Adenocarcinoma of the cervix is managed in the same manner used for squamous cell carcinoma. Adenocarcinoma was believed to be associated with a worse prognosis and outcome when compared with squamous cell carcinoma. A study of 203 women with adenocarcinoma and 756 women with squamous carcinoma supported this assertion (30). This study showed 5-year survival rates of 90% versus 60%, 62% versus 47%, and 36% versus 8% for stages I, II, and III, respectively. Although some attributed these rates to a relative resistance to radiation, they are more likely a reﬂection of the tendency of adenocarcinomas to grow endophytically and to be undetected until a large volume of tumor is present. When adjusted for tumor size, it appears that there is no difference in prognosis between the two histologic subtypes. Adenocarcinoma may be detected by cervical sampling, but less reliably so than squamous carcinomas. A definitive diagnosis may require cervical conization.
The clinical features of stage I adenocarcinomas are well studied (30,37–39). These studies identified size of tumor, depth of invasion, grade of tumor, and age of the patient as significant correlates of lymph node metastasis and survival. When matched with squamous carcinomas for lesion size, age, and depth of invasion, the incidence of lymph node metastases and the survival rate appear to be the same (38,39). Patients with stage I adenocarcinomas can be selected for treatment according to the same criteria as for those with squamous cancers (39).
The choice of treatment for bulky stage I and II tumors is controversial. Some advocated treatment with radiation alone, whereas others support radiation plus extrafascial hysterectomy (40–42). In 1975, Rutledge et al. reported an 85.2% 5-year survival rate for all patients with stage I disease treated with radiation alone and an 83.8% survival rate for those who had radiation plus surgery (41). The central persistent disease rate was 8.3%, compared with 4% for those who had radiation plus surgery. In stage II disease, the 5-year survival rate was 41.9% for radiation alone and 53.7% for radiation plus surgery. A subsequent report revealed no significant difference in survival among patients treated with radiation alone or radiation plus extrafascial hysterectomy (43).
Invasive adenocarcinoma may be pure (Fig. 36.5A, B) or mixed with squamous cell carcinoma. Within the category of pure adenocarcinoma, the tumors are quite heterogeneous, with a wide range of cell types, growth patterns, and differentiation (30). About 80% of cervical adenocarcinomas consist predominantly of the endocervical type cells with mucin production. The remaining tumors are populated by endometrioid cells, clear cells, intestinal cells, or a mixture of more than one cell type. By histologic examination alone, some of these tumors are indistinguishable from those arising elsewhere in the endometrium or ovary. Within each cell type, the growth patterns and nuclear abnormalities vary according to the degree of differentiation. In well-differentiated tumors, tall columnar cells line the well-formed branching glands and papillary structures, whereas pleomorphic cells tend to form irregular nests and solid sheets in poorly differentiated neoplasms. The latter may require mucicarmine and periodic acid–Schiff (PAS) staining to confirm their glandular differentiation.