The status and distance of cone biopsy margins as a predictor of excision adequacy for endocervical adenocarcinoma in situ

Margin Status Post Cervical Conization Predicts Residual Adenocarcinoma In Situ (AIS) and Occult Adenocarcinoma in a Predominantly Hispanic Population

Background: Adenocarcinoma in situ (AIS) of the cervix, is increasing in incidence, particularly in women of reproductive age. Fertility preservation is often desired. In a predominantly Hispanic population, we sought to determine the incidence of occult cervical cancer co-existing with AIS, and evaluate how conization margin status correlates with residual disease upon hysterectomy. Methods: A retrospective study utilizing a comprehensive cancer center database was conducted. Data from patients with histologically proven AIS of the cervix were abstracted. Results: Of 47 patients that met the criteria, 23 (49%) were Hispanic, 21 (45%) were White, two (4%) were Asian, and one (2%) was Black. The median age was 37. Forty-two patients underwent cervical conizations; 13/42 (48%) had positive margins upon conization; 28/42 (67%) underwent hysterectomies. Furthermore, 6/13 (46%) patients with positive conization margins had residual disease in hysterectomy specimens, with 2/13 (15%) found to have invasive cancer. In contrast, 0/14 (0%) of patients with negative margins had residual disease (p = 0.036, Chi-squared 4.41, df = 1). In total, 2/27 (7%) patients who underwent hysterectomies had invasive cancer (7%). Conclusions: Positive margins upon cervical conization for AIS of the cervix were correlated with a relatively high rate of residual AIS and occult invasive cancer. Negative conization margins were correlated with no residual disease. Those patients may be candidates for fertility-sparing treatment.

Follow-up Findings in Postconservative Treatment Surveillance for Women With Cervical Adenocarcinoma In Situ

OBJECTIVES

The risks of adenocarcinoma in situ (AIS) recurrence or progression after conservative treatment are uncertain. The aim of this study was to examine the role of high-risk human papillomavirus (hrHPV) and cytology in the posttreatment surveillance of AIS patients.

MATERIALS AND METHODS

Follow-up results of hrHPV status, cytology results, and clinicopathological features of 207 patients were retrospectively analyzed, in whom AIS was initially treated by loop electrosurgical excision procedure (LEEP)/cone biopsy between September 2009 and June 2018.

RESULTS

Among 207 patients diagnosed AIS on LEEP/cone biopsy, 30.9% (64/207) had positive margins. Persistent/recurrent AIS rate was substantially higher in the patients with positive margins than in those with negative margins (47.2% vs 9.3%, p < .001). Of 74 patients with hrHPV surveillance, 17 (17/74, 23.0%) were found to have positive hrHPV and 4 (4/17, 23.5%) had the persistent/recurrent AIS regardless of margin status. On the contrast, no AIS were found in negative surveillant hrHPV patients (23.5% vs 0%, p < .001). Lastly, 27.8% patients (22/79) were reported atypical glandular cells on surveillant cytology, and 9 persistent/recurrent AIS cases were further identified on second biopsy or hysterectomy with a positive detection rate of 40.9%.

CONCLUSIONS

In this study, we concluded the positive margin on LEEP/cone biopsy in AIS patients was associated with a significantly greater risk of disease persistence or recurrence. The posttreatment surveillance by cytology and adjunct hrHPV would be an ideal strategy in predicting AIS persistence and recurrence, which will warrant further treatments.

Villoglandular adenocarcinoma of the uterine cervix: a systematic review and meta-analysis

Purpose

Villoglandular adenocarcinoma (VGA) of the uterine cervix has been classified as a rare subtype of cervical adenocarcinoma with good prognosis. A conservative surgical approach is considered feasible. The main risk factor is the presence of other histologic types of cancer.

In this largest systematic review to date, we assess oncological outcomes associated with conservative therapy compared to those associated with invasive management in the treatment of stage Ia and Ib₁ VGA.

Methods

Case series and case reports identified by searching the PubMed database were eligible for inclusion in this review (stage Ia–Ib₁).

Results

A total of 271 patients were included in our literature review. 54 (20%) patients were treated by “conservative management” (conization, simple hysterectomy, and trachelectomy) and 217 (80%) by “invasive management” (radical hysterectomy ± radiation, hysterectomy, and radiation). Recurrences of disease (RODs) were found in the conservative group in two (4%) cases and in the invasive group in nine (4%) cases. There was no significant difference in disease-free survival (DFS) according to conservative or invasive treatment (p = 0.75). The histology of VGA may be complex with underlying usual adenocarcinoma (UAC) combined with VGA.

