Cervical adenocarcinoma

　　The etiology of cervical adenocarcinoma is not yet clear. Some believe that the risk factors for the disease have similar characteristics to those of cervical squamous cell carcinoma, such as early sexual intercourse, sexual disorder, multiple sexual partners, and also have similar characteristics to endometrial cancer, such as infertility, low pregnancy rate, obesity, hypertension, and diabetes, which are significantly higher than those in cervical squamous cell carcinoma. Some scholars believe that the risk factors for cervical adenocarcinoma are different from those of cervical squamous cell carcinoma, considering that the occurrence of adenocarcinoma is not closely related to sexual life and childbirth, but may be related to endocrine disorder and the use of exogenous hormones. Cervical adenocarcinoma often occurs during menopause, which is related to the frequent hormonal disorder during this period. Microadenomatous gland hyperplasia can be seen in the cervix of pregnant women using progesterone drugs, indicating that gland hyperplasia is related to progesterone.

　　The occurrence of cervical cancer is closely related to human papillomavirus (HPV) infection. HPV DNA can be detected in both cervical squamous cell carcinoma and adenocarcinoma tissues. HPV types associated with cervical cancer are mainly 16, 18, and 31, but the proportion of HPV types in cervical squamous cell carcinoma and adenocarcinoma is not the same. HPV16 is the predominant type in cervical squamous cell carcinoma, while HPV18 accounts for only 5% to 17% of HPV-positive tumors. In cervical adenocarcinoma, HPV18 is the predominant type, accounting for up to 34% to 50% of the tumors, suggesting that HPV16, 18, especially HPV18, may play an important role in the pathogenesis of cervical adenocarcinoma.

　　Cervical adenocarcinoma can coexist with breast cancer, vulvar in situ carcinoma, vulvar Paget's disease, rectal cancer, and others, with an incidence rate of about 1.8%; patients with cervical adenocarcinoma often have CIN, and the factors for the formation of these two conditions are unclear. Some believe that both lesions originate from the same precursor - the reserve cells. Mair reported that 99 out of 230 cases of cervical adenocarcinoma had CIN, accounting for 43%, including 23 cases of mild, 21 cases of moderate, 22 cases of severe, and 33 cases of cervical in situ carcinoma. There were also 6 cases with invasive squamous cell carcinoma. Shingleton reported that 1/3 of patients had concurrent malignant squamous cell components. Teshima reported that 10 out of 30 early cervical adenocarcinoma cases had concurrent cervical in situ squamous cell carcinoma.

　　The symptoms of cervical adenocarcinoma are mostly: increased leukorrhea, anal prolapse, cervical erosion, menopause, cavity formation, anemia, increased vaginal discharge, squamous cell metaplasia, etc.
　　1. Cervical intraepithelial adenocarcinoma with precancerous lesions:They often lack specific clinical manifestations, are asymptomatic, or present with cervical inflammation, and are diagnosed by pathological histological examination.

　　2. Clinical manifestations of microinvasive adenocarcinoma:15% to 20% of patients with cervical microinvasive adenocarcinoma have no symptoms. The main symptoms are increased vaginal discharge, sometimes watery or mucoid, followed by abnormal vaginal bleeding, often during sexual intercourse. The cervix can present varying degrees of erosion, or polypoid, papillary, about 1/3 of the patients have a normal cervical appearance.

　　3. Clinical manifestations of cervical invasive adenocarcinoma:Its clinical manifestations are similar to those of cervical squamous cell carcinoma. In the early stage, there may be no symptoms, and abnormalities are found through abnormal cytological smears. In patients with symptoms, the main manifestations are abnormal vaginal bleeding and increased leukorrhea. In advanced patients, a series of secondary symptoms may appear according to the extent of lesion spread and the organs involved, such as pain, anal prolapse, anemia, urinary system symptoms, etc. Especially in cervical mucinous adenocarcinoma, patients often complain of a large amount of mucous leukorrhea, a few with a little purulent yellow water-like, often requiring perineal pads due to the large amount.

