated in women with a cytologic diagnosis of atypical glandular cells (AGC). H-HPV was detected using hybrid capture 2 (HC2) in liquid-based cytology, and CA-IX immunoreactivity was studied on conventional Pap smears. Of 403 patients, 111 (28%) were positive for significant cervical lesions (SCLs) including CIN2, CIN3, adenocarcinoma in situ or invasive carcinoma. CA-IX testing alone (n = 403) had a sensitivity of 75, 95 or 65% for SCLs, significant GLs or squamous lesions (SLs), respectively, with a specificity of 88% and a false negative rate (FNR defined as 1 minus negative predictive value) of 10%. Testing for H-HPV (n = 122) had a sensitivity of 97, 100 or 96% for SCLs, GLs or SLs, respectively, with a specificity of 87% and a FNR of 1%. The combination of CA-IX and H-HPV testing (n = 122), collectively, had the same sensitivity, specificity and FNR for SCLs, GLs or SLs as H-HPV testing alone. The conclusions of our study are that both H-HPV and CA-IX testing are useful diagnostic markers for GLs. However, H-HPV testing is a better diagnostic marker for SLs. The combination of CA-IX with H-HPV testing does not improve the diagnostic accuracy for cervical neoplasia in women with AGC diagnosis over that of H-HPV testing alone.

Current concepts in cervical pathology

CONTEXT

The correct diagnosis and reporting of cervical in situ and invasive carcinoma are essential for the appropriate clinical management of patients with human papillomavirus-associated disease.

OBJECTIVES

To review common mistakes made in the diagnosis of cervical dysplasia and invasive carcinoma, describe variants and benign mimics of high-grade squamous intraepithelial lesion and adenocarcinoma in situ, and discuss available ancillary studies that can be useful in making the distinctions as well as to review important factors related to prognosis that should be included in the pathology report.

DATA SOURCES

Review of current literature.

CONCLUSIONS

There are many mimics and variants of cervical squamous and glandular lesions that can be resolved with ancillary studies and careful histologic examination. Prognostically important features, such as tumor size, presence of vascular invasion, and margin status, should always be included in the pathology report.

Adenocarcinoma in situ of the uterine cervix: a metaanalysis of 1278 patients evaluating the predictive value of conization margin status

OBJECTIVE

We sought to determine the value of conization margin status in predicting residual and recurrent adenocarcinoma in situ (ACIS) of the cervix.

STUDY DESIGN

In all, 33 studies (1278 patients) were identified. Metaanalysis with pooled Mantel-Haenszel odds ratio (OR) was used to compare the risk of residual and recurrent disease according to margin status.

RESULTS

A repeated excisional procedure was performed in 607 patients; a positive conization margin was associated with a significant increase in the risk of residual disease (OR, 4.01; 95% confidence interval [CI], 2.62-6.33; P < .001). Of the 671 patients followed up with surveillance only, 2.6% with negative margins and 19.4% with positive margins developed a recurrence (OR, 2.48; 95% CI, 1.05-6.22; P < .001). Invasive adenocarcinoma was more commonly associated with positive margins (5.2%) compared with negative margins (0.1%).

CONCLUSION

After conization for ACIS, patients with positive margins are significantly more likely to have residual or recurrent disease, whereas those with negative margins may be treated conservatively.

[Persistence and recurrence of in situ cervical adenocarcinoma after primary treatment. About 121 cases]

OBJECTIVE

The aim of this study is to assess the results of conservative management of adenocarcinoma in situ (AIS) of the uterine cervix.

PATIENTS AND METHODS

Retrospective multicentric study with 121 cases. Patients with cervical invasive lesions were excluded. General characteristics of population, diagnosis circumstances, treatment, histology and evolution were studied.

RESULTS

Conservative treatment was performed in 98.3% of cases with 64% of negative margins. In the positive margins group, 80% of conservative treatments were performed by electrosurgical loop. Length of cone resection is significantly higher for conization with negative margins (p<0.001). The rate of residual lesion was 18% in negative margins group and 46% in positive margins group. Two noninvasive and one invasive recurrence were deplored.

DISCUSSION AND CONCLUSION

Conservative surgery for patients with AIS could be considered in young patients but several conditions should be respected: careful follow-up after conservative treatment; cold knife conization; length of cone specimen greater than 25 mm and negative margins.

Cold knife versus laser cone biopsy for adenocarcinomain situof the cervix-a comparison of management and outcome

Eighty-two patients with adenocarcinoma in situ of the cervix managed at Royal Prince Alfred Hospital were reviewed and data were collected on those treated by cold knife cone biopsy (n= 38) and laser cone biopsy (n= 44). No differences were found in patient age, cytologic or referral history, or outcomes. Having laser excision did not compromise margin status or subsequent management. Invasive disease was found in 24 patients, 16 of whom were managed conservatively with good outcome. Twelve of these were in the laser cone group. In those patients from both groups managed conservatively, there was only one recurrence, squamous preinvasive disease after 8 years. Laser cone biopsy is as effective as cold knife cone biopsy with no compromise of outcome for these patients.

