Predictors of invasive adenocarcinoma after conization for cervical adenocarcinoma in situ

ObjectiveModified radical hysterectomy has been advocated for the definitive treatment of patients with cervical adenocarcinoma in situ (ACIS) with positive conization margins due to the risk of a co-existing invasive cervical adenocarcinoma (ICA). We sought to identify patients who can be safely managed with an extrafascial hysterectomy based on predictors of invasion in the conization specimen.MethodsBetween 1996 and 2010, we identified 33 patients who had definitive surgical management for cervical ACIS following conization with positive margins and/or positive endocervical curettage (ECC). Demographic and pathologic characteristics were collected by chart review. Statistical analysis was performed using Fisher's exact test.ResultsAmong 33 patients, 4 (12%) had ICA in the hysterectomy specimen. Predictors of ICA included pathologic suspicion of invasion (PSI) in the conization specimen and positive ECC. In patients with ICA at hysterectomy, PSI and ACIS-positive ECC were found in 75% (p = 0.32) and 100% (p = 0.09) respectively. When PSI was present and the ECC was positive, the positive predictive value (PPV) for ICA was 33% (2 of 6). When PSI was absent, the negative predictive value (NPV) for ICA was 94% (1 of 16). When both PSI and ECC were negative, the NPV for ICA was 100% (0 of 6).ConclusionsWomen with cervical ACIS have the highest risk for ICA in the setting of positive cone margins, positive ECC, and presence of PSI in the conization specimen. Extrafascial hysterectomy remains a viable option for women with positive cone margins when ECC is negative and PSI is absent.

► ACIS patients with involved cone margins, negative ECC, and absent PSI are at low risk for ICA.
► ACIS patients with positive margins, positive ECC and PSI at time of conization have 33% risk for ICA.
► ACIS patients with positive cone margins and involved ECC bed have a high risk for persistent residual ACIS.