Adenocarcinoma in Situ of the Cervix: Management and Outcome
Adenocarcinoma in Situ of the Cervix: Management and Outcome
Abstract & commentary
Synopsis: Adenocarcinoma in situ of the cervix is difficult to diagnosis and manage.
Source: Azodi M, et al. Gynecol Oncol 1999;73: 348-353.
Adenocarcinoma in situ of the uterine cervix is a disease that has been diagnosed since 1952. Currently the pathologic criteria for the diagnosis are relatively standardized. Unfortunately, the management of patients with this disease varies greatly from one center to another.
Azodi and colleagues performed a retrospective study at their medical center, reviewing the records of all patients who had a conization of the cervix (cold knife cone, loop excision, or laser conization) and had a diagnosis of adenocarcinoma in situ, between January 1988 and December 1996. Forty patients comprised the clinical material for this study.
The mean age of the patients with this diagnosis was 37 years. All but one patient had colposcopic evaluation prior to conization.
Seventy percent of the colposcopic biopsies showed some form of glandular cell abnormality and an additional 20% showed mixed glandular and squamous abnormalities. Twenty-five patients had a cold knife conization, eight had loop excision, and eight had laser conization. An ECC was performed after the conization specimen was obtained in 70% of the cases. Thirty percent of the ECCs that were read as negative had positive endocervical margins in the cone specimen. Many of the women had a hysterectomy as definitive treatment, and 58% of the patients with a negative ECC above the cone had residual disease in the hysterectomy specimen.
Endocervical margins were more likely to be positive with laser conization or loop excision than with cold knife conization. However, 31% of the patients with negative endocervical cone margins who underwent hysterectomy had residual cervical disease.
Eight patients had no additional therapy following the conization. All of these patients had negative endocervical and ectocervical cone margins with negative ECCs. One of these eight patients had a cytology specimen that indicated the presence of adenocarcinoma 15 months following the conization, and the hysterectomy specimen showed invasive disease.
Azodi et al drew several conclusions from this paper. First, they suggest that, at the present time, cold knife conization should be the preferred diagnostic procedure of choice in patients who have cervical glandular lesions. Secondly, ECC after cervical conization is not a reliable method to determine whether residual disease is present. Finally, though a positive endocervical cone margin is more likely to leave residual disease than a negative one, a negative endocervical margin does not guarantee that all diseased tissue has been removed.
Comment by Kenneth Noller, MD
Several times in the last three years, I have commented on articles which reported the outcomes of series of patients with AGUS pap smears. This study goes one step further. Azodi et al identified 40 patients who had a conization procedure performed because of a glandular lesion of the cervix. Like several similar articles, they found that neither a negative ECC nor negative cone mar- gins were good predictors of a disease-free state. At pre- sent, it appears that simple hysterectomy is the treatment of choice for patients who have adenocarcinoma in situ on a conization specimen, even if the margins are negative.
But what about the patient who wants (demands) to maintain her fertility? Certainly, if the endocervical cone margin is positive, a repeat-procedure must be performed.
Once negative margins have been established, the patient needs to have frequent endocervical sampling, preferably using an endocervical brush rather than an ECC. Based on numerous reports in the literature, I believe that there is no longer any doubt that the endocervical brush is superi- or to the ECC for detecting disease in the canal.
Perhaps someday we will have better indicators of residual disease, and will be able to avoid hysterectomy as the primary treatment for these women. However, in the meantime, hysterectomy must remain the treatment method of choice.
In the article by Azodi et al, 40 patients underwent conization of the cervix for adenocarcinoma in situ. Which of the following statements regarding the conization specimen is correct?
a. A negative endocervical margin is a good predictor of a disease-free state.
b. A negative ECC is a good indicator of a disease-free state.
c. There was no difference in positive cone margins between cold knife cone and loop electroexcision.
d. Hysterectomy is the treatment of choice for adenocarcinoma in situ.
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