Gastric-type mucinous endocervical adenocarcinomas: A case report and literature review

Diagnosis and management of gastric-type endocervical adenocarcinoma: A case report and review of the literature

Gastric-type endocervical adenocarcinoma (GEA), a rare subtype of cervical cancer, has garnered increasing attention recently for its distinctive histopathological features, unique classification, genetic characteristics, and variable clinical outcomes compared to squamous cell and adenocarcinoma subtypes. Historically, GEA has evolved from a poorly understood entity to a distinct subtype of cervical adenocarcinoma, only recently recognized in the 2020 World Health Organization (WHO) classification. Accordingly, characteristic morphological features define GEA, shedding light on the diagnostic challenges and potential misclassification that can occur in clinical practice. Genetic alterations, including KRAS, ARID1A, and PIK3CA mutations, play a pivotal role in the development and progression of GEA. This article reviews a case of GEA and aims to provide a contemporary overview of the genetic mutations and molecular pathways implicated in GEA pathogenesis, highlighting potential therapeutic targets and the prospects of precision medicine in its management. Patients with GEA have variable clinical outcomes, with some exhibiting aggressive behavior while others follow a more indolent course. This review examines the factors contributing to this heterogeneity, including stage at diagnosis, histological grade, and genetic alterations, and their implications for patient prognoses. Treatment strategies for GEA remain a topic of debate and research. Here, we summarize the current therapeutic options, including surgery, radiation therapy, and chemotherapy, while also exploring emerging approaches, such as targeted therapies and immunotherapy. This article provides a comprehensive overview of GEA, synthesizing current knowledge from historical perspectives to contemporary insights, focusing on its classification, genetics, outcomes, and therapeutic strategies.

Clinical characteristics of non-HPV infection-associated gastric-type endocervical adenocarcinoma

OBJECTIVES

Gastric-type endocervical adenocarcinoma (GAS) is a special type of cervical adenocarcinoma that is not associated with high-risk human papilloma virus (HPV) infection, making early diagnosis challenging. This study aims to investigate the clinical characteristics, diagnosis, treatment, and prognosis of non-HPV infection-associated GAS, summarize relevant experiences, and improve the ability to recognize early lesions.

METHODS

A total of 21 patients with GAS treated at the Department of Gynecology, Third Xiangya Hospital of Central South University, from April 2016 to February 2023, were included. Clinical data, including age, clinical manifestations, HPV/thin-prep cytology test (TCT) results, tumor markers, imaging examinations, diagnostic methods, Federation International of Gynecology and Obstetrics (FIGO) (2018) staging, pathological results, immunohistochemistry findings, treatment, and follow-up outcomes were collected and analyzed. Kaplan-Meier method was used to calculate survival rates, log-rank test was used to calculate survival rates, log-rank test was used to compare survival differences, and Cox regression method was used to analyze prognostic factors.