Cervical adenocarcinoma in situ: the predictive value of conization margin status

OBJECTIVE

We evaluated the impact of conization margin status on outcomes of patients diagnosed with cervical adenocarcinoma in situ.

STUDY DESIGN

A retrospective chart review identified patients at a University hospital from 1988-2006 with adenocarcinoma in situ (AIS) on conization.

RESULTS

Seventy-four patients were included. Median follow-up was 26 months. Twenty-two of 74 patients (30%) had positive margins, 46 patients (62%) had negative margins, and 6 patients had indeterminate margins. Of patients with positive margins, 55% (12/22) were diagnosed with residual or recurrent disease, including 3 patients diagnosed with adenocarcinoma on hysterectomy. Thirteen percent of patients with negative conization margins (6/46) were diagnosed with residual or recurrent disease, including 2 patients diagnosed with adenocarcinoma during follow-up. Cold knife conization resulted in a significantly higher number of negative margins compared to other conization procedures (P = .013).

CONCLUSIONS

Even with negative conization margins, women still face a risk of residual, recurrent, or invasive disease.

Lobular endocervical glandular hyperplasia as a presumed precursor of cervical adenocarcinoma independent of human papillomavirus infection

OBJECTIVES

The aim of this study was to investigate differences in the process of carcinogenesis between adenocarcinoma coexistent with LEGH and conventional adenocarcinoma. And we intend to describe appropriate treatment plans for LEGH in this study.

METHODS

Using the surgical pathology files of patients who visited the University of Yamanashi Hospital, Yamanashi Central Hospital and Kofu Municipal Hospital between 1996 and 2005, pathological diagnoses were reevaluated based on criteria for the diagnosis of LEGH by Nucci et al. As for the cases including adenocarcinoma with LEGH: (a) we created a map showing position of the LEGH component and adenocarcinoma component and squamo-columnar junction (SCJ) in HE-stained specimens, (b) immunohistochemical staining was performed using antibodies to CEA, HIK1083 and p53, and (c) detection of HPV DNA was performed using PCR and in situ hybridization (ISH).

RESULTS

Endocervical adenocarcinoma was observed coexistent with LEGH in 5 cases (19.2%). (a) LEGH was located in a remote place from the SCJ. Sizes of lesions in the 5 cases ranged from 18 to 35 mm in width and 7 to 16 mm in depth. (b) HIK1083 was diffusely immunopositive in the cytoplasm of LEGH component and focal immunopositive in 4 cases with adenocarcinoma component. Immunopositivity for CEA was seen in the cytoplasm of adenocarcinoma component in 4 cases. Immunopositivity for p53 was seen in adenocarcinoma component nuclei in 2 cases. (c) HPV DNA was not detected using PCR and ISH in either LEGH or adenocarcinoma components.

CONCLUSIONS

The present study suggests that clear differences exist in the process of carcinogenesis between adenocarcinoma associated with LEGH and conventional adenocarcinoma. LEGH may represent a precursor of cervical adenocarcinoma independent of HPV infection. As LEGH displays characteristics of precancerous mucinous adenocarcinoma, surgical treatment should be considered for LEGH growing beyond a certain size.

Human papillomavirus (HPV) test and PAP smear as predictors of outcome in conservatively treated adenocarcinoma in situ (AIS) of the uterine cervix

OBJECTIVE

The present study assessed (i) the clinical outcome of patients with conservatively treated cervical adenocarcinoma in situ (AIS), (ii) the accuracy of diagnosing AIS by cytology, colposcopy and histology, as well as (iii) the performance of cervical cytology and HPV testing in detection of residual or recurrent disease after conservatively treated AIS.

METHODS

A series of 42 consecutive women (mean age 40.5 years; range 27-63 years) underwent conservative (cone) treatment of AIS and were prospectively followed up for a mean of 40 months (median 42 months), using colposcopy, PAP smear, biopsy and HPV testing (with hybrid capture II) repeated at 6-month intervals.

RESULTS

In their referral PAP test, only 42.9% of patients had atypical glandular cells (AGC) smear. Colposcopy was unsatisfactory in 54.8% cases and negative in 16.7%. Twenty four patients (57.1%) had AIS as a pure lesions and 18 combined with squamous cell lesion (four had invasive SCC). Persistent or recurrent disease was observed in 17 (40.4%) cases, 19% in patients with free margins, and 65% among those with involved margins on the first conization. In four patients, an adenocarcinoma (AdCa) stage IA1 was diagnosed during the follow-up. HPV testing significantly predicted disease persistence/clearance with OR 12.6 (95% CI 1.18-133.89), while the predictive power of PAP smear did not reach statistical significance at any of the follow-up visits. The combination of PAP smear and HPV testing gives SE of 90.0%, SP 50.0%, PPV 52.9% and NPV 88.9% at first follow-up, and 100% SE and 100% NPV at the second follow-up visit.

