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Cervical adenocarcinoma in situ

INTRODUCTION

Adenocarcinoma in situ (AIS) of the cervix is a precursor of adenocarcinoma of the cervix [1], which comprises about 25 percent of cervical cancers in the United States [2]. The incidence of both in situ and invasive disease is rising [3,4]. This increase may reflect improved detection as a result of changes in the Bethesda cytologic classification system or use of liquid-based cytology or human papillomavirus (HPV) DNA testing. Alternatively, a true rise in incidence may have occurred [5], possibly related to an increase in the prevalence of HPV 18 or use of oral contraceptives [6,7]. As with squamous intraepithelial neoplasia, HPV infection is necessary for development of AIS. In contrast to its squamous counterpart, cigarette smoking is not a risk factor. (See "Cervical intraepithelial neoplasia: Definition, incidence, and pathogenesis".)

This topic will review diagnosis and management of AIS. Diagnosis and management of microinvasive and invasive adenocarcinoma of the cervix are discussed separately. (See "Invasive cervical cancer: Epidemiology, clinical features, and diagnosis" and "Management of adenocarcinoma and neuroendocrine carcinoma of the cervix".)

HISTOPATHOLOGY

Histologically, AIS is characterized by endocervical glands that are in a crowded, cribriform pattern and lined with atypical columnar epithelial cells. Cytologically, the atypical glandular cells resemble those of cervical invasive adenocarcinoma, but histologically no invasion is present. Ten to 13 percent of patients with AIS have multi-centric disease, ie, foci of AIS are separated by at least 2 mm of normal mucosa [1,8]. Approximately 50 percent of women with AIS have concomitant squamous cervical intraepithelial neoplasia or cancer [9].

CLINICAL MANIFESTATIONS AND DIAGNOSIS

Most patients are asymptomatic. AIS has no pathognomonic clinical, cytological, or colposcopic features. The lesion is usually located at the transformation zone with contiguous involvement of the endocervical canal, but is not grossly visible on examination [1,10]. The diagnosis is made by excisional biopsy, typically performed during work-up of a cervical smear showing either abnormal squamous or glandular cytology [11]. (See "Cervical cytology: Evaluation of atypical and malignant glandular cells".)

The cytologic diagnosis of AIS is difficult to make, but is very important as it is associated with histologically proven AIS in 48 to 69 percent of cases and with invasive cancer in 38 percent [12,13]. Cervical cytology and colposcopy-directed biopsies can miss up to 60 percent of AIS, although the addition of endocervical curettage (ECC) significantly improves the detection rate [14].
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