Management of adenocarcinoma in situ of the uterine cervix: a comparison of loop electrosurgical excision procedure and cold knife conization

2023 Canadian Colposcopy Guideline: A Risk-Based Approach to Management and Surveillance of Cervical Dysplasia

This guideline provides evidence-based guidance on the risk-based management of cervical dysplasia in the colposcopy setting in the context of primary HPV-based screening and HPV testing in colposcopy. Colposcopy management of special populations is also discussed. The guideline was developed by a working group in collaboration with the Gynecologic Oncology Society of Canada (GOC), Society of Colposcopists of Canada (SCC) and the Canadian Partnership Against Cancer (CPAC). The literature informing these guidelines was obtained through a systematic review of the relevant literature via a multi-step search process led by information specialists. The literature was reviewed up to June 2021 with manual searches of relevant national guidelines and more recent publications. Quality of the evidence and strength of recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The intended users of this guideline include gynecologists, colposcopists, screening programs and healthcare facilities. Implementation of the recommendations is intended to promote equitable and standardized care for all people undergoing colposcopy in Canada. The risk-based approach aims to improve personalized care and reduce over-/under-treatment in colposcopy.

Comparison of the safety between cervical conization and hysterectomy for patients with cervical adenocarcinoma in situ

OBJECTIVE

To compare the safety between cervical conization (CC) alone and hysterectomy for patients with adenocarcinoma in situ (AIS) of the cervix.

METHODS

Patients diagnosed with AIS after CC during 2007-2021 were identified by computerized databases at Women's Hospital of Zhejiang University School of Medicine. A total of 453 AIS patients were divided into 2 groups according to uterus preservation: hysterectomy group (n=300) and CC(s) alone group (n=153). The prevalence of residual disease and disease recurrence was compared between patients treated by CC(s) alone and hysterectomy. The prevalence of residual disease in specimens from women who had a hysterectomy and repeat CC were compared between positive and negative margins of CC. The factors influencing residual disease and disease recurrence were assessed.

RESULTS

Among 310 specimens from women who had a hysterectomy or repeat CC, the prevalence of residual disease was 50.6% (45/89) for a positive margin and 2.3% (5/221) for a negative margin (p=0.000). Four patients had recurrence of vaginal intraepithelial neoplasia in those treated by hysterectomy and one had recurrence of cervical squamous intraepithelial neoplasia in those treated by CC(s) alone. The prevalence of recurrence was 0.7% (1/153) for CC(s) alone and 1.3% (4/300) for hysterectomy (p=0.431). Hysterectomy did not influence residual disease or disease recurrence.

CONCLUSION

CC is an efficacious and safe option for patients with AIS of the cervix provided the margin is negative.

Conservative Treatment for Cervical Adenocarcinoma In Situ: Long-Term Results

OBJECTIVE

This study aimed to evaluate the effectiveness of conservative treatment for cervical adenocarcinoma in situ (AIS).

MATERIALS AND METHODS

This is a retrospective study on women with histologically confirmed AIS on cervical loop electrosurgical excision procedure specimen, treated conservatively between 2008 and 2020 in our center, Ospedale Maggiore Policlinico, Milan. The main outcome investigated was the risk of recurrence defined as a subsequent finding of recurrent AIS or invasive adenocarcinoma in a long-term follow-up. The disease-free survival curve was computed using the Kaplan-Meyer method. All patients underwent colposcopy with endocervical curettage and cytology every 6 months for the first 2 years after initial surgery and then annual cytology.

RESULTS

Thirty women, aged 26 to 51 years, with histologically proven AIS on excisional specimen with negative margins, negative apex, and negative endocervical curettage were included. The median follow-up was 5.4 years. One woman had a recurrence of AIS after 8 years of follow-up and underwent total hysterectomy. No invasive cervical disease was detected during surveillance.

CONCLUSIONS

Women with cervical AIS can be managed conservatively by an excisional procedure, provided that the margins are free and a close and long-term follow-up is guaranteed.

Splenic oligometastasis from cervical adenocarcinoma three years after disease free survival: A case report and a review of literature

Introduction

Cervical cancer is the fourth most common cancer among females. Squamous cell carcinoma is the most common subtype of cervical cancer, followed by adenocarcinoma. The most reported sites of metastasis are the lungs, bones, liver, and brain. One of the rarest sites of metastasis, particularly from the adenocarcinoma subtype, is the spleen, with only four reported cases in the literature.

Case report

A 54-year-old post-menopausal female was diagnosed with adenocarcinoma of the endocervix (FIGO stage IIIB) after she presented to the gynecologist complaining of post-coital vaginal bleeding. The patient received chemoradiotherapy followed by brachytherapy. After completion of treatment, she had a restaging work-up which revealed a complete radiological and pathological response. During her routine follow-up, she was found to have a new splenic lesion by surveillance abdominopelvic MRI three years after completion of treatment. Surgical resection was performed, and pathological analysis confirmed the diagnosis of metastatic cervical adenocarcinoma to spleen.