CONCLUSIONS

These results suggest that HR-HPV test in conjunction with cytology offers clear advantages over single cytology in monitoring the women conservatively treated for cervical AIS.

Clinical utility of atypical glandular cells (AGC) classification: Cytohistologic comparison and relationship to HPV results

OBJECTIVES

To determine the utility of the category of atypical glandular cells (AGC) in the management of patients with putative cervical neoplasia and to correlate HPV-DNA test results when available.

METHODS

The Johns Hopkins Hospital cytopathology records of 50,668 women patients were searched for all liquid-based gynecologic cytology (LBP) results of Atypical Glandular cells of Undetermined Significance (AGUS) and AGC from January 1, 2001 through December 31, 2003, yielding 98 patients (0.19%). Oncogenic HPV-DNA tests were performed on the residual fluids of 43 of these patients, 37 of whom had follow-up biopsy. During the period of January 1, 2000 and December 31, 2002, we identified 237 patients (0.58%) with conventional Pap smears in the AGUS or AGC category, among 41,024 conventional smears collected contemporaneously. To avoid confusion in this paper, AGC will be used to replace those results that originally were AGUS.

RESULTS

Following the 98 LBP AGC interpretations, 24 lesions (33.8%) were discovered out of 71 biopsies. HPV-DNA tests were performed on the residual of 43 LBPs, 18 (41.9%) were positive for oncogenic HPV. Only 37 patients had follow-up biopsy and 15 (40.5%) were positive for oncogenic HPV, of which 40% (6/15) had a significant lesion. Of the 237 conventional AGC Paps, 18 lesions (15.3%) were discovered out of 118 biopsies.

CONCLUSIONS

Comparison of liquid-based and conventional Pap tests revealed a significant difference (33.8% vs. 15.3% respectively) (OR: 2.84, 95% CI: 1.4-5.73, p=0.004) in the detection of glandular and squamous lesions. HPV testing may prove beneficial to triage AGC patients with negative colposcopic findings and positive HPV results.

[Management of in situ cervical adenocarcinoma]

The management of adenocarcinoma in situ of the cervix (ACIS) is difficult because it is often diagnosed in younger women who may wish to preserve their potential of fertility. Conservative treatment has been accepted as an appropriate strategy but interrogations persist as to carcinological safety. We report a complete review of the literature on this subject where conservative attitude appears possible but is associated with recurrence risk (5 to 10%) and invasive disease (2%). Conditions to perform conservative management are: cold knife cone biopsy, negative margins, cone resection of at least 25 mm, realization of endocervical curettage and total patient compliance. In all cases, regular cytological and histological monitoring must be performed. If maintaining reproductive capacity is not desired, hysterectomy is systematically proposed to patient.

Measurement of endocervical canal extension of the transformation zone on fresh hysterectomy specimens

OBJECTIVE

Determine the extent of endocervical canal extension of the transformation zone on fresh hysterectomy specimens.

MATERIALS AND METHODS

After removal for standard gynecologic indications, 201 uteri were evaluated in the pathology accessioning area of a community hospital before formalin fixation. Uteri were opened in standard fashion. The length of the endocervical canal and the distance from the external cervical os to the most cranial extension of the squamocolumnar junction (SCJ) into the canal were measured grossly to the nearest millimeter. Patient age, menopausal status, and indication for surgery were extracted from the pathology consultation sheet.

RESULTS

The upper limit of the SCJ was located within the canal in 188 of 201 cases (93.5%), including 152 of 162 premenopausal cases (93.8%), 25 of 27 postmenopausal cases (92.6%), and 11 of 12 cases of unknown postmenopausal status (91.7%). The mean distance of SCJ extension was 3.8 mm (SD, 2.5 mm), with a trend toward a shorter distance in the postmenopausal women. The SCJ distance was > or =10 mm in 5 of 188 women (2.7%), all of whom were premenopausal, and > or =5 mm in 41 of 188 women (21.8%). Among women with SCJ extension into the canal, the mean canal length was 33.2 mm (SD, 5.4 mm) for the premenopausal women and 28.3 mm (SD, 5.6 mm) for the postmenopausal women (p < .001).

