The "hidden" escapee: cervical adenocarcinoma

Author: Ye Dan, attending physician, Obstetrics and Gynecology Hospital, Fudan University

Reviewer: Shen Haoran, deputy chief physician, Obstetrics and Gynecology Hospital, Fudan University

With the popularization of cervical vaccines and doctors' unremitting popularization of science, most women in my country now realize the importance of annual B-ultrasound and cervical screening. But here, I still need to remind everyone that there is a type of cervical cancer that is very cunning and good at "hiding" and "escaping", so we need to be more cautious.

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Cervical adenocarcinoma is hidden in the endocervical canal, which is not easily visible to the naked eye, and may "escape" through routine screening, making it difficult to fully detect through cervical cytology screening and HPV testing.

Case Study

The outpatient clinic received a 38-year-old young woman, Ms. Zhang, who had repeated abnormal leucorrhea in the past six months, sometimes watery, and was very distressed. She had undergone a cervical HPV test at a local hospital, and the result was negative. The cervical screening indicated that the atypical squamous epithelium could not be clearly defined. The doctor did not give clear advice and only asked her to follow up. Due to increased vaginal discharge, she had been treated for vaginitis, but the effect was not good. So she came to our outpatient clinic for consultation.

Considering that vaginitis is generally not difficult to treat, and Ms. Zhang has not seen any improvement after six months of treatment, I decided to perform a gynecological examination on her first. The examination found that Ms. Zhang had mild erosion on the surface of her cervix, but no obvious lesions were found. However, during palpation, it was found that her cervix was significantly thickened and enlarged. Subsequently, I arranged for her to undergo a B-ultrasound examination, which showed a space-occupying lesion with a diameter of about 2 cm and blood flow signals in the cervical canal.

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Science Time

The normal length of the cervix is ​​3 to 4 cm, and its shape can be understood as a bucket with two openings. During cervical screening, we mainly scrape the external opening and take cells for testing. However, some tumors are very "cunning" and will "hide" in the endocervical canal, making it difficult to obtain samples, reducing the positive rate of screening and biopsy, and easily leading to missed diagnosis.

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After arranging a colposcopy biopsy for Ms. Zhang, she came to the clinic again a week later with the pathology report. The report clearly stated "invasive cervical adenocarcinoma." She was shocked and said that she had been screened every year and had also received the HPV vaccine.

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Not all cervical cancers are related to HPV infection. At the same time, due to the possible blind spots in screening, B-ultrasound and gynecological examinations by gynecologists are equally important. Once abnormal cervical screening is found, colposcopy biopsy is also essential.

Cervical cancer includes a variety of histological types, of which squamous cell carcinoma is the most common. However, in recent years, the incidence of invasive endocervical adenocarcinoma and its variants has increased dramatically. Risk factors for endocervical adenocarcinoma include:

1. Estrogen exposure: Both endogenous estrogen (such as obesity) and exogenous estrogen (such as hormonal contraception, postmenopausal estrogen therapy) are risk factors.

2. HPV infection: Long-term infection with high-risk human papillomavirus subtypes (especially subtypes 16 and 18) is associated with cervical adenocarcinoma, but not all adenocarcinomas are related to HPV infection. About 10% to 15% of adenocarcinomas are not HPV-related.

3. Genetic factors: Nearly half of gastric adenocarcinomas are accompanied by TP53 gene mutations. Patients with Peutz-Jeghers syndrome (Jeghers-Jeghers syndrome) may also develop cervical adenocarcinoma.

4. Chronic inflammatory stimulation and sexual behavior: Having sexual intercourse at a young age, having more sexual partners, poor local development of the cervix, frequent stimulation, trauma and infection may also lead to lesions.

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Patients with cervical adenocarcinoma often have no typical symptoms, and the main manifestation is increased vaginal mucous or watery secretions. During gynecological examination, the cervix may appear enlarged and without obvious lesions, but the lesions are often hidden in the cervical canal. Therefore, patients with cervical hypertrophy and/or barrel-shaped cervix accompanied by vaginal discharge, irregular vaginal bleeding, or pelvic mass should be highly alert to the possibility of cervical adenocarcinoma. Strengthening the sampling of cervical cytology, timely multiple multi-point deep biopsies, endocervical canal curettage, and even cervical cone resection can improve the diagnosis rate.