　　The local appearance of the cervix can be smooth or erosive, polypoid growth, or even cauliflower-like. In advanced cases, the surface of the cervical tumor can have ulcers or cavities, covered by necrotic tissue, with vaginal or parametrial invasion. About 1/3 of the patients have a normal cervical appearance, and the tumor is often located within the cervical canal, while the surface is smooth. The vaginal fornix and cervix of postmenopausal patients may atrophy, making the lesion less obvious.

　　Preventing premarital early sexual behavior, late marriage and late childbirth, and strictly implementing family planning are of great significance in reducing the incidence of cervical cancer. Pay attention to self-protection. Pay attention to personal hygiene and sexual partner hygiene in daily life. If the sexual life of husband and wife is moderate, wash the vulva before and after sexual life, do not have sexual life during menstruation, and do not do inappropriate vaginal cleaning, etc. Timely and scientific treatment of cervical erosion. If cervical erosion is not treated in time or is not treated correctly, it can cause long-term inflammation accumulation, leading to atypical hyperplasia of the lesion tissue and eventually developing into cancer.

　　Routine examination: cervical biopsy, colposcopy smear, serum protein-bound iodine, vaginal cytology examination, etc.
　　1. Desquamation cell cytology examination:When multiple round, flake-like, or single polymorphic glandular cells are observed in the cervical scraping specimens, adenocarcinoma can be considered. Most adenocarcinoma cells have prominent nucleoli, but about half of the patients' cytological smears may show no abnormalities.

　　Cervical cytology is used to detect cervical adenocarcinoma, but its positive rate is significantly lower than that of cervical squamous cell carcinoma, only 30%, with a high rate of false negatives, so misdiagnosis and missed diagnosis are likely to occur. This may be related to the following factors:

　　(1) Cervical adenocarcinoma is often located in the cervical canal covered by columnar epithelium and stromal glands, with the lesion concealed, often resulting in insufficient tissue sampling.

　　(2) The nuclear atypia of cervical adenocarcinoma, especially early adenocarcinoma, is not as prominent as that of squamous cell carcinoma, especially in well-differentiated mucinous adenocarcinoma, which is often overlooked during film reading.

　　2. Iodine test:The iodine test is not specific for cancer. Utilizing the fact that normal cervical epithelium is rich in glycogen, it will be stained brown-black by iodine, while the cancerous epithelium lacks glycogen and will not be stained, so a biopsy can be taken from the unstained area to improve the accuracy of diagnosis.

　　3. Colposcopy:The colposcopic findings of cervical adenocarcinoma include the presence of highly differentiated glands, scattered or dense and prominent columnar villi around normal ciliated structures, and a honeycomb-like image. The colposcopic images of adenocarcinoma are different from those of squamous cell carcinoma, as the special growth of tumor tissue causes the central blood vessels of the cervical columnar epithelium to expand greatly, ending in a villous papillary carcinoma tissue similar to normal columnar epithelium, forming large and scattered dot-like blood vessels, and sometimes also in hairpin-shaped atypical blood vessels. The blood vessels are large and abnormally distributed, and the cervical surface gland orifices are abnormally increased and (or) irregularly distributed, with white gland orifices of irregular size, making the cervical surface resemble a honeycomb-like pattern, especially in mucinous adenocarcinoma. Therefore, it is necessary to perform multiple biopsies at suspicious sites under colposcopy and send them for pathological histological examination.

　　4. Cervical canal scraping:If the lesion is located within the cervical canal, simultaneous cervical canal scraping should be performed during colposcopic examination to significantly improve the accuracy of diagnosis.

　　5. Cervical cone:Although cervical biopsy can make a definite diagnosis, due to the limited amount of tissue obtained, it is sometimes not possible to determine the depth of invasion. Therefore, at least a cervical conization should be performed to diagnose whether it belongs to stage Ia.

