Diagnosis and Management of Adenocarcinoma in Situ

Key points

• The incidence of cervical adenocarcinoma in situ (AIS) is rising, especially at ages 30-40; mean age at diagnosis is 35-37 years, about 55% of patients have a coexisting squamous lesion, and HPV-18 is associated with 38-50% of AIS diagnoses.
• A diagnostic excisional procedure is recommended for all AIS diagnosed on cervical biopsy, even when hysterectomy is planned, to rule out invasive adenocarcinoma (AII).
• Cold knife conization is preferred unless the surgeon can consistently remove an intact specimen; top-hat endocervical excision is unacceptable (AII). Specimen length should be at least 10 mm, or 18-20 mm after childbearing is complete (BII).
• Simple hysterectomy is preferred when conization margins are negative (BIII); modified radical or simple hysterectomy is acceptable when margins are positive (CIII).
• Fertility-sparing management with conization is acceptable with negative margins and reliable surveillance (AII), but not recommended if negative margins cannot be achieved after multiple excisions (DIII).

Overview

This Society of Gynecologic Oncology guideline, endorsed by the ASCCP, gives recommendations for the diagnosis and management of cervical AIS and harmonizes with the ASCCP Risk-Based Management Consensus Guidelines. AIS often arises inside the endocervical canal and can have skip lesions, so its management differs from that of squamous dysplasia. When AIS is diagnosed on cervical biopsy, about 15% is associated with invasive adenocarcinoma. This overview covers the recommendations on evaluation, excision, definitive surgery and fertility-sparing management; the sections on surveillance and pregnancy were not reviewed.

Evaluation

Abnormal cytology or positive HPV results are evaluated per the ASCCP guidelines (BII). Atypical glandular cells and HPV-16 or -18 should be evaluated with colposcopy, endocervical sampling and endometrial biopsy, and endocervical sampling is acceptable after a positive HPV-18 test regardless of colposcopy findings (CIII). A diagnostic excision is also recommended when biopsy and endocervical curettage are negative but cytology shows AIS or AGC-favor neoplasia.

Excision technique

In a meta-analysis, LEEP and cold knife conization had similar residual disease (9.1% vs 11%) and recurrence (7.0% vs 5.6%), but LEEP had more positive margins (44% vs 29%; relative risk 1.55). Endocervical sampling above the excisional bed to check for residual disease is preferred (CIII).

Margins and definitive surgery

Recurrence of AIS is 2.6% with negative margins and 19% with positive margins. Even with negative margins, residual AIS is found on a second excision in 20% and invasive cancer in 2% (53% and 6% with positive margins). Lymph node assessment at hysterectomy is acceptable (CIII), and ovarian management should be individualized. After fertility-sparing treatment and completed childbearing, hysterectomy or continued surveillance is acceptable if HPV tests stayed negative, while hysterectomy is preferred if HPV tests were positive (CIII).

FAQ

Is LEEP acceptable for AIS?

Yes, if the surgeon removes one intact, non-fragmented specimen of adequate length; otherwise cold knife conization is preferred, and top-hat serial excisions are unacceptable.

Why is hysterectomy preferred even with negative margins?

AIS can have non-contiguous skip lesions: even with negative margins, a second excision finds residual AIS in 20% and invasive cancer in 2%.

Can patients who want children avoid hysterectomy?

Yes, conization with negative margins is acceptable if they can adhere to surveillance; it is not recommended when negative margins cannot be achieved after multiple excisions.

Source

Teoh D, Musa F, Salani R, Huh W, Jimenez E. Diagnosis and Management of Adenocarcinoma in Situ: A Society of Gynecologic Oncology Evidence-Based Review and Recommendations. Obstet Gynecol 2020;135(4):869-878. DOI: 10.1097/AOG.0000000000003761. Open access under CC BY-NC-ND 4.0. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.