CONCLUSIONS

Postmenopausal status and advancing age were not associated with an increased depth of the SCJ into the endocervical canal. The high rates of unsatisfactory colposcopy reported for postmenopausal women are more likely the result of anatomic changes precluding visualization of the canal rather than the skill of the colposcopist. A device designed to detect cervical intraepithelial neoplasia within the cervical canal should be capable of evaluating to a depth exceeding 5 mm.

In situ adenocarcinoma and squamous carcinoma of uterine cervix. Pathological and immunohistochemical analysis with cytokeratin 13

OBJECTIVES

The aim of the study was the pathological and immunohistochemical analysis of cytokeratin 13 (CK13) in intraepithelial cervical tumors.

STUDY DESIGN

We studied 415 in situ squamous carcinomas and 13 in situ mucinous cervical type adenocarcinomas of the uterine cervix. All patients underwent laser cervical conization and had a follow-up ranging 12-135 months.

RESULTS

3% of the squamous carcinoma patients recurred during the follow-up period, while the percentage of recurrence of in situ adenocarcinoma patients was 7.6%. We observed positive surgical edges in 46.1% of glandular tumors, and in 5% of squamous tumors. The percentage of recurrence was high among the cases with positive borders independently from their histopathologic type (14.3% in the squamous carcinomas versus 50% in the adenocarcinomas), compared to cases with negative edges (2.3% in the squamous carcinomas versus 0% in the adenocarcinomas). We observed CK13 positive staining in cervical squamous tumors and in mucinous cervical type adenocarcinomas, while there was no positive staining in non-neoplastic cervical glandular elements.

CONCLUSION

CK13 positive immunostaining among in situ squamous and in situ mucinous cervical type adenocarcinoma cases adds additional evidence to data supporting a common origin of the two lesions.

Concepts in gynaecological pathology: recent advances and their clinical relevance

This is a review of the surgical pathology of the neoplastic and preneoplastic conditions of the female genital tract as well as the secondary Mullerian system. The review is aimed at discussion of entities and concepts that affect prognosis and patient management.

Prognostic factors and clinicopathologic characteristics of invasive adenocarcinoma of the uterine cervix

OBJECTIVE

The purpose of this study was to evaluate the outcome of patients with cervical adenocarcinoma and to determine the characteristics and the prognostic factors of this entity.

STUDY DESIGN

This retrospective study was done in the Department of Surgical Oncology of the Salah Azaiz Institute of Tunis with 79 cases of invasive adenocarcinoma of the uterine cervix that were collected from 1990 to 1999. Survival was analyzed according to the Kaplan-Meier method. Univariate analysis of prognostic factors was performed with the test of log rank. Cox regression model was used in multivariate analysis of prognostic factors.

RESULTS

Mean age was 50 years, and metrorrhagia was mostly revealing in 73% of the cases. Early stages (I, IIa, IIb with 1/3 proximal parametrial invasion) and "pure" type adenocarcinoma were found in 78% and 87% of the cases, respectively. Treatment consisted of a radiosurgical combination in 52 cases; exclusive radiotherapy was practiced with 17 patients. The 5 year-overall and disease-free survival percentages were, respectively, 68% and 72.4%. Poor prognostic factors were age >50 years, tumor size >4 cm, advanced stage, tumor grade, and lymph nodes and lymph-vascular space involvement. With the use of multivariate analysis, only stage and lymph node metastases remained significant prognostic factors.

CONCLUSION

This report shows survival and prognostic factors that are similar to those found in previous studies, but unlike the Western countries, our results demonstrate a high rate of early stages and no increase in frequency of cervical adenocarcinoma.

Cytological study of early cervical adenocarcinoma: special reference to the depth of invasion

OBJECTIVE

Early cervical adenocarcinoma (ECA) with a tumour depth of <3 mm has a good prognosis. To clarify the cytological features of ECAs with depth <3 mm, these were compared with those of ECA with 3-5 mm and invasive adenocarcinoma (IA) invading the cervical wall with more than 5 mm in depth.

METHODS

The cervical cytological features of ECAs with depth <3 mm (14 cases) were compared with those of ECA with 3-5 mm (four cases) and IA (13 cases). Cytologically, the presence or absence of tumour diathesis, number of atypical cells, crowded cell groups, groups with glandular structures, feathering, groups with palisading borders, rosettes, clusters, cell shape and size, nuclear shape and size, nucleolar shape and size, chromatin distribution, border and character of cytoplasm, and single cell pattern were evaluated.

RESULTS

A tumour diathesis was seen in five of 14 ECA <3 mm in depth (36%), all four ECA with 3-5 mm (100%) and 11 of 13 IA with more than 5 mm (85%). Single cells, macronucleoli and coarsely granular chromatin pattern were less frequent in ECA of <3 mm than that in ECA with 3-5 mm and IA. The number of atypical cells and glandular structures in ECA was significantly less than that in IA. Cell crowding, feathering, palisading and rosettes were common in both ECA and IA.

