CIN 3 at the endocervical limits of conization specimen in selected patients 3.
Poor compliance with follow-up 4.
Other gynecologic problems requiring hysterectomy, such as fibroids, prolapse, endometriosis, and pelvic inﬂammatory disease 5.
Atypical Glandular Cells The Bethesda System created the term atypical glandular cells to describe the spectrum of glandular cell abnormalities. This classification is subdivided with the qualifier into the categories
Table 19.9 Unsuspected Invasion in Electrosurgical Excision Specimens
Table 19.10 Grade of Discomfort of Large-Loop Excision versus Laser Conization
From Gunasekera PC, Phipps JH, Lewis BV. Large loop excision of the transformation zone (LLETZ) compared to carbon dioxide laser in the treatment of CIN: a superior mode of treatment. Br J Obstet Gynaecol 1990;97:995–998, with permission.
favor neoplasia and not otherwise specified (NOS). The latter qualified with the cell of origin when identifiable as either endocervical or endometrial origin. Included in the glandular cell category is endocervical carcinoma in situ and adenocarcinoma (129).
Atypical glandular cells are important because of their risk for significant disease. In a series of 63 patients from whom subsequent cervical biopsy or hysterectomy specimens were evaluated, 17 women had CIN 2 or 3, five women had adenocarcinoma in situ, and two women had invasive adenocarcinoma (125). An additional eight patients had CIN 1, and two women had endometrial hyperplasia. Overall, 32 patients (50.8%) had significant cervical lesions. This is a much higher positive rate than that for ASC-US Pap test results.
Adenocarcinoma In adenocarcinoma in situ (AIS), the endocervical glandular cells are replaced by tall columnar cells with nuclear stratification, hyperchromasia, irregularity, and increased mitotic activity (130). Cellular proliferation results in crowded, cribriform glands. The normal branching pattern of the endocervical glands is maintained. Most neoplastic cells resemble those of the endocervical mucinous epithelium. Endometrioid and intestinal cell types occur less often. About 50% of women with cervical AIS have squamous CIN. Some of the AIS lesions represent incidental findings in specimens removed for treatment of squamous neoplasia. Because AIS is located near or above the transformation zone, conventional cervical specimens may not be effective for detecting glandular disease. Obtaining good endocervical specimens by cytobrush may improve detection of AIS. If the focus of AIS is small, cervical biopsy and endocervical curettage may have negative findings. In such cases, a more comprehensive survey of the cervix by diagnostic conization may be necessary. This type of specimen allows exclusion of coexisting invasive adenocarcinoma. The term microinvasion should not be used to describe adenocarcinomas. After the gland is invaded, it is methodologically problematic to estimate a true “depth of invasion” because the invasion may have originated from the mucosal surface or the periphery of the underlying glands. The “breakthrough” of the basement membrane cannot be described; therefore, the tumor is either AIS or invasive adenocarcinoma.
Table 19.11 Results of Loop Electrosurgical Excision
Table 19.12 Recurrence of Cervical Intraepithelial Neoplasia After Cone Biopsy