Conclusion

Cervical cancer metastasis to spleen is very rare, especially in the cervical adenocarcinoma subtype. A high index of suspicion is necessary during follow-up. Once there is a suspicion of splenic metastasis, surgical intervention should be considered for both curative and palliative intents.

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Solitary splenic metastasis of cervical adenocarcinoma is rare.

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A high index of suspicion is necessary during follow-up of cervical cancer.

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Splenectomy is the definitive treatment in cases of solitary splenic metastasis.

The safety of fertility preservation for microinvasive cervical adenocarcinoma: a meta-analysis and trial sequential analysis

PURPOSE

This study sought to evaluate the safety of conservative treatment in the management of patients with microinvasive cervical adenocarcinoma.

METHODS

The PubMed, PMC, EMBASE, Web of Science and Cochrane databases were searched to collect correlational studies published in English between January 1949 and May 2018. Series reports that evaluating the oncological prognoses of patients with microinvasive cervical adenocarcinoma who were treated with fertility-sparing surgery versus hysterectomy were pooled for meta-analysis and trial sequential analysis.

RESULTS

A total of 8 articles with 1256 patients were collected, including 7 retrospective reviews and 1 prospective study. Only one (0.08%) patient had parametrial involvement. Positive margins of surgical specimens were identified in 6 patients (2.2%). Lymph node metastasis was found in 5 patients (0.4%). The progression-free survival and overall survival rates were 99.3 and 98.2%. Fertility-sparing surgery had no adverse impact on recurrence or survival (P = 0.524 and 0.485, respectively). Regarding potential selection bias, significantly more patients with stage IA2 tumors than those with stage IA1 disease were treated with hysterectomy (P < 0.001). The trial sequential analysis indicated that the cumulative number of patients failed to meet the required sample size (number of patients).

CONCLUSIONS

The prognosis for patients with microinvasive cervical adenocarcinoma is excellent. Fertility preservation is at least appropriate for young women with stage IA1 adenocarcinoma. Further studies are still warranted to evaluate the safety of this procedure in managing patients with microinvasive cervical adenocarcinoma.

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.

Excisional treatment in women with cervical adenocarcinoma in situ (AIS): a prospective randomised controlled non-inferiority trial to compare AIS persistence/recurrence after loop electrosurgical excision procedure with cold knife cone biopsy: protocol for a pilot study

INTRODUCTION

Adenocarcinoma in situ (AIS) of the uterine cervix is the precursor to invasive endocervical adenocarcinoma. An excisional biopsy such as a cold knife cone biopsy (CKC) should be performed to exclude invasive adenocarcinoma. Loop electrosurgical excision procedure (LEEP) is an alternative modality to CKC but is controversial in AIS. There is a perception that there is a greater likelihood of incomplete excision of AIS with LEEP because the depth of excised tissue tends to be smaller and the tissue margins may show thermal artefact which can interfere with pathology assessment. In the USA, guidelines recommend that any treatment modality can be used to excise AIS, provided that the specimen remains intact with interpretable margins. However, there are no high-quality studies comparing LEEP with CKC and well-designed prospective studies are needed. If such a study were to show that LEEP was non-inferior to CKC for the outcomes of post-treatment persistence, recurrence and adenocarcinoma, LEEP could be recommended as an appropriate treatment option for AIS in selected patients. This would benefit women because, unlike CKC, LEEP does not require general anaesthesia and may be associated with reduced morbidity.

METHODS AND ANALYSIS

The proposed exploratory study is a parallel group trial with an allocation ratio of 2:1 in favour of the intervention (LEEP: CKC). Participants are women aged ≥18 to ≤45 years diagnosed with AIS on cervical screening and/or colposcopically directed biopsy in Australia and New Zealand, who are to receive excisional treatment in a tertiary level centre.

ETHICS AND DISSEMINATION

Ethical approval for the study has been granted by the St John of God Healthcare Human Research Ethics Committee (reference number #1137). Results from the study will be presented at conferences and published in a peer-reviewed scientific journal.

REGISTRATION

ANZCTR registration number ACTRN12617000132347 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372173&isReview=true.

Risk of persistent or recurrent cervical neoplasia in patients with 'pure' adenocarcinoma-in-situ (AIS) or mixed AIS and high-grade cervical squamous neoplasia (cervical intra-epithelial neoplasia grades 2 and 3 (CIN 2/3)): a population-based study

OBJECTIVE

To compare outcomes of patients with pure adenocarcinoma-in-situ (AIS) and mixed AIS/CIN 2/3 lesions including the incidence of AIS persistence, recurrence and progression to adenocarcinoma.

DESIGN

Retrospective cohort study.

SETTING

Statewide population in Western Australia.

POPULATION

Women diagnosed with AIS between 2001 and 2012.