CONCLUSION

The characteristic cytological features of ECA with depth <3 mm, having a good prognosis, were clean background, fewer single cells and macronucleoli, and less frequent coarsely granular chromatin pattern compared with those in ECA with 3-5 mm and IA. The number of atypical cells and glandular structures in ECA was significantly less than that in IA. Familiarity with the cytological features of ECA and its mimics is essential.

Endocervical adenocarcinomas associated with lobular endocervical glandular hyperplasia: a report of four cases with histochemical and immunohistochemical analyses

We report on four cases of endocervical adenocarcinoma associated with lobular endocervical glandular hyperplasia using histochemical and immunohistochemical analyses. The patients ranged in age from 59 to 67 years (mean 62 years). Chief complaints were watery vaginal discharge in two cases, genital bleeding in one and no subjective symptoms in one. Cytological examinations of the cervical smears revealed adenocarcinoma cells and benign-looking glandular cells with intracytoplasmic golden-yellow mucin in all cases. Radical hysterectomy was performed in three patients, and simple total hysterectomy was performed in one. From surgical specimens, three tumors were diagnosed as mucinous adenocarcinoma and one was adenocarcinoma in situ. All adenocarcinomas were located proximally on the cervix, and did not involve the transformation zone. Adjacent to carcinoma tissues in the cervix, lobular endocervical glandular hyperplasia was detected. The cells of lobular endocervical glandular hyperplasia were dominantly positive with neutral mucin, and immunohistochemistry revealed that these cells had prominent pyloric gland mucin (HIK1083). Focal immunopositivity for pyloric mucin was also observed in three adenocarcinomas. Either CEA or p53 were immunopositive in all adenocarcinomas and negative in the tissues of lobular endocervical glandular hyperplasia. Histopathological features of the present cases suggest that some endocervical adenocarcinomas may originate from lobular endocervical glandular hyperplasia.

Is laser conization adequate for therapeutic excision of adenocarcinoma in situ of the uterine cervix?

AIMS

To determine the safety of uterine-preserving operations for adenocarcinoma in situ of the cervix.

METHODS

Fifteen cases of adenocarcinoma in situ (AIS) were diagnosed using neodymium:yttrium aluminum garnet (Nd:YAG) laser conization. The accuracy of preconization histology or cytology was evaluated in 15 AIS cases. In these AIS cases, we investigated how far the tumor was located from the squamocolumnar junction (SCJ) and the endocervix. Fourteen cases of the 15 AIS-affected patients were treated using laser conization alone. These patients were closely followed up.

RESULTS

Precise agreement between preconization diagnosis and conization histology was seen in 46.7% (7/15) of the AIS cases. In 14 of the 15 cases of AIS (93.3%), the tumor was adjacent to the transitional zone, within 3 mm of the SCJ, and in the other case (6.7%), the tumor was between 0 and 5 mm away from the SCJ. In all subjects, cone height was 8-18 mm (mean 13.1 mm). None of the 15 patients showed any recurrence of AIS during follow up ranging from 15 to 75 months (43.1 months on average).

CONCLUSIONS

Women with AIS who want to preserve their fecundity might be treated with laser conization alone.

Long-Term Surveillance Is Required for All Women Treated for Cervical Adenocarcinoma In Situ

OBJECTIVE

To measure the recurrence rate of disease in women treated for cervical adenocarcinoma in situ (ACIS) by either hysterectomy or conservative surgical management.

PATIENTS AND METHODS

One hundred patients with a histopathologic diagnosis of ACIS or glandular dysplasia were identified in a retrospective clinicopathological review. Sixty-seven of the 100 patients were managed conservatively by local excision and were followed up for a mean period of 59 months (range, 1-222 months). The remaining 33 patients underwent hysterectomy as the primary management method and were followed up for a mean of 88 months (range, 1-248 months). If there was histologic documentation of ACIS or invasive adenocarcinoma more than 1 year after treatment, this was considered a recurrence.

RESULTS

A total of four recurrences were noted in the 100 patients, three in the conservatively managed group and one in the hysterectomy group. Two late recurrences were noted at 97 and 153 months, one each in the conservatively managed and hysterectomy groups.

CONCLUSIONS

Women who have been treated for cervical ACIS require long-term surveillance for at least 10 years regardless of whether they have undergone hysterectomy or conservative management.

Atypical glandular cells?an update

The diagnostic category of atypical glandular cells (AGC) in the Bethesda system for the reporting of cervicovaginal cytology has undergone significant modification since its inception in 1988. More than a decade later, this category remains a diagnostic challenge to both clinicians and cytopathologists because of the lack of uniform cytologic criteria, the lack of interobserver agreement in the diagnosis, and the lack of standardized patient management guidelines. This article reviews the current classification of AGC in the Bethesda system, the cytomorphologic features and differential diagnosis, the clinical significance of a diagnosis of AGC, and the clinical management of patients with AGC. This article provides a comprehensive clinicopathologic review of the category of AGC.