Conclusion

The excellent prognosis of pure VGA and the young age of the patients may justify the management of this tumor using a less radical procedure. The histological diagnosis of VGA is a challenge, and pretreatment should not be based solely on a simple punch biopsy but rather a conization with wide tumor-free margins.

Oncologic and obstetric outcomes after conization for adenocarcinoma in situ or stage IA1 cervical cancer

This study aims to reveal the risk factors associated with recurrence or new-onset high-grade squamous intraepithelial lesions (HSILs) or more severe lesions (HSILs +) and analyze obstetrical outcomes in patients with adenocarcinoma in situ (AIS) or stage IA1 cervical cancer patients after conization. A retrospective cohort study was developed from January 1, 2002, and July 1, 2018, in a single center, where all patients with AIS or stage IA1 cervical cancer who accepted conization for primary surgery were reviewed and followed up until July 1, 2019, for the pathological findings of HSILs + and obstetric outcomes. Two hundred and seventeen patients were identified, including 114 cases of AIS, 76 cases of stage IA1 squamous cell carcinoma (SCC) and 27 cases of stage IA1 adenocarcinoma (ADC). A total of 88 (40.6%) patients had an intact uterus without radiotherapy. Five patients experienced HSIL+ recurrence. The cumulative 3-, 5- and 10-year incidence rates of HSILs + were 1.0%, 1.5% and 2.0%, respectively. No significant risk factors, including primary disease, margin status and hysterectomy, were associated with recurrence. Twenty (66.7%) of 30 patients who attempted pregnancy had 23 successful pregnancies, which result in 7 miscarriages, 16 live births and 5 preterm births. Age at conization was the only independent risk factor associated with pregnancy, live births and preterm births. In conclusion, conization is safe for young women with AIS, stage IA1 SCC and ADC who desire future fertility, and the associated HSIL recurrence rate is low. Increased age significantly lowered the conception or live birth rate.

The Evolving Spectrum of Precursor Lesions of Cervical Adenocarcinomas

Modern classification schemes divide cervical adenocarcinomas into human papillomavirus (HPV)-associated and HPV-independent types. The precursor lesions of the former are well known and comprise HPV-associated (usual/endocervical) adenocarcinoma in situ (AIS) and the much less common stratified mucin-producing intraepithelial lesion (SMILE). The precursor lesions of HPV-independent cervical adenocarcinomas are much less well known, although postulated precursors of gastric-type adenocarcinoma include atypical lobular endocervical glandular hyperplasia and gastric-type AIS. In this review, we cover HPV-associated and HPV-independent precursor lesions of cervical adenocarcinomas concentrating on diagnostic criteria (morphology and immunophenotype) and differential diagnosis. We propose a uniform terminology and diagnostic criteria for precursor lesions showing intestinal differentiation with goblet cells because this may be a feature of both HPV-associated and HPV-independent AIS.

Post-conization follow-up of patients with CIN 2/3 with different amount of distance to negative cone biopsy margin: a retrospective cohort study

The aim of this study was to investigate whether patients with CIN 2/3 with different amount of distance to negative cone biopsy margin differ in terms of post-conization follow-up results. Cold-knife cone specimens with a negative surgical margin with a diagnosis of CIN-2/3 were selected. The minimum distance between the margin and lesion was categorised as less than 2 mm (Group-1), 2-5 mm (Group-2), or more than 5 mm (Group-3). There were no statistically significant differences between groups in terms of postoperative cone-biopsy results (p = .61). Furthermore, there were no statistically significant differences between groups in terms of cytology at 6 months and 12 months (p = .33 and p = .80, respectively). Results of the present study indicate that the amount of distance of lesion to cone biopsy margin seems to have no effect on follow-up results in patients with negative surgical margin.Impact StatementWhat is already known on this subject? Negative surgical margins on conization are associated with lower rates of lesion recurrence. Only the efficacy of volume and size of cone biopsy specimens have been analysed on lesion recurrence. However, there is no clear definition of the minimum distance of a negative margin during cone biopsy.What do the results of this study add? To the best of our knowledge, this is the first study describing the post-conization follow-up of patients with CIN 2/3 with different amount of distance to negative cone biopsy margin. Patients who underwent surgical treatment with a wider cone biopsy margin and narrower cone biopsy margin demonstrated similar follow-up results.What are the implications of these findings for clinical practice and/or further research? The present study provides valuable information to guide physicians performing conizations with an appropriate amount of negative surgical margin. Future studies investigating the effect of different amount of distance to negative cone biopsy margin on gynaecologic and obstetrics complications such as stenosis, bleeding, and preterm labour, low birth weight, and perinatal mortality are needed to show the benefits of a narrower distance to negative cone biopsy margin.

