Fertility-sparing treatment in younger women with adenocarcinoma in situ of the cervix Nehalennia van Hanegem a, b , Lisa M. Barroilhet a , Marisa R. Nucci c , Marilyn Bernstein a , Sarah Feldman a, ⁎ a Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA b Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands c Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA abstract article info Article history: Received 30 June 2011 Accepted 7 September 2011 Available online xxxx Keywords: Adenocarcinoma in situ Cervix Loop excision Cold knife conization Objective. For women who have completed childbearing, the treatment of choice for adenocarcinoma in situ (ACIS) of the cervix is hysterectomy. In women who desire future fertility, however, conservative ther- apy is an acceptable alternative. In this study we compare the outcomes for young women who underwent loop conization or were treated with cold knife conization. Methods. We performed a retrospective analysis in 112 patients with ACIS, age 30 or younger, treated with cold knife conization or loop conization between 1998 and 2010. Decision to perform office loop coni- zation was based on the size of the cervix and the colposcopic lesion. Main outcomes were negative margins after the procedure and recurrence of ACIS. Results. Fifty-eight patients (52%) were treated with cold knife conization and 54 (48%) underwent loop conization. The odds ratio for cold knife conization to achieve negative cone margins compared with loop conization was 1.4 (95% CI 0.6–3.5). We observed no difference in residual or recurrent ACIS between pa- tients treated with loop conization versus cold knife conization. Conclusions. In select young patients who desire future fertility, loop conization and cold knife conization have equivalent rates of negative margins and negative follow-up. For optimal results, patients must have a lesion which can be removed in one pass of a loop, confirmed by expert colposcopy. Loop excision should be considered the treatment of choice in this specific group of patients. © 2011 Published by Elsevier Inc. Introduction In the last few decades the incidence of cervical cancer has de- creased. However, the incidence of adenocarcinoma has mainly rela- tive to the incidence of squamous cell carcinoma of the cervix, due to better detection of squamous lesions. In the 1950s and 1960s ade- nocarcinoma accounted for only 5% of cervical cancers, while this ratio has increased to 20–25% in the 1990s, due to a decrease in squa- mous carcinomas [1-3]. In younger patients with invasive adenocarci- noma, a small increase is seen in prevalence, mainly in patients 30 years and younger (16%) [2]. The increased prevalence in younger women is also found for adenocarcinoma in situ (ACIS), the precursor of adenocarcinoma of the uterine cervix [4, 5]. Historically, the treatment of choice for women with ACIS has been hysterectomy. However, because the mean age of patients with ACIS is 37 years, [6] many patients have not completed child- bearing and desire more conservative treatment. Fertility-sparing treatment with conization has gained acceptance in the treatment of women with ACIS. Since patients with positive margins have a 50% risk of residual ACIS and a risk of about 6% for coexistent invasive disease, achieving negative margins is critical [7, 8]. Several studies have compared cold knife conization with loop conization, favoring cold knife conization because this procedure is more likely to yield negative margins [7-10]. Historically, doctors think of ACIS as a lesion of the endocervical canal with ‘skip’-lesions. However, multifocal disease is found in only 13–17% of cases; the le- sion is usually unicentric, contiguous with the SCJ, and extends up the canal for a variable distance [11]. Further data show a relationship be- tween age and proximal linear extent of disease, suggesting that more limited excision of the endocervix, until 1 cm above the SCJ, may be reasonable in young women [12]. No