Glandular cell atypia on Papanicolaou smears

BACKGROUND

The 2001 Bethesda System recommended qualification of atypical glandular cells (AGC) to indicate the site of origin and separated endocervical adenocarcinoma in situ (AIS) from "AGC favor neoplastic" as a specific diagnostic category. To the authors' knowledge, the literature evaluating the reproducibility of Papanicolaou (Pap) smear diagnosis of glandular cell abnormalities with emphasis on the cell of origin is limited. The aim of the current study was to investigate whether a variety of benign to neoplastic glandular lesions can be reliably classified on Pap smear with regard to diagnosis and cell of origin.

METHODS

Twenty-three conventional Pap smears (CPS) with glandular cellular changes varying from benign to adenocarcinoma (ACA) were reviewed by six observers. They were asked to categorize each smear according to cell of origin (endocervical vs. endometrial) and diagnosis (benign, AGC, or ACA). Kappa statistics were used to evaluate interobserver agreement and correlation of interobserver agreement with experience.

RESULTS

There was no consensus among observers for both the origin of the cells and the diagnosis. Interobserver agreement for site was poor (kappa < 0.4) especially in the AGC category. Unanimous agreement for site was reached for 7 of 23 smears (30%). Two of five endocervical AIS were classified as endometrial and another two were classified as benign by four observers. Interobserver agreement was poor in all diagnostic categories (kappa < 0.4) and showed slight correlation with level of experience. Unanimous agreement for diagnosis was reached for only 2 smears (9%). Three of 11 (27%) smears demonstrating preneoplastic/neoplastic processes were diagnosed as benign by 3 observers. Three (25%) benign CPS were diagnosed as ACA by 2 observers. Accurate prediction of the final histologic diagnosis by observers varied from 30% to 87% and did not correlate closely with experience.

CONCLUSIONS

Cytologic diagnosis of glandular lesions by CPS was problematic and suffered from significant interobserver subjectivity.

Atypical glandular cells

The 2001 Bethesda System has radically altered the classification of glandular abnormalities. The recognition of the cytologic features of atypical glandular cells on cervicovaginal smears is important because a significant number of patients will be found to have an underlying cancerous or dysplastic lesion of the exocervix, endocervix, or endometrium. The differential diagnosis of AGC on cytology is diverse and accurate classification is necessary because the most appropriate form of follow-up depends on the specific subcategorization of the atypical glandular cells. Because the level of interobserver agreement in the diagnosis of AGC is poor, effective communication between cytopathologists and clinicians is essential to accurately triage these patients. This article should help the cytology practitioner by providing a comprehensive review of the approach to the interpretation, clinical significance, histopathologic correlation, and management of patients who have atypical glandular cells on gynecologic cytology specimens.

Proposal of a new scoring scheme for the diagnosis of noninvasive endocervical glandular lesions

The differential diagnosis of endocervical glandular lesions can be very difficult, and the interobserver agreement on borderline cases can be low. We are proposing a new scoring system to aid in the reproducibility of the diagnosis of noninvasive endocervical glandular lesions. The total of 67 diagnostically difficult cases were independently reviewed by five pathologists. After the completion of the first round review, a consensus diagnosis was reached for each lesion by all participants. This consensus diagnosis was used as the reference diagnosis. According to the consensus, the lesions included 21 benign/reactive conditions, 7 endocervical glandular dysplasias, and 39 adenocarcinomas in situ. During the second round review, all cases were assessed using the new scoring scheme, according to which separate scores from 0 to 3 were given to each lesion for: 1) nuclear atypia, 2) stratification, and 3) sum of mitoses/apoptoses (counted in the two most active glands, and the average number used). These three scores were then added to result in the total score (0-3 = benign; 4-5 = endocervical glandular dysplasia; 6-9 = adenocarcinoma in situ). Complete agreement between all observers in the first round review was seen in 35 of 67 cases (52.2%), kappa = 0.565. This agreement improved in the second round with the use of the scoring scheme: 52 of 67 cases (77.6%), kappa = 0.705. If the benign and endocervical glandular dysplasia diagnostic categories were combined, the overall agreement in the second round review would be 63 of 67 cases (94%), meaning that the scheme affords accurate distinction between adenocarcinoma in situ and lesser lesions. We propose applying this new scoring scheme to the diagnosis of noninvasive endocervical glandular lesions to improve interobserver agreement. The use of this scheme will result in more consistency of data in series from different institutions and will allow uniformity on the issue of adenocarcinoma in situ precursor lesions.

