Glandular lesions of the cervix: diagnostic and therapeutic dilemmas

Evaluation of causes of increased incidence of cervical cancer in Slovenia

OBJECTIVE

In Slovenia the opportunistic cervical cancer (CC) screening programme has been performed within the regular gynaecological practice since 1960. The incidence rate 28.8/10(5) decreased to 16.1/10(5) in 1982, and increased to 23/10(5) in 1996. To explain the increased CC incidence the patients' screening histories, occurrence of symptoms, and details of preventive measures were studied on the basis of medical records and questionnaire. Errors of cytological screening were analysed by reviewing previous smears.

MATERIAL

The answers obtained from 324 women, treated for CC in the period 1995-2000, were analysed in relation to age, stage and histology. The mean women's age was 46.76 +/- 13.07 (S.D.) years (range 23-85 years). After therapy, 271 patients were followed-up by the end of January 2004, (mean follow-up time 80.3 +/- 20 S.D. months, range 29.7-110.3 months). Statistical analysis was performed using Chi-square test.

RESULTS

In 208 (80%) cases, CC was detected in stage 1, in 43 (17%) in stages 2A to 3B. Squamous-cell carcinoma (192, 74.1%) was followed by adenocarcinoma (61, 23.5%) and (5, 1.9%) other malignancies. The screening interval ranged from 6 months to 4 years. Statistically significant differences existed between clinical and screening variables. CC was diagnosed in higher stages in women who were ignorant of the Pap test. Re-screened smears (n = 126) showed 27.8% of false negative results.

CONCLUSIONS

The reasons for high incidence of CC are poor performance of cytological screening, failures in gynecological examinations and diagnostic procedures, and the patients' negligence of attending regular screening.

Cytology suggestive of glandular neoplasia: outcomes and suggested management

Eighty-three cases having a cervical smear result showing abnormal glandular cells were identified and matched up with the diagnostic histology result. Thirty-four (41.0%) were associated with malignancy and 26 (31.3%) with a cervical intraepithelial lesion without invasion. Thirty-eight (45.8%) had conditions of the cervix as follows: 12 cases had invasive disease of the cervix; nine (10.8%) adenocarcinoma of cervix and three (3.6%) squamous carcinoma of cervix. Nineteen (22.9%) had cervical intraepithelial neoplasia (CIN/SIL) alone and seven (8.4%) had cervical glandular intraepithelial neoplasia (CGIN) +/- CIN. There were 16 (19.3%) cases with malignancies of the uterine corpus and six (7.2%) had a malignancy arising from another primary site. Twenty-three (27.7%) had no malignant or pre-malignant condition. The risk of malignancy was related to age and ranged from 18.2% in those under 35 years to 67.9% in those 55 years and over. A protocol for the management of these cases is described.

[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.

Factors predicting disease outcome in early stage adenocarcinoma of the uterine cervix

CONTEXT

Adenocarcinoma (AC) and adenosquamous carcinoma (ASC) comprise the second principal histological types of cervical carcinoma. As compared with the squamous cell cancer (SCC), these lesions are far less frequent, and their epidemiology, natural history and prognostic determinants are less well understood.

OBJECTIVE

Patients with an early stage AC of the uterine cervix diagnosed in our clinic were subjected to detailed analysis for the prognostic determinants.

STUDY SUBJECTS

A series of 94 women with early stage (adenocarcinoma in situ (AIS) to IIB) cervical ACs or ASCs diagnosed and treated in our department during 1995-1999 and subsequently followed-up for a mean of 43.1 +/- 16.2 (S.D.) months.

MAIN OUTCOME MEASURES

Patients were examined by colposcopy, Papanicolaou (PAP) smear and biopsy. The stage of the disease (FIGO) and tumour histology in operative specimens were recorded, and univariate (Kaplan-Meier) and multivariate survival analysis (Cox) were run to explore the factors predicting disease outcome.

RESULTS

Mean age of the women was 44.2 +/- 2.5 (S.D.) years (range 24-81 years), which is significantly (P=0.000) lower than that (49.9 +/- 14.2) of 464 SCC patients in our material. Minority of the women (38.2%) reported any clinical symptoms, but these correlated with the stage (P=0.041). Screening history was acceptable (i.e. screening interval 3 to 4 years) in 56 women, whereas 28 (29.8%) had no previous PAP smear taken. Interpretation errors were established in 17 (23.6%) and sampling errors in 6 (8.3%) of the 72 smears available for re-screening. No colposcopic lesions were found in 29 (30.9%) women. Follow-up data were available from 72 patients, of whom the disease progressed in four (one died), whereas 68 patients are alive and well at the moment. Patient's age (P=0.000), screening history (P=0.0127), FIGO stage (P=0.001), mode of therapy (P=0.0187), and presence of co-existent squamous cell lesions (P=0.0184) were significant prognostic indicators in univariate survival analysis. Cox's multivariate survival analysis disclosed FIGO stage (P=0.001) and screening history (P=0.006) as the only significant independent predictors of the disease outcome.

CONCLUSIONS

The present data emphasise the importance of early cervical AC as a disease of younger women, making early detection of its precursors (AIS) by regular PAP smear screening mandatory in prevention of disease progression. This can only be achieved by increasing the sensitivity of the PAP smear in detecting abnormal glandular cells in asymptomatic women.

Relation of cervical glandular intraepithelial neoplasia to microinvasive and invasive adenocarcinoma of the uterine cervix: a study of 121 cases

AIMS

To examine the relation between invasive adenocarcinoma and its alleged precursor, cervical glandular intraepithelial neoplasia (CGIN), and to assess the management and outcome of CGIN and the validity of using the term "microinvasive adenocarcinoma."

METHODS

The clinical and pathological features of 121 cases of glandular neoplasia of the cervix diagnosed between the years 1990 to 1995 were examined for the following: histological diagnosis, smear records, type of treatment, the association between the precursor lesions and invasive disease, and follow up.

RESULTS

27 cases were identified as low grade CGIN (L-CGIN) and 38 as high grade CGIN (H-CGIN), 10 as microinvasive adenocarcinoma (less than 5 mm in depth), and 46 as invasive adenocarcinoma. The ratio of non-invasive to invasive disease was 1.12:1. The mean age of women was 39, 43, 43, and 48 years for L-CGIN, H-CGIN, microinvasive, and invasive adenocarcinoma, respectively. L-CGIN was seen in 13% and 18% of H-CGIN and microinvasive disease, respectively. H-CGIN was seen in 100% of microinvasive and 26% of invasive adenocarcinomas. The available smears before diagnosis predicted 59% of L-CGIN, 70% of H-CIGN, 100% of microinvasive adenocarcinoma, and 32% of invasive adenocarcinomas. Treatment of 74% of L-CGIN, 52% of H-CIGN, and 10% of microinvasive adenocarcinoma was by diathermy loop excision only. The remaining cases had hysterectomy. Residual disease was found in 43%, 50%, and 33% of hysterectomies for L-CGIN, H-CGIN, and microinvasive adenocarcinoma, respectively. This is correlated with positive margins, or disease within 3 mm of margins on loop specimens. Cervical smear follow up for two to seven years revealed no recurrence of glandular lesions in any of the cases of CGIN or microinvasive adenocarcinoma.

CONCLUSIONS

Precursor glandular lesions tend to progress to invasive carcinoma. There is a progressive increase in age of patients from L-CGIN to invasive disease, a span of approximately 10 years. There is a high association between H-CGIN and invasive disease. In the management of such alleged precursors, it is important to ensure adequate free margins of at least 3 mm. Microinvasive adenocarcinoma appears to have an excellent prognosis if treated by hysterectomy.