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Adenocarcinoma in Situ
Amy Mitchell, MD
Adenocarcinoma in Situ (AIS) of the cervix is often thought of as a rare diagnosis; however, it appears to be on the rise. This case is that of a patient of childbearing age who strongly desired preservation of fertility, and thus, was managed conservatively.
A 33-year-old gravida 1, para 1 patient presented for evaluation to a referral colposcopy clinic 6 months after her initial abnormal Pap test. The Pap showed atypical glandular cells (AGC). The patient had no medical problems, was a non-smoker, and had regular menses lasting 3 to 5 days.
Colposcopic evaluation was concerning for abnormal vasculature, with minimal acetowhite changes. Biopsy of the region of abnormal vasculature was performed, as well as endocervical curettage (ECC). The biopsy was read as “endocervical glands with marked atypia, at least AIS.” The patient underwent an office LEEP with top hat and ECC 2 weeks after biopsy. The LEEP specimen showed focal AIS without evidence of invasion and the top hat was negative; however, the ECC showed atypical glands, concerning for high-grade endocervical gland dysplasia.
Following these results, the patient was offered a hysterectomy or further conization. The positive ECC at time of LEEP was discussed, and was the most concerning portion of her results. Despite the risks, she did not want either option offered. She chose to come back for follow-up in 3 months.
Colposcopic exam in 3 months was adequate. Pap was normal, HPV testing was negative, and ECC was negative. After further discussion with the patient, she agreed to undergo a second conization if we thought it was still necessary, despite her recent negative results. Because of the unpredictable nature of AIS, the second conization procedure was recommended.
The patient postponed the procedure two times, and underwent a LEEP cone in the operating room 3 months later. LEEP cone was negative for AIS and dysplasia, top hat was negative, and ECC was negative.
The patient will be following up in 3 months for colposcopic exam, Pap, and ECC.
AIS remains a difficult management issue, and optimal follow-up has not been defined. It is important to keep in mind that physicians should have a high index of suspicion when evaluating all AIS patients.
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Figure 1. Pap test: Atypical glandular cells. |
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Figure 2. Colposcopy Image: This image taken from the colposcopy shows ginger root-like vessels. |
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Figure 3. 20x, Cervical Biopsy: This low-power view shows both abnormal endocervical glands (surface) and normal glands (deeper). |
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Figure 4. 100x Cervical Biopsy: The normal glands in this photo (in the upper left corner) can be compared to the abnormal glands to the lower right. |
Editors:
Thomas F. Purdon, MD, FACOG
Clinical Professor of Obstetrics and Gynecology
Department of Obstetrics and Gynecology
University of Arizona Health Sciences Center, Tucson, Arizona
Consultant, United Community Health Centers of Arizona
Kenneth D. Hatch, MD
Professor of Obstetrics and Gynecology
Head, Division of Gynecologic Surgery
University of Arizona College of Medicine, Tucson, Arizona
Amy Mitchell, MD
Amy Mitchell, MD, received her medical degree from University of Arizona College of Medicine, where she also completed her residency in obstetrics and gynecology. She is board certified by the American Board of Obstetrics & Gynecology. Dr. Mitchell is currently in practice at UPH Women's Health and Resource Center at University Medical Center in Tucson and United Community Health Center in Green Valley, AZ. Her research interests include cervical dysplasia and colposcopy, and patient education through a woman's life.
She is Co-director of the Colposcopy Clinic at the University of Arizona with Francisco Garcia, MD, MPH.