Symposium part I: adenocarcinoma in situ, glandular dysplasia, and early invasive adenocarcinoma of the uterine cervix

A relative and an absolute increase in the incidence of adenocarcinoma of the uterine cervix has occurred in the United States since 1970. Currently, most pathologists recognize the histologic and cytologic features of invasive adenocarcinoma of the cervix, but there is confusion surrounding the histologic features and biologic behavior of adenocarcinoma in situ, endocervical glandular dysplasia, and the definition of microinvasive adenocarcinoma of the cervix. Similarly, the distinction of in situ adenocarcinoma from an early invasive adenocarcinoma of the cervix may be problematic. This article focuses on the histologic criteria, biologic behavior, and some approaches to therapy for these challenging lesions. General conclusions based largely on published studies include the following: 1) adenocarcinoma in situ (AIS) is a recognizable precursor to invasive adenocarcinoma and can be divided according to distinct histologic subtypes; 2) AIS is multifocal or involves multiple quadrants of the cervix in about half of cases; 3) AIS can be cured by simple hysterectomy and in many cases may be treated effectively by cone biopsy; 4) endocervical glandular dysplasia is not a reproducibly recognizable lesion, and its behavior and existence are undefined; 5) criteria exist to permit the distinction of early invasive adenocarcinoma from AIS in about 80% of cases; 6) microinvasive adenocarcinoma of the cervix is complicated by the presence of multiple definitions; clinical decision making is best guided by assessment and reporting of the depth, horizontal extent, and presence of lymphatic or vascular invasion.

Adenocarcinoma in situ of the cervix: a prospective study of conization as definitive treatment

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of combination laser conization alone as definitive treatment of adenocarcinoma in situ (AIS) and to evaluate the safety of a conservative expectant strategy irrespective of cone margin status.

METHODS

Sixty consecutive patients with histologically proven adenocarcinoma in situ were treated with combination laser conization from 1990 to April 2001. In 58 cases this was considered final therapy, and patients were followed for a mean period of 49 months.

RESULTS

The mean age was 34.9 years. Preconization evaluation demonstrated AIS in 76.7%. In 58 cases conization was considered final therapy, and in these cone margins were involved in 15 cases. Twenty-seven patients (46.6%) were followed for more than 60 months. Totally, 4 recurrences (6.9%) were observed. One recurrence was observed in patients with involved margins (6.7%) 4 months after conization, and 3 recurrences in patients with uninvolved margins (6.9%) were registered, in 2 cases more than 5 years after conization. No case of invasive disease was diagnosed during follow-up. The mean cone height was 19 mm; 16.7% of the cone biopsies were more than 25 mm.

CONCLUSIONS

Combination laser conization was an effective treatment of AIS, and an expectant follow-up schedule based on cytology was demonstrated to be safe irrespective of cone margin status after a significant follow-up period. A potential risk of overtreatment and unnecessary worrying of the patients exists if further treatment is based solely on the status of the cone margins. Only prospective studies of similar strategies will give sufficient evidence for valid recommendations concerning the management of AIS.

Distribution of cervical glandular intraepithelial neoplasia: are hysterectomy specimens sampled appropriately?

AIMS

To establish the validity of assuming that by examining midline blocks from the anterior and posterior lips of the cervix, a previously unsuspected cervical intraepithelial glandular neoplasia (CIGN) lesion would be identified.

METHODS

The distribution of CIGN in 30 cone biopsy specimens of cervix was examined.

RESULTS

Nine low grade and 21 high grade cases were identified involving one or other lip in 29 patients and one or both lateral edges in 20. The distribution of CIGN was unifocal in 20 patients, involved two distinct foci in nine, and three distinct foci in one. Only three patients had a circumferential distribution. Midline disease, either CIGN or squamous cervical intraepithelial neoplasia (CIN), or both, was present in 27 patients.

CONCLUSION

These findings suggest that examining the midline blocks from hysterectomy specimens will result in the identification of CIGN lesions in over 90% of patients, either because the CIGN lesion is present in the midline or because an associated squamous CIN lesion will be identified, which will result in the examination of the entire cervix, with the consequent identification of the CIGN lesion.

Early invasive adenocarcinoma of the uterine cervix: criteria for nonradical surgical treatment

OBJECTIVE

This retrospective study was undertaken to identify selection criteria for nonradical surgery for early invasive adenocarcinoma of the uterine cervix.

METHODS

Seventy-nine patients with surgically treated cervical adenocarcinomas (with invasion to 5 mm or less) were examined clinicopathologically. The evaluation of stromal invasion was conducted according to the FIGO (1995) staging system.