METHODS

We conducted a retrospective, population-based cohort study.

MAIN OUTCOME MEASURES

De-identified linked data were utilised to ascertain the association between patient age at excisional treatment, margin status, lesion type, lesion size, and risk of persistent AIS (defined as the presence of AIS <12 months from treatment), recurrent AIS (≥12 months post-treatment), and adenocarcinoma.

RESULTS

636 patients were eligible for analysis. The mean age was 32.3 years and median follow-up interval was 2.5 years. Within the study cohort, 266 patients (41.8%) had pure AIS and 370 (58.2%) had mixed AIS/CIN 2/3. Overall, 47 patients (7.4%) had AIS persistence/recurrence and 12 (1.9%) had adenocarcinoma. Factors associated with persistence/recurrence were pure AIS (hazard ratio (HR) 2.3; 95%CI 1.28-3.94; P = 0.005), age >30 years (HR 2.1; 95%CI 1.16-3.81; P = 0.015), positive endocervical margins (HR 5.8; 95%CI 3.05-10.92; P = <0.001) and AIS lesions >8 mm (HR 2.5; 95%CI 1.00-6.20; P = 0.049). A histologically positive AIS ectocervical margin was not associated with persistence/recurrence.

CONCLUSION

In this study, pure AIS was associated with greater risk of persistence/recurrence than was mixed AIS/CIN 2/3. AIS lesions >8 mm and positive endocervical margins were significant predictors for persistent or recurrent disease.

TWEETABLE ABSTRACT

Pure cervical adenocarcinoma-in-situ (AIS) may have greater risk of recurrence than AIS co-existing with CIN 2/3.

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.

Comparison of Cold-Knife Conization versus Loop Electrosurgical Excision for Cervical Adenocarcinoma In Situ (ACIS): A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this systematic review was to conduct a more comprehensive literature search and meta-analysis of original studies to evaluate the efficacy and safety of the loop electrosurgical excision procedure (LEEP) versus cold-knife conization (CKC) in conservative surgical treatment of cervical adenocarcinoma in situ (ACIS) for women who have not completed childbearing.

METHODS

Systematic searches were conducted in the PUBMED, EMBASE, Cochrane, and China National Knowledge Infrastructure (CNKI) databases to identify all potential studies involving patients with ACIS treated with LEEP versus CKC published until December 2015.

RESULTS

Eighteen retrospective studies were included in this systematic review. All the 18 included studies reported the rate of positive margins, and the results of the individual studies varied. The positive margins were 44% (267/607) after LEEP and 29% (274/952) after CKC. The pooled meta-analysis exhibited significantly different outcome (RR, 1.55; 95% CI, 1.34-1.80, P<0.00001) without significant heterogeneity (P = 0.34). The residual rate following LEEP was 9.1% (17/186) and 11% (39/350) after CKC in re-cone or hysterectomy cases. Recurrent ACIS following LEEP was reported in 10 of 142 (7.0%) cases compared to 10 of 177 (5.6%) cases following CKC. There were no significant differences in the residual rate (RR, 1.02; 95% CI, 0.60-1.72, P = 0.95) or recurrence rate (RR, 1.13; 95% CI, 0.46-2.79; P = 0.79) between the two procedures.

CONCLUSIONS

The present systematic review demonstrates that both LEEP and CKC are safe and effective for the conservative treatment of ACIS. LEEP appears to be as equally effective as CKC regarding the residual and recurrence rates. Due to the findings showing that LEEP achieves comparable oncologic outcomes with fewer obstetric complications to that of CKC, LEEP may be the preferred option in patients whose fertility preservation is important. However, further prospective studies with a larger sample size and longer follow-up periods are needed to establish the superiority of either procedure.

Accuracy of conization procedure for predicting pathological parameters of radical hysterectomy in stage Ia2-Ib1 (≤2 cm) cervical cancer

The accuracy of conization for the prediction of radical hysterectomy (RH) pathological variables in patients with stage Ia2 to Ib1 (≤2 cm) cervical cancer was retrospectively evaluated in the present study. Endocervical or deep resection margin (RM) involvement in the conization specimens was found to be independently associated with residual disease in the hysterectomy specimens (P < 0.001, = 0.003, respectively). When a tumor width of >20 mm in the final RH pathology analysis was predicted by a tumor width of >2 mm or involvement of endocervical or deep RMs in the conization specimens, the sensitivity and negative predictive value (NPV) of conization were 98.2% and 95.2%, respectively. In addition, when deep stromal invasion in the final RH pathology analysis was predicted by deep stromal invasion or involvement of the endocervical or deep RMs in the conization specimens, the sensitivity and NPV of conization were 98.4% and 95.8%, respectively. The sensitivity and NPV of this prediction model for identifying LVSI in the final RH pathology analysis were both 100%. These findings suggest that conization variables and endocervical and deep resection margin statuses can be analyzed to effectively predict RH pathological parameters.