Fertility Sparing Treatment for In Situ and Early Invasive Adenocarcinoma of the Cervix

Abstract

The controversy surrounding the definition of early invasive adenocarcinoma of the cervix was ended in 1997 when the International Federation of Obstetrics and Gynecology (FIGO) described stage IA1 cervical cancer. The definition included both squamous and glandular lesions with less than 3 mm depth of invasion beyond the basement membrane and less than 7 mm lateral extension of the lesion. Since 1997, little has been published regarding the long-terra outcome of fertility-sparing surgery for the treatment of early adenocarcinoma of the cervix. To explore the consequences of such surgery, the authors reviewed the cases of cervical adenocarcinoma in situ and stage I that had been seen at their institutions between 1985 and 1996. The pathological specimens were reviewed and characterized according to the 1997 definition. Of 133 cases of stage I adenocarcinoma of the cervix identified, 20 were rediagnosed as FIGO stage IA1. In the early years of the study, women with this cancer were treated with radical hysterectomy and pelvic lymphadenectomy (N = 14). In the course of the study years, treatment regimens have devolved to the point that more recent patients have undergone only simple hysterectomy with no lymphadenectomy (N = 2). Four patients (mean age, 31 years) who were adamant about preserving their fertility were treated with cervical conization alone. None of these women had disease with greater than 1.5 mm depth of invasion. The margins of the initial cone specimen were negative in two patients, with a third having negative margins after a repeat conization. The fourth woman had adenocarcinoma in situ diagnosed at the margin of the cone specimen. She is one of the three women who have had a successful pregnancy. With an median 48 months of follow-up (range, 25-108), there have been no recurrences among these four patients. Thirteen of the 16 women who underwent hysterectomy had positive margins in the preoperative cone biopsy specimen. Residual disease was found in the hysterectomy specimen of 10 women, including 4 with residual cancer and 6 with adenocarcinoma in situ. None of the women treated with hysterectomy had positive lymph nodes, and none have had a recurrence in the follow-up period. Among the 133 women with cervical adenocarcinoma, there were 40 cases of adenocarcinoma in situ. Twenty-two women (mean age, 42 years) underwent simple hysterectomy. The remaining 20 (mean age, 32 years) chose fertility-sparing surgery and were treated with conization. Negative margins were seen in 15 cone specimens and were positive in 5. In a median follow-up of 42 months, three patients have had a recurrence. Two patients had a recurrence of adenocarcinoma in situ, but one woman developed invasive disease 5 years after initial treatment. Despite radical treatment, her disease metastasized, and she eventually died. None of the women with negative margins have had a recurrence. The 22 women with adenocarcinoma in situ who had simple hysterectomy all underwent cone biopsy before surgery. There were 14 with positive margins in the cone specimen, 10 of whom had residual disease in the cervix. In comparison, residual disease was found in the hysterectomy specimen of one of the six women with negative cone biopsy margins. Both of the women with undetermined margin status had residual disease in the cervix at hysterectomy.