　　6. Cervical and cervical canal biopsy:It is the most reliable and indispensable method to confirm the lesion.

　　Appropriate diet for cervical adenocarcinoma patients:

　　The main focus should be on improving the immune function, and as much as possible, nutrients such as proteins, sugars, fats, and vitamins should be consumed reasonably. When the patient has excessive vaginal bleeding, foods that can nourish blood, stop bleeding, and fight cancer should be taken, such as lotus root, Job's tears, hawthorn, black fungus, and plum. When the patient has excessive watery leukorrhea, it is advisable to take tonifying foods, such as turtle, pigeon eggs, and chicken. When the patient has excessive sticky leukorrhea with an unpleasant smell, it is advisable to eat light and diuretic foods, such as Job's tears, red bean, and white mugwort root.

　　After surgery, the diet should focus on replenishing Qi and nourishing blood, and foods like yam, longan, mulberry, goji, pork liver, turtle, sesame, and donkey hide glue are recommended.

　　During radiotherapy, the diet should focus on nourishing the blood and moistening the Yin, and foods such as beef, pork liver, lotus root, black fungus, spinach, celery, pomegranate, and water chestnut can be consumed. If radioactive cystitis and radioactive proctitis occur due to radiotherapy, a diet with清热利湿, nourishing Yin and detoxifying effects should be given, such as watermelon, Job's tears, red bean, water caltrop, lotus root, and spinach.

　　4. During chemotherapy, diet should focus on strengthening the spleen and kidney, and can use山药powder, Job's tears congee, animal liver, placenta, ejiao, turtle, mushrooms, goji, lotus root, banana, etc. When there are gastrointestinal reactions, such as nausea, vomiting, and loss of appetite, the diet should be adjusted to strengthen the spleen and stomach, such as sugarcane juice, ginger juice, black plum, banana, tangerine, etc.

　　5. High-protein, high-calorie foods should be selected, such as milk, eggs, beef, turtle, red bean, mung bean, fresh lotus root, spinach, winter melon, apple, etc.