Adenocarcinoma in situ of the uterine cervix: Clinical practice guidelines from the Italian society of colposcopy and cervical pathology (SICPCV)

OBJECTIVE

to provide a practical tool for the evidenced-based management of adenocarcinoma in situ (AIS) of the uterine cervix, a challenging diagnosis encountered by colposcopists in their daily practice.

METHODS

the proposed recommendations were drafted by the Italian Society of Colposcopy and Cervical Pathology (SICPCV) based on comprehensive reviews of previous guidelines, large uncontrolled studies, metanalysis, and sytematic reviews. The quality Level and the strength of the recommendations were graded and respectively expressed in Roman numbers (I-VI) and letters (A-E).

RESULTS

Women with all subcategories of abnormal glandular cells and AIS on cervical citology should be offered colposcopy with endocervical sampling (Strength of recommendation: A). In women with cytological AIS and negative colposcopy or endocervical curettage, an excisional treatment under colposcopic guidance is recommended (Strength of recommendation: A). If immediate post-conization endocervical sampling is positive, further conization is indicated (Strength of recommendation: C). In women who desire to preserve fertility with positive cone margins, further conization should be performed (Strength of recommendation: B). If colposcopy is adequate, a cylindrical excision that includes the whole transformation zone and at least 1-1.5 cm of endocervix beyond the squamous-columnar junction should be performed (Strength of recommendation: B). If colposcopy is inadequate, it is recommended that conization includes the whole transformation zone with a depth of 20-25 mm (Strength of recommendation: B). Hysterectomy is the standard definitive treatment for AIS in women who do not wish to preserve fertility (Strength of recommendation: B).

CONCLUSION

the proposed recommendations should enable clinicians to correctly diagnose, treat and follow AIS patients, avoiding mismanagement.

Role of Close Endocervical Margin in Treatment Failure After Cervical Excision for Cervical Intraepithelial Neoplasia: A Retrospective Study

CONTEXT.—

A significant negative trend in length of cone excision has been observed in recent years, leading to a higher percentage of positive endocervical excision margin and close (<1 mm) negative endocervical margin cases.

OBJECTIVE.—

To evaluate the rate of disease persistence and recurrence after cervical excision for cervical intraepithelial neoplasia in relation to a close (<1 mm), negative, or positive endocervical margin.

DESIGN.—

We retrospectively analyzed a cohort of patients with cervical intraepithelial neoplasia having a carbon dioxide laser cervical excision performed by the same operator. We evaluated the rate of positive follow-up in relation to the status of endocervical margin.

RESULTS.—

We found a higher percentage of positivity at follow-up and recurrence rate between 13 and 24 months in patients with positive margin than for patients with negative or close endocervical margin (P = .005 and P = .006, respectively), with no difference between negative and close margin (7.0% versus 8.3%, P = .89, and 1.2% versus 0%, P = .83, respectively).

CONCLUSIONS.—

Women with close and negative endocervical margin presented similar risk of positivity at long-term follow-up, disease persistence, and recurrence between 13 and 24 months, so the histopathologic report of a free endocervical margin less than 1 mm should not categorize the patient as being at increased risk of treatment failure. Therefore, the only information that the pathologist should report is the state of the margin (positive or negative), regardless of the negative endocervical margin length.

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.

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.

Adenocarcinoma in situ of the uterine cervix--a systematic review

OBJECTIVE

This study aimed to review literature if therapeutic strategies in adenocarcinoma in situ of the cervix could lead to a more conservative approach.

METHODS

A review of the literature was conducted using a Medline search for articles published between 1966 and 2013.

RESULTS

Thirty-five studies showed that after a radical cone, 16.5% residual disease in the re-cone or uterus was found. After cone with positive margins, residual abnormalities were found in 49.3%. Thirty-seven studies showed 5% recurrence rate after conservative therapy (large loop excision transformation zone-cold knife conization. After conization with negative margins, the risk of recurrence was 3%.