RESULTS

The patients' ages ranged from 18 to 67 years [(48.4±12.0) years]. The most common initial symptom was noticeable vaginal discharge in 13 cases, followed by purulent vaginal discharge in 1 case, postmenopausal vaginal bleeding in 3 cases, bleeding during intercourse in 2 cases, prolonged menstruation in 1 case, and lower abdominal distension in 1 case. Except for 2 patients without sexual experience, the remaining patients underwent TCT and HPV testing, with 17 HPV-negative cases and 2 HPV-positive cases (1 for type 16 and 1 unclassified); TCT results were negative in 13 cases, with 2 cases of atypical squamous cells of undetermined significance (ASC-US), 1 case of atypical glandular cells-not otherwise specified (AGC-NOS), 1 case of atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H), and 2 cases of atypical glandular cells (AGC). Preoperative tumor markers were elevated in 6 of 12 cases for CA199, 4 of 21 cases for CA125, 3 of 13 cases for human epididymal protein 4 (HE4), and 1 of 19 cases for squamous cell carcinoma antigen (SCC). Among the 21 patients who underwent preoperative ultrasound, 9 cases were suspected to have cervical malignancy, and 1 case of endometrial malignancy was identified. In the 17 patients who underwent pelvic MRI, 9 cases were suspected of having cervical malignancy, along with 2 cases of endometrial malignancy. In the 9 patients who underwent pelvic CT, 7 cases were suspected of cervical malignancy. For preoperative pathology, 9 patients had a single biopsy with a confirmation rate of 33.3% (3/9), 7 patients had 2 biopsies with a confirmation rate of 71.4% (5/7), and 5 patients had 3 biopsies with a confirmation rate of 100% (5/5), leading to an overall confirmation rate of 61.9% (13/21). All patients underwent surgical treatment, with postoperative pathological staging: 3 cases at stage ⅠB1, 1 case at stage ⅠB2, 2 cases at stage ⅠB3, 1 case at stage ⅡA1, 1 case at stage ⅡA2, 2 cases at stage ⅡB, 7 cases at stage ⅢC1p, and 4 cases at stage ⅢC2p. Para-cervical infiltration was observed in 7 cases, with residual cancer at the vaginal stump in 2 cases, deep stromal infiltration (depth ≥1/2) in 19 cases, lymphovascular space invasion in 15 cases, neural invasion in 9 cases, pelvic lymph node metastasis in 11 cases, and para-aortic lymph node metastasis in 4 cases. The follow-up time ranged from 3.5 to 28.0 months (median: 13.5 months), with 13 cases not experiencing recurrence, 7 cases relapsing (6 deceased, 1 alive with tumor), and 1 case lost to follow-up. The overall survival (OS) ranged from 3.5 to 28.0 months [(22.7±1.8) months], and disease-free survival (DFS) ranged from 3.5 to 28.0 months [(20.4±2.3) months]. OS showed no correlation with age, tumor stage, tumor size, depth of stromal infiltration, lymphovascular space invasion, lymph node metastasis, or treatment method (all P>0.05). Cox regression analysis indicated that age, pathological stage, tumor size, depth of stromal infiltration, lymphovascular space invasion, neural invasion, and lymph node metastasis were not associated with DFS or OS (all P>0.05).

CONCLUSIONS

GAS is rare in clinical practice, prone to missed or misdiagnosis, with a low early diagnosis rate, strong invasiveness, high recurrence and metastasis rates, and poor prognosis. Clinicians should be vigilant for this disease in HPV-negative patients with significant vaginal discharge and consider performing multiple deep tissue biopsies in conjunction with imaging examinations for early diagnosis.

Case Report: A rare case of gastric-type adenocarcinoma of stumps of duplicated cervices in a 49-year-old woman: A case with hidden focus confused us a lot

Gastric-type endocervical adenocarcinoma (G-EAC) is a rare special type of cervical mucinous adenocarcinomas, and it is reported the incidence is unrelated to human papilloma virus infection. We report a rare case of G-EAC in stumps of duplicated cervices in a 49-year-old female patient. The woman complained of post-coital bleeding. She had a didelphic uterus with a duplex cervix, and had undergone subtotal hysterectomy 16 years ago. Gynecological examination revealed a normal-appearing right cervix, but the non-dominant side of the left cervix, which was buried and covered by the side wall of the left vagina, was difficult to view. After exposing, the left side cervix presented a mature appearance which was smaller than a normal cervix. Her serum carbohydrate antigen-19-9 levels was 112.59 U/ml. The right cervix's cytology was normal, whereas the left cervix had unusual glandular epithelial cells. HPV testing on both cervical smears was negative. Adenocarcinoma was identified at 3, 6, 12 o'clock at the right cervix in a colposcopy-directed punch biopsy, while no abnormality was found in the biopsy of the left cervix, nor in the curettage of the double cervices. Pelvic magnetic resonance imaging (MRI) revealed two cervical canals, with a 1.9cm×1.6cm mass inside the left cervix, and the left wall of the right cervix may be involved by the tumor of the left cervix. After much deliberation, we considered that the patient had adenocarcinoma of the left cervix stage IB1. Then, the patient underwent radical cervical resection with bilateral salpingo-oophorectomy and bilateral pelvic lymphadenectomy. Her final histopathology indicated G-EAC of the duplicated cervices. After surgery, she received concurrent chemoradiation. Currently, 29 months after the final chemotherapy was administered, the patient remains healthy. Because G-EAC with duplicated cervices is an uncommon cunning tumor with a bad prognosis, early identification and therapy are recommended to enhance the prognosis. The comprehensive evaluation of symptoms and gynecological examination with cervical cytology, colposcopy-directed punch biopsy, endocervical curettage and MRI examine together may assist in determining an accurate preoperative diagnosis.