What is the recommended treatment for Adenocarcinoma in situ (AIS) of the uterine cervix?

Management of Adenocarcinoma in situ (AIS) of the Uterine Cervix

Hysterectomy is the definitive treatment for adenocarcinoma in situ (AIS) of the uterine cervix in women who have completed childbearing, while conservative management with cold knife conization (CKC) is appropriate for women desiring fertility preservation. 1

Diagnosis and Initial Evaluation

• AIS is a premalignant glandular lesion of the cervix that is less common than squamous intraepithelial lesions, with an incidence of only 1.25 per 100,000 compared to 41.4 per 100,000 for squamous carcinoma in situ 1
• All patients with atypical glandular cells (AGC) on cytology should undergo colposcopy, endocervical curettage (ECC), and HPV DNA testing as part of initial evaluation 1
• CKC is the preferred diagnostic procedure for patients at risk for AIS as it provides better assessment of margins compared to loop electrosurgical excision procedure (LEEP) 1
• Referral to a gynecologic oncologist or similar specialist should be strongly considered for all patients with AIS 1, 2

Treatment Algorithm Based on Fertility Desires

For Women Who Have Completed Childbearing:

• Hysterectomy is the definitive and preferred treatment 1
• This recommendation is based on the fact that approximately 30% of patients have residual disease on subsequent hysterectomy even with negative margins on excisional specimens 1, 2
• Repeat CKC should be considered before hysterectomy if invasive disease is suspected (category 2B recommendation) 1

For Women Desiring Fertility Preservation:

• Conservative management with CKC is acceptable if future fertility is desired 1
• If CKC margins are positive for abnormal glandular cells:
  • Re-excision to attain negative margins is recommended 1
  • Patients should receive counseling regarding the risks of this conservative strategy 1
• If CKC margins are negative:
  • Follow-up with cervical cytology with or without ECC every 6 months until hysterectomy 1
  • Patients should still receive counseling on the risks of this strategy 1
• Hysterectomy should be strongly considered when childbearing is completed 1, 2

Important Clinical Considerations

• AIS has several characteristics that make management challenging:
  • Colposcopic changes associated with AIS can be minimal, making it difficult to determine lesion extent 1
  • AIS frequently extends deep into the endocervical canal 1
  • AIS is often multifocal and may have "skip lesions" (non-contiguous lesions) 1
• Clear margins on excisional specimens do not rule out persistent disease, as approximately 30% of patients have residual disease on subsequent hysterectomy 1, 3
• CKC is preferred over LEEP for AIS as LEEP has been associated with an increased incidence of positive excision margins 1, 2
• Margin status is one of the most clinically useful predictors of residual disease 1
• Recent data suggest that endocervical sampling at the time of excisional biopsy is also predictive of residual disease 1

Follow-up Recommendations

• For women undergoing conservative management:
  • Cervical cytology with or without ECC every 6 months 1
  • Continue screening every 6 months for those with negative findings 1
  • Women with positive findings on follow-up cervical cytology/ECC should be managed according to guidelines 1
• Long-term follow-up is essential for women who do not undergo hysterectomy 1
• Studies show that the failure rate after an excisional procedure (recurrent/persistent AIS or invasive adenocarcinoma) ranges from 0% to 9% 1, 3

Special Circumstances

• During pregnancy, diagnostic procedures should be limited, and ECC should not be performed to avoid possible disruption of the pregnancy 1
• Treatment for AIS during pregnancy should be delayed until after delivery 1, 4
• Consultation with or referral to an experienced colposcopist should be considered for pregnant women 1