The American society for colposcopy and clinical pathology recommended that biopsy should be performed under colposcopy when cytological screening results were atypical glandular cells (AGC)、HPV16 or 18 were positive,or colposcopy showed mild or translucent white acetate change in 2017[7]. In this case, the AIS patient was misdiagnosed with CIN III in 2013 after cervical conization. Because of the difficulty in obtaining cervical gland cells, it is very difficult to make AIS diagnosis if there are not enough cervical gland cells.Therefore, an experienced pathologist or multiple pathologists are required to jointly diagnose .
The treatment for AIS tends to be conservative and general cervical conization or loop electrosurgical excisional procedure(LEEP) is considered an effective treatment for women who want to maintain their fertility[8]. Sometimes even very small and superficial AIS cells may cause recurrence and follow-up is recommended for appearance for more than 10 years after surgery[9]. Although AIS was missed in the patient in 2013, the specimens after hysterectomy in 2018 did not show the presence of AIS primary lesions which indicated that AIS did not progress in the primary lesion of the cervix in the past 5 years. This proved that cervical conization at that time was also effective. Metastatic adenocarcinoma was found in the inguinal、pelvic and para-aortic lymph nodes 14 years after hysterectomy[10]. The patient was confirmed to have AIS only because of the discovery of pelvic metastases which indicated that the biological behavior of AIS was more active.More effective means were needed for follow-up monitoring. TCT combined with HPV can not effectively detect AIS and cervical adenocarcinoma. We suggest that colposcopy examination and pelvic ultrasound or contrast-enhanced MRI may be more conducive to the discovery of lesions outside the cervix.
The tumor markers CA125 and CEA are of particular value in the follow-up of AIS and cervical adenocarcinoma, CA125 and CEA generally show an upward trend if the lesion progresses. In this patient, CA125 and CEA continued to increase for recent 2 years and metastatic lesions were found by ultrasound and pelvic MRI 5 years after AIS was treated by cervical conization. Therefore,the occurrence of metastases should be strictly monitored in the clinical follow-up of AIS or cervical adenocarcinoma if CA125 or CEA is elevated.We should follow up these patients for over 15 years.
Although the side effects of radiotherapy made patient uncomfortable, she was satisfied with the whole treatment process.