Adenocarcinoma In Situ of the Cervix-Controversies in Diagnosis and Treatment

Cervical Cancer in Women with Normal Papanicolaou Tests: A Korean Nationwide Cohort Study

Purpose

This study aimed to evaluate the risk of cervical cancer diagnosed within 1 year after the last of multiple consecutive normal Papanicolau (Pap) tests.

Materials and Methods

The database of the National Health Insurance Service was used. We obtained Pap test data for 11,052,116 women aged 30–79 between 2007–2012. The cumulative incidence rates and 5-year overall survival rates of cervical cancer diagnosed within 1 year after the last normal Pap test were compared between women with one (N1), two (N2), and three consecutive normal Pap tests (N3). Women who did not receive a Pap test during the study period were assigned in the N0 group.

Results

The 1-year cumulative incidence rates of cervical cancer were 58.9, 24.6, 20.3, and 14.2 per 10⁵ in the N0, N1, N2, and N3 groups, respectively. Compared to the N1 group, the risk of cervical cancer diagnosed within 1 year of the last normal Pap test decreased by 17% (relative risk [RR], 0.825; 95% confidence interval [CI], 0.716 to 0.951) in the N2 group and 42% (RR, 0.578; 95% CI, 0.480 to 0.695) in the N3 group. However, the 5-year survival rate in women diagnosed with cervical cancer within 1 year of the last normal Pap test in the N3 group was not higher than that of the N1 group (79.6% vs. 81.3%, p=0.706).

Conclusion

As normal Pap tests are consecutively repeated, cervical cancer risk significantly decreases. However, previous consecutive normal Pap tests are not associated with improving survival outcomes in women shortly diagnosed with cervical cancer after the last normal Pap test.

Results of cytology and high-risk human papillomavirus testing in females with cervical adenocarcinoma in situ

The incidence rates of cervical adenocarcinoma have been increasing over the last two decades, contrary to those of squamous cell carcinoma. This trend is particularly evident among females aged <40 years and has occurred despite extensive cytology-based screening programs. The aim of the present retrospective database study was to investigate adenocarcinoma in situ (AIS) with respect to previous cytological results, high-risk (HR) human papillomavirus (HPV) infections and histological results from AIS-adjacent squamous mucosa. Databases were used to identify 32 female patients with AIS treated for various conditions between 2009 and 2012 at the Department of Gynecology, Uppsala University Hospital (Uppsala, Sweden) and previous cytological, HPV and histological results. Of the individuals in the study, 64.3% had a previously recorded cytological result showing squamous cell abnormalities; five had glandular cell abnormalities (18%) and two had AIS (7.1%). Among the patients with available HPV results, 95% were HR-HPV-positive; HPV18/45 predominated (77%), followed by HPV16 (27%). The patients with multiple HPV infections were aged ≤32 years, while patients aged ≥38 years were only infected with HPV18/45. All but three patients had cervical intraepithelial neoplasia (CIN) in the AIS-adjacent squamous mucosa, 79% of which was CIN2 or worse. The present retrospective database study suggests that AIS is detected at screening mainly due to simultaneous squamous precursor lesions and that HPV18/45 infection is an increasing cofactor for AIS in older patients. HPV analyses of glandular precursor lesions aid in the identification of female individuals at risk of progression to invasive disease, and thus have a favorable effect on adenocarcinoma prevention, together with vaccination.

Significant decrease of adenocarcinoma in situ not reflected in cervical adenocarcinoma incidence in the Netherlands 1989-2003

Over the period 1989–2003, the incidence of cervical adenocarcinoma (n=1615) was stable whereas that of cervical adenocarcinoma in situ (n=1884) significantly decreased (P=0.008), mainly caused by adenocarcinoma in situ lesions with a concurrent squamous dysplasia.

Endocervical curettage at conization to predict residual cervical adenocarcinoma in situ

OBJECTIVE

To determine if performing an endocervical curettage (ECC) at the time of conization is a useful diagnostic tool for predicting residual cervical adenocarcinoma in situ (AIS) among women who might wish to preserve their fertility.

METHODS

All patients diagnosed with AIS from 1995 to 2000 at four institutions were identified. Data were retrospectively extracted from clinical records. Women included in the statistical analysis were (1) younger than 40 years, (2) had an ECC performed at the time of the initial cone biopsy, (3) had a clearly demarcated surgical margin pathologically, and (4) underwent a second surgical procedure.

RESULTS

Twenty-nine (24%) of 123 AIS patients met criteria for inclusion. The median age was 33 years (range, 17 to 39) and 13 (46%) were nulliparous. Initial surgery was a cold-knife conization (n = 17) or loop electrosurgical excision procedure (n = 12). Twelve (41%) ECCs and 15 (52%) cone margins were histologically positive. Sixteen patients underwent a repeat conization; 13 underwent hysterectomy. Thirteen (45%) patients had residual AIS at the time of their second surgical procedure. ECC had a superior positive predictive value (100% vs 47%; P < 0.01) and negative predictive value (94% vs 57%; P = 0.01) compared to cone margin in predicting residual AIS. None of the women undergoing fertility-sparing surgery developed recurrent AIS or adenocarcinoma.

CONCLUSION

ECC performed at the time of conization may be a useful tool for predicting residual AIS in women considering fertility preservation.