CONCLUSIONS

Adenocarcinoma in situ is a relatively rare premalignant but increasingly frequent lesion of the cervix. Although there is a risk of relapse (3%) with a chance of malignancy (<1%), this risk is so small that conservative treatment with negative margins by large loop excision transformation zone or cold knife conization is justified and justifiable not only for women to have children.

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.

Predictive value of negative cone margin status for risk of residual disease among women with cervical adenocarcinoma in situ

OBJECTIVE

To determine the value of negative cone margins in predicting residual disease in women with adenocarcinoma in situ (ACIS).

METHODS

Data were retrospectively analyzed from 60 women with ACIS who underwent conization at Chiang Mai University Hospital between March, 1998, and December, 2010. Negative margin status was defined as absence of neoplastic epithelium at all margins, coupled with presence of normal cervical epithelium. The association between the incidence of residual lesions and cone margin status was analyzed via χ(2) or Fisher exact test.

RESULTS

When adjusted for age and completeness of visualization of the cervical squamocolumnar junction during colposcopy, women who underwent loop electrosurgical excision procedure were 4 times more likely to have positive cone margins than those who underwent cold-knife conization (95% CI, 1.13-16.43). Residual disease was not found among 26 women who had negative cone margins, but was observed in 17 (65.4%) of 26 women with positive cone margins (P<0.001).

CONCLUSION

Women with ACIS who had negative cone margins were found to have a notably low risk of residual disease. Adherence to the standard method of cone sampling and criteria for negative margin status might contribute to a high predictive value of negative cone margins.

[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.

Do FIGO stage IA and small (≤2 cm) IB1 cervical adenocarcinomas have a good prognosis and warrant less radical surgery?

OBJECTIVES

There is a controversy regarding the optimal management of small cervical adenocarcinomas, and more radical surgery is often undertaken compared to similar size squamous carcinomas. We wished to determine the risk of parametrial involvement and metastatic disease and the outcome in International Federation of Gynecology and Obstetrics (FIGO) stage IA and small (≤2 cm) stage IB1 cervical adenocarcinomas.

METHODS

All women with a diagnosis of International Federation of Gynecology and Obstetrics stages IA1, IA2, or IB1 cervical adenocarcinoma with a maximum tumor size of 2 cm were identified between 1999 and 2010 in Northern Ireland. A single pathologist reviewed all pathology prospectively at a cancer center tumor board.

RESULTS

A total of 74 women were identified (mean age, 39 years; range, 25-72 years). In total, 36 women had stage IA1, 9 women had stage IA2, and 29 women had stage IB1 cervical adenocarcinomas. Surgical treatment ranged from local excision (cone or large loop excision of transformation zone) to radical hysterectomy and pelvic lymph node dissection; adjuvant therapy was not administered in any case. No parametrial involvement was seen in the 36 women who underwent parametrial resection. No lymph node metastasis was identified in the 45 women who underwent pelvic lymph node dissection. Lymphovascular space invasion was identified in 6 cases. No tumor recurrence or metastasis was noted during a mean follow-up of 35 months.

CONCLUSIONS

The optimal management of women with IA or small IB1 cervical adenocarcinoma is controversial, and radical surgery is often undertaken. Our data suggest that there is an extremely low risk of parametrial and lymph node involvement with tumors 2 cm or smaller and a low recurrence rate. Less radical surgery may be warranted for small cervical adenocarcinomas, and this should be addressed by future studies.

Conservative treatment of stage IA1 adenocarcinoma of the uterine cervix with a long-term follow-up

OBJECTIVES

The adenocarcinoma of the uterine cervix tends to arise in women of childbearing age. Conservative treatment by conization is an alternative to a hysterectomy that allows future pregnancy; however, much less is known about the management of adenocarcinoma because of its rarity and relatively short time frame of follow-up. The purpose of this study was to determine the long-term outcome of patients treated by conization alone.

METHODS

All patients diagnosed to have FIGO (International Federation of Gynecology and Obstetrics) stage IA1 cervical adenocarcinoma between 1990 and 2004 with more than 5 years' follow-up at 2 institutions were reviewed. Information was abstracted on clinical data including margin status of conization and recurrence.

RESULTS

Twenty-seven patients were identified, and 10 patients who expressed a strong desire to preserve fertility were offered a conization and careful surveillance without hysterectomy. The median age was 35 years, and 40% were nulliparous. All tumors were endocervical-type adenocarcinoma, and all tumors were grade 1. None had lymphovascular space invasion. Two patients had a repeated conization because of a positive margin. No recurrence was observed during an average follow-up of 75 months.

CONCLUSIONS

Although further studies on the management of microinvasive cervical adenocarcinoma are desirable, conization seems to be acceptable treatment modality for patients with stage IA1 cervical adenocarcinoma who desire to preserve their fertility. A careful and long-term follow-up is needed because of lack of sufficient evidence for the safety of this treatment.

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.

To ECC or not to ECC: the question remains

The usefulness of endocervical curettage (ECC) in evaluating women who have abnormal cervical cytology and histopathology has been debated for years; data regarding performance of ECC in the diagnostic evaluations of squamous and glandular lesions are mixed. There are no well-done randomized trials or systematic reviews regarding the usefulness of ECC. The yield on ECC increases in the setting of unsatisfactory colposcopy; in this situation, there seems less controversy regarding performance of an ECC. Reproducibility of ECC-rendered diagnosis is a concern. Data are needed to further define the role of ECC in evaluating women who have cervical disease.

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.

Intraoperative techniques and tumor margin status--room for improvement for cervical cancer patients of childbearing age

OBJECTIVE

Inadequate tumor margin status in cervical cancer and pre-cancer patients is associated with repeat procedures and an increased risk of recurrence and progression. This review will outline information regarding the current treatment options for women who wish to maintain fertility, the methods currently used in practice to evaluate tumor margin involvement, and a look at potential solutions to this critical issue.

METHOD

We performed a PUBMED literature search of relevant research articles pertaining to tumor margin evaluation for multiple cancers, current treatment options for patients of cervical dysplasia and the effects of those treatments on fertility.

RESULTS

Previous studies have correlated cancer recurrence and progression to obtaining clear margins upon resection. The most common need to obtain clear margins with respect to conservative treatment in patients with cervical neoplasia occurs with women who wish to preserve fertility. However, current detection methods are limited and current treatments present additional fertility concerns.

CONCLUSION

In order to provide the best care for patients wishing to retain fertility post-treatment for cervical dysplasia, a superior option for detecting tumor margins accurately at the microscopic scale must be further explored.

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.

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.

[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.

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.

Atypical Papanicolaou smear in pregnancy

Atypical glandular cells (AGC) in Papanicolaou (Pap) smears can be associated with premalignant and malignant cervical and endometrial lesions. AGC is difficult to diagnose in pregnancy due to confusion with normal cellular changes that accompany graviditas. While guidelines have been established for management of AGC cases in the non-pregnant patient, special considerations are required when this is discovered during a pregnancy. A routine Pap smear performed on a 29-year-old woman being seen for a history of infertility yielded AGC and a high-grade squamous intraepithelial lesion. The patient achieved pregnancy 1 month later. Satisfactory colposcopic exam was performed with cytobrush sampling of the endocervical canal, in addition to 2 exocervical biopsies at 11 weeks gestation. Positive diagnosis of endocervical adenocarcinoma in situ resulted in a risk-informed decision to proceed with a cold knife conization of the cervix. Final pathology showed complete resection of the lesion with negative margins and an additional area of squamous dysplasia (cervical intraepithelial neoplasia, grade II to III). Appropriate follow-up was recommended. AGC found upon Pap smear during a pregnancy can be associated with significant pathology for which an aggressive management approach is warranted.

Modalités et limites du traitement conservateur des adénocarcinomes in situ du col utérin : analyse de neuf cas et revue de la littérature

OBJECTIVE

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

PATIENTS AND METHODS

Data of 16 patients treated for AIS were reviewed: 10 were treated initially conservatively (cold knife conization in five patients, loop excision in three patients and cervical amputation in two patients) and six radically. One patient treated initially conservatively with loop excision and positive margins underwent a completion surgery (hysterectomy).

RESULTS

None patient had recurrence whatever the type of surgery (radical or conservative) with a mean follow-up of 74 months. Two pregnancies were observed.

DISCUSSION AND CONCLUSIONS

Conservative surgery for patients with AIS could be considered in young patients. But [for] reviewing literature several conditions should be respected: careful follow-up after conservative treatment; cold knife conization; length of cone specimen >25 mm and free margins. If those criteria are respected the risk of recurrent disease under the form of invasive carcinoma is low.

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.

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.

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.