RESULTS

The mean age was 46 (range: 29-73) years, and the median follow-up was 118 (9-348) months. Definitive treatment modalities included radical hysterectomy in 71 (89.9%) cases, modified radical hysterectomy in 2 (2.5%), and simple extrafascial hysterectomy without pelvic lymphadenectomy in 6 (7.6%). Postoperative adjuvant external radiation therapy was given to 5 (6.3%) patients. The histological subtypes were endocervical in 37 (46.8%) cases, endometrioid in 32 (40.5%), and adenosquamous in 10 (12.7%). Forty-one (51.9%) patients had lesions with up to 3 mm of stromal invasion; of these, 24 (58.5%) had lesions with up to 7 mm of horizontal extension (stage IA1). Thirty-eight (48.1%) patients had lesions with stromal invasion greater than 3 mm and no greater than 5 mm; of these, 4 had lesions with no wider than 7 mm of horizontal extension (stage IA2). Of 73 patients with pelvic lymphadenectomy, one (1.4%) tumor (depth: 5 mm; width: 15 mm) had node metastases. Parametrial involvement was present in one (1.4%) patient (lesion depth: 5 mm; lesion width: 16 mm). None had adnexal metastasis. Eighty-eight percent of the patients with stromal invasion up to 3 mm had well-differentiated adenocarcinoma, compared to 53% of the patients with lesions invading more than 3 mm. Of all of the patients, 5 (6.3%) patients who received curative radical hysterectomies had recurrences and died. Among 5 patients, one patient with central pelvic recurrence had a lesion invading to a depth of 3 mm and width of 7 mm, and the others had lesions with more than 3 mm of invasion and 15 to 36 mm of width.

CONCLUSIONS

Patients with early invasive adenocarcinoma to a depth of 3 mm or less stromal invasion, including those who meet the criteria for FIGO stage IA1, may be treated with simple extrafascial hysterectomy without lymphadenectomy and oophorectomy.

Is there a difference in survival for IA1 and IA2 adenocarcinoma of the uterine cervix?

OBJECTIVE

The goal of this study was to determine if International Federation of Obstetrics and Gynecology (FIGO) subdivision into IA1 versus IA2 is predictive of survival differences for early invasive adenocarcinoma.

METHODS

The Surveillance, Epidemiology, and End-Results (SEER) Public-Use Database was used to identify all cases of IA1 and IA2 adenocarcinoma diagnosed between 1983 and 1997. A systematic literature search (MEDLINE 1966-2000) was used to identify all previously published cases. Stage, depth of invasion, node status, therapy, and survival were analyzed using Fisher's exact and log-rank tests.

RESULTS

In SEER, 560 cases were identified: 200 IA1, 286 IA2, and 74 localized. Simple hysterectomy was performed in 272 (48.6%) and radical hysterectomy in 210 (37.5%). Positive lymph nodes were found in 3 of 197 (1.5%) who underwent lymphadenectomy, 2 of whom died. The censored survival by stage (mean follow-up 51.6 months) was not significantly different (P = 0.77) for IA1 versus IA2 (98.5% vs 98.6%). Combining these data with all other published series of early cervical adenocarcinoma, 1170 cases were identified, including 585 IA1, 358 IA2, and 227 "others," with less defined early disease. Of 531 (45.4%) who underwent lymphadenectomy, 15 (1.28%) had one or more positive nodes; of these, 11 (73.3%) recurred or died. For IA1 versus IA2 disease, there were no significant differences in the frequency of positive lymph nodes, recurrence, or death. However, "others," those with less well-defined lesions, or larger than IA2, were at increased risk.

CONCLUSION

Early invasive adenocarcinoma (IA1 and IA2) has an excellent prognosis and conservative surgery may be appropriate. Since current FIGO staging definitions do not distinguish high- from low-risk disease, individualization of therapy based on pathology review, risk assessment, and patient preference is recommended.

[In situ adenocarcinoma of the uterus cervix: difficulties of its cytohistological diagnosis]

In situ adenocarcinoma is regarded as the precursor of invasive adenocarcinoma. It is asymptomatic and early diagnosis relies solely on cytopathologist. It is usually discovered on a cone for squamous CIN. When diagnosis is made by biopsy, conisation is required to exclude invasive adenocarcinoma. Lesion is histologically characterised by epitheliomatous transformation of endocervical glands without invasion of the chorion. By the appearance of glandular cells, different histological varieties are described. They have no influence on the prognosis. Several benign lesions may mimic adenocarcinoma: tubal metaplasia, glandular atypia due to inflammation or irradiation, mesonephric remnants and microglandular hyperplasia. Precursor lesions (atypical hyperplasia, glandular dysplasia, CIGNI and II) are badly morphologically defined. Preferential location of in situ adenocarcinoma is the transformation zone. Because of this topography, if the surgical margins are disease free, conisation alone may be adequate therapy. HPV infection (mainly HPV 18) are incriminated in its pathogenesis.