Frozen-section evaluation of cervical adenocarcinoma at time of radical trachelectomy: Pathologic pitfalls and the application of an objective scoring system
Introduction
Adenocarcinoma of the uterine cervix accounts for approximately 20–25% of all cervical carcinomas and has become more prevalent in recent years. While the incidence of squamous cell cancers has declined since the introduction of widespread screening in developed countries, the absolute frequency of adenocarcinoma and the proportion of adenocarcinomas relative to squamous carcinomas has increased [1]. Since cervical cancer is a disease that often affects young women who are still in their childbearing years, fertility-sparing procedures such as the radical trachelectomy have become an increasingly popular option for these patients, and more gynecologic oncologists are performing the procedure when clinically appropriate. The resected cervix is usually sent for frozen-section evaluation of the proximal margin with recommended tumor (invasive and in situ) clearance of 5–10 mm [2]. If this clearance is not achieved, either additional cervical tissue is excised to obtain that clearance or a completion hysterectomy is performed if adequate margin clearance is not possible. Therefore, it is critical that an accurate diagnosis of the margin be reported at the time of intraoperative consultation. We retrospectively collected 19 cases of endocervical adenocarcinoma for which radical trachelectomy was performed with frozen-section analysis of the proximal margin. The aim of the study was to report on the incidence of diagnostic discrepancy between frozen-section and final pathology and to apply an objective scoring system for grading non-invasive glandular cervical lesions proposed by Ioffe et al. [3] to determine whether this could be a useful tool in differentiating benign from malignant lesions on frozen-section slides.
Section snippets
Materials and methods
A retrospective review of all cervical carcinoma patients who underwent fertility-sparing radical trachelectomy and pelvic lymphadenectomy was performed at Memorial Sloan-Kettering Cancer Center from 11/01 to 5/06. All patients had frozen sections of the endocervical resection margins performed at the time of surgery. Only cases of adenocarcinoma were selected for this study, and all trachelectomy slides, including the original frozen section and corresponding permanent sections were retrieved
Results
Forty-six consecutive radical trachelectomies for cervical carcinoma were identified, 19 of which were for adenocarcinoma (41%). Four of these showed grossly visible tumors, all of which showed invasive carcinoma. Seven showed no grossly visible lesions, 2 of which had either AIS or minimally invasive adenocarcinoma. The trachelectomy margins were negative for both patients. Five showed non-specific changes, including hemorrhage, fibrosis, and irregular borders correlating microscopically with
Discussion
The overall incidence of cervical adenocarcinoma has been steadily increasing over the past several years and currently accounts for approximately 20–25% of all cervical carcinomas [1]. These tumors commonly affect women in their childbearing years, and radical trachelectomy is now a viable option for women who want to preserve fertility. The procedure is considered for patients with stage IA2–IB1 adenocarcinoma and sometimes for IA1 patients with lymphoinvasive adenocarcinoma. The resected
Conflict of interest statement
YS has served on the Speaker's Bureau for Genzyme and as a consultant for Covidien. All other authors have no conflicts of interest to declare.
References (22)
- et al.
The rising incidence of adenocarcinoma relative to squamous cell carcinoma of the uterine cervix in the United States—a 24-year population-based study
Gynecol Oncol
(2000) - et al.
Pregnancies after radical vaginal trachelectomy for early-stage cervical cancer
Am J Obstet Gynecol
(1998) Glandular lesions of the uterine cervix
Mod Pathol
(2000)- et al.
Endocervical glandular lesions: a diagnostic approach combining a semi-quantitative scoring method to the expression of CEA, MIB-1 and p16
Gynecol Oncol
(2006) - et al.
IMP3 is a novel biomarker for adenocarcinoma in situ of the uterine cervix: an immunohistochemical study in comparison with p16(INK4a) expression
Mod Pathol
(2007) - et al.
Evaluation of p16INK4a and pRb expression in cervical squamous and glandular neoplasia
Hum Pathol
(2004) - et al.
Vaginal radical trachelectomy in the treatment of cervical cancer: the role of frozen section
Int J Gynecol Pathol
(2004) - et al.
Proposal of a new scoring scheme for the diagnosis of noninvasive endocervical glandular lesions
Am J Surg Pathol
(2003) - et al.
The effects of endocervical canal topography, tubal metaplasia, and high canal sampling on the cytologic presentation of nonneoplastic endocervical cells
Am J Clin Pathol
(1996) - et al.
Superficial endometriosis of the uterine cervix: a report of 20 cases of a process that may be confused with endocervical glandular dysplasia or adenocarcinoma in situ
Int J Gynecol Pathol
(1999)
Tubal metaplasia of the uterine cervix: a prevalence study in patients with gynecologic pathologic findings
Int J Gynecol Pathol
Cited by (28)
Clinical view of gynecologic intraoperative frozen section diagnosis
2022, Gynecology and Obstetrics Clinical MedicineBritish Gynaecological Cancer Society (BGCS) cervical cancer guidelines: Recommendations for practice
2021, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :The resected cervix is sent for frozen section evaluation of the proximal margin with a recommended tumour (invasive and in-situ) clearance of 5−10 mm ([76]). If this clearance is not achieved, additional cervical tissue is excised to obtain that clearance, or a completion hysterectomy is performed if intraoperative assessment indicates that an adequate margin clearance is not possible [77]. There are limitations of frozen section on trachelectomy specimens and the discrepancies are mainly due to inherent difficulties in discrimination of subtle invasion from benign mimics.
Diagnostic Pathology: Cytopathology
2018, Diagnostic Pathology: CytopathologyA new method of surgical margin assuring for abdominal radical trachelectomy in frozen section
2015, European Journal of CancerThe role of frozen sections in gynaecological oncology: Survey of practice in the United Kingdom
2013, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :In our experience assessment of margins in trachelectomy specimens is practical and reliable in macroscopically visible tumours and in cases of invasive squamous cell carcinoma. There may be difficulty, however, in some cases of cervical adenocarcinoma, as tubo-endometrioid metaplasia, which commonly occurs particularly after conisation or loop excision, may simulate CGIN on FS [18]. There are also difficulties in cases where there is no macroscopically visible tumour.