Cervical adenocarcinoma in situ: a systematic review of therapeutic options and predictors of persistent or recurrent disease

The incidence of cervical adenocarcinoma in situ is increasing in frequency, and our limited knowledge about this lesion presents the physician with a therapeutic dilemma. Treatment for this lesion has included conservative therapy, large loop excision or cold-knife cone biopsy, or definitive therapy consisting of hysterectomy. But, rates of residual adenocarcinoma in situ after cone biopsy with negative margins vary from 0% to 40%, and residual disease rates as high as 80% have been noted when the margins are positive. Despite these recent data on follow-up after conservative therapy such as cone biopsy, it seems that this method is safe and gaining acceptance by many physicians and patients. However, the short follow-up duration and small number of patients limit the conclusions of many studies. The relative infrequency of this diagnosis has precluded extensive clinical experience with the natural history of this lesion.

Adenocarcinoma in situ and early invasive adenocarcinoma of the uterine cervix

As data continue to accumulate, the clinical characteristics of preinvasive and early invasive glandular cervical neoplasia are becoming progressively better defined. Cytologic screening for these lesions is imprecise; however, modifications to current classification systems may improve the overall accuracy. All glandular abnormalities on the Papanicolaou smear, nevertheless, require judicious evaluation and careful follow-up. Cervical conization is the most definitive means of diagnosing adenocarcinoma in situ (ACIS). Because ACIS has been thought to represent a multifocal process, with negative conization margins having limited predictive value, conservative management protocols have been difficult to endorse. Several large studies now indicate that the surgical margin status may be a more reliable indicator of true disease clearance than previously thought. For young patients desiring to maintain reproductive capacity, ACIS appears to be safely managed by cold-knife conization combined with diligent surveillance. Early invasive adenocarcinoma of the uterine cervix is associated with an excellent prognosis, and recent data suggest that radical surgery may be unnecessary.

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

Adenocarcinoma in situ (AIS) of the uterine cervix is a rare condition. Pap smear screening is unsatisfactory, and the disease has no morphologic reliable colposcopic features. Diagnosis is often made by chance during the treatment of squamous pre-invasive disease, which commonly coexists with AIS. Although the entire endocervical canal can be the site of disease, most lesions lie within 1 cm of the squamocolumnar junction. Skip lesions are rare, making fertility-sparing surgery a possibility under certain conditions. Recurrent disease occurs in 14% of cases when cone margins are free of disease and rise to more than 50% if the margins are involved. The method of conization is immaterial provided a large enough specimen is taken and that the endocervical margins can be evaluated by the pathologist. Follow-up of conservatively managed women is not defined; however, we recommend that regular endocervical cytology be performed in addition to conventional cytology and colposcopy.

Conservative management of adenocarcinoma in situ of the cervix

OBJECTIVE

The purpose of this study was to determine the method of treatment and outcome of women with cervical adenocarcinoma in situ (AIS).

METHODS

Following institutional review board approval, all women diagnosed with cervical AIS from 1987 to 1999 were identified. Data were retrospectively collected by record review and correspondence with medical providers.

RESULTS

Of 132 women treated with cone biopsy for AIS, 95 (72%) were managed conservatively after cold knife cone or loop electrical excisional procedure alone; 37 (28%) eventually underwent hysterectomy. The median age of diagnosis was 29 years (range, 17-47) in the conservative management group and 40 years (range, 25-72) in the hysterectomy group (P < 0.0001). Seventy-four percent were nulliparous in the conservative group compared with 27% in the hysterectomy group (P < 0.0001). Of the 95 conservatively managed patients, 92 obtained negative margins; three were followed despite positive or unevaluable margins. During a median follow-up of 30 months, 9 women required evaluation for follow-up abnormalities after cone biopsy with negative margins. None had pathologic evidence of recurrent AIS. Twenty-three infants were delivered. Hysterectomy was generally performed for undesired fertility or persistently positive cone margins. One woman required hysterectomy for recurrent AIS. Thirteen (62%) of twenty-one hysterectomy specimens had residual AIS following cone biopsy with positive or unevaluable margins; 1 (6%) of 16 had residual AIS following cone biopsy with negative margins (P < 0.0001). No patient developed invasive adenocarcinoma.

CONCLUSIONS

Younger women with cervical AIS may be effectively treated with cone biopsy alone if negative margins can be achieved.

Can glandular lesions be diagnosed in pap smear cytology?