　　It is generally believed that: ① Adenocarcinoma is less radiosensitive than squamous cell carcinoma, especially well-differentiated adenocarcinoma with secretory function. ② Cervical adenocarcinoma originates from the endocervical canal, often presents as a barrel-shaped lesion and often extends to the lower uterine segment and deeply into the muscular layer. Treating cervical adenocarcinoma with the technique used to treat squamous cell carcinoma is insufficient. ③ About 40% to 50% of cases have residual lesions after radiotherapy for cervical adenocarcinoma, and even up to 2/3, so it is recommended to perform surgery after radiotherapy.
　　Due to the poor radiosensitivity of cervical adenocarcinoma to radiotherapy, the treatment principle is to strive for surgical treatment as long as the patient can tolerate surgery and the lesion is estimated to be resectable. For advanced cases with difficult surgery or those estimated to be inoperable, radiotherapy can be supplemented for tumors with a diameter >4cm, bulky stage I b, and lesions extending to the lower uterine segment, and preoperative radiotherapy is recommended followed by surgery.
　　With the development of interventional technology and its wide application in clinical practice, there have been reports in recent years that some inoperable cervical adenocarcinomas have undergone preoperative interventional therapy, followed by surgery after the lesion is reduced.
　　Stage I
　　The pelvic lymph node metastasis rate of extensive total hysterectomy and bilateral pelvic lymph node dissection for cervical adenocarcinoma is high, with Nojales reporting 16.6% in stage I and 32.4% in stage II; Berek reported 14.16% in stage I and 40.4% in stage II; Cao Binrong et al. reported 10.3% in stage I and 34.4% in stage II, so stage I cervical adenocarcinoma should also undergo pelvic lymph node dissection. The ovarian metastasis rate of invasive cervical adenocarcinoma is relatively high, with Tabata (1993) studying 674 autopsies of cervical cancer and finding that the ovarian metastasis rate of squamous cell carcinoma is 17.4%, while adenocarcinoma reaches 28.6%. There is no report on the safety of retaining the ovary in cervical adenocarcinoma, so it is generally recommended not to retain the ovary during surgery. As for whether to add radiotherapy routinely after surgery and whether it improves survival rate, there is much controversy. Kinney et al. believe that adjuvant radiotherapy does not significantly improve survival rate but can reduce the recurrence rate in the pelvis and prolong the cancer-free survival period. Most scholars believe that when there are adverse prognostic factors, such as the lesion close to the surgical margin, deep infiltration of the tumor into the stroma, large lesion involving the parametria, lymph node metastasis, etc., radiotherapy should be added after surgery.
　　Stage II
　　The combined treatment of surgery and radiotherapy, namely extensive total hysterectomy and bilateral pelvic lymph node dissection, suggests preoperative or postoperative radiotherapy for cervical adenocarcinoma lesions ≥4cm. It is recommended to perform preoperative radiotherapy or interventional therapy before the lesion is reduced, and then perform surgery. Some scholars advocate performing total pelvic radiotherapy and intracavitary irradiation first, followed by extraperitoneal total hysterectomy 2 weeks or 6 weeks after radiotherapy.
　　Advanced stage patients
　　Adopt a comprehensive treatment approach mainly based on radiotherapy, that is, external beam radiation plus intracavitary radiation, supplemented by chemotherapy. Commonly used chemotherapeutic drugs include etoposide (VP-16), mitomycin (MMC), ADM vinblastine (VCR), cisplatin (DDP), epirubicin, etc. There have been recent reports of arterial infusion followed by surgery in patients with lesions localized to the pelvis and no metastasis to paraaortic lymph nodes. Narimatsu et al. (1996) reported that arterial infusion with DDP 10mg/d and 5-FU 250mg/d for 10 times as one course, with a 3-week interval between courses, achieved a tumor regression rate of 83.5%, allowing for complete resection of the tumor through radical total hysterectomy. There are also a few reports of pelvic exenteration in patients with central recurrence of cervical adenocarcinoma, which achieves a survival rate similar to that of squamous cell carcinoma, but the incidence of surgical complications is higher, and caution should be exercised.
　　The optimal treatment plan for microinvasive adenocarcinoma is as difficult to differentiate as distinguishing in situ carcinoma and microinvasive adenocarcinoma. To date, there is a lack of large sample size statistical data, and the existing materials are mostly case reports, which are difficult to make reliable judgments. Currently, there is no unified opinion on the treatment of this disease, ranging from simple hysterectomy to radical hysterectomy, and radiotherapy can also be used. Burshardt suggests that the surgical treatment of microinvasive adenocarcinoma should be the same as the recommended plan for cervical squamous cell carcinoma, performing simple total hysterectomy or radical hysterectomy according to the size of the lesion. In their treated cases, there was no recurrence. Teshima et al. reported that in 30 patients, there was one case of vaginal top tumor recurrence after extensive hysterectomy in a patient with cervical adenocarcinoma infiltrating the stroma 3mm deep. Du Xinggu et al. also reported a similar case. Buscema Woodruff reported that adenosquamous carcinoma with an infiltrative stroma of 3mm deep occurred with widespread metastasis.
　　It is generally believed that surgical treatment and radiotherapy are equally effective for microinvasive adenocarcinoma of the cervix, but surgery is superior to radiotherapy. Due to the high rate of involvement of the cervical cone margin in microinvasive adenocarcinoma (up to 32%), conservative treatment is not recommended. If there are no surgical contraindications, it is recommended to perform a total hysterectomy with pelvic lymphadenectomy. If the patient requests it, the normal ovary can be preserved, as the chance of microscopic spread of early cervical adenocarcinoma to the ovary is below 2%.