Many reports have been published on the accuracy of the cervical vaginal smear for squamous lesions, and the literature contains fewer reports on the accuracy of the cervical vaginal smear for glandular lesions. The sensitivity of glandular lesion diagnosis depends on the subtype of lesion. The diagnostic sensitivity is highest for invasive endocervical adenocarcinoma and lowest for endometrial adenocarcinoma. The ability of some of the Bethesda system categories for glandular lesions to describe what they purport to describe is questionable. The Bethesda system categories of adenocarcinoma accurately classify adenocarcinomas. The Bethesda System category of atypical glandular cells of undetermined significance (AGUS) is a misnomer. Although many cases of adenocarcinoma in-situ are placed in this category, follow-up of patients with AGUS show that the majority of patients with clinically significant lesions have squamous dysplasias. Other categories of AGUS, such as AGUS favor endometrial origin, are more appropriately named and encompass endometrial lesions which are either neoplastic or non-neoplastic.

Margin status and excision of cervical intraepithelial neoplasia: a review

Excisional biopsy of the cervix for diagnosis and treatment of cervical neoplasia is common. Management of patients with involved margins of resection is unresolved. Data concerning use of thermal techniques show that this technique yields equivalent results in most cases. Important exceptions are microinvasive squamous disease and adenocarcinoma. Conservative management of involved squamous margins is possible. Techniques for follow-up include cytology, colposcopy, and endocervical curettage. Adenocarcinoma in situ (AIS) should be treated with cold-knife conization. The standard of care for AIS is hysterectomy except in certain specific indications. Data concerning technique, follow-up, use of endocervical curettage, and the need for reexcision will be presented.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to compare the efficacy of the various excisional procedures in the treatment of cervical dysplasia, list the indications for additional surgery after positive margins on cervical excisions, and describe the proper management of a patient with adenocarcinoma in situ.

Recurrent invasive adenocarcinoma after hysterectomy for cervical adenocarcinoma in situ

BACKGROUND

Unlike its squamous counterpart, therapy for cervical adenocarcinoma in situ with positive endocervical cone margin remains controversial.

CASE

A 52-year-old gravida 2, para 1,0,1,1, presented with vaginal bleeding. Gynecologic history was significant for cervical cold knife conization with a positive endocervical margin and endocervical curettage with atypical endocervical cells. Repeat cone biopsy was considered unsafe given the large initial cone specimen. An extrafascial hysterectomy was performed 5 weeks later and pathology confirmed a disease-free cervix. Pap smear performed 1 year later was interpreted as recurrent adenocarcinoma but later downgraded to inflammation. Inspection and random biopsies of the vaginal cuff revealed only inflammation. Two subsequent Pap smears also returned inflammation. Seventeen months after the hysterectomy physical examination revealed a 2 x 3-cm smooth mass at the vaginal cuff. Biopsy revealed invasive adenocarcinoma. The patient underwent an upper vaginectomy followed by postoperative pelvic radiation.

CONCLUSION

This case suggests that despite extrafascial hysterectomy for presumed adenocarcinoma in situ of the cervix, a residual focus could remain and present later as invasive adenocarcinoma.

Glandular lesions of the uterine cervix

During the past 20 years, pathologists have more carefully examined and more precisely classified glandular lesions of the endocervix, largely reflecting increased concerns about the diagnosis and pathogenesis of adenocarcinoma of the cervix. This review of glandular lesions of the cervix focuses on the following six issues surrounding the histologic diagnosis of the more common types of adenocarcinoma of the endocervix and their mimics: (1) the classification and recognition of preinvasive glandular lesions, (2) the distinction of invasive from preinvasive adenocarcinoma, (3) the definition and significance of microinvasive adenocarcinoma, (4) the epidemiology and pathogenesis of adenocarcinoma, (5) the identification and behavior of the more common subtypes of invasive adenocarcinoma, and (6) the recognition of benign lesions that mimic adenocarcinoma It is the author's opinion that most in situ and invasive adenocarcinomas of the cervix can be recognized and distinguished from benign mimics. In contrast, glandular dysplasia and microinvasive adenocarcinoma of the cervix are currently ill-defined and irreproducible terms that should not be used for diagnostic purposes. Although only brief descriptions of the biologic behavior of the various lesions and their therapy are included in this review, certain variants of endocervical adenocarcinoma have distinctive behaviors and should be classified appropriately to provide prognostication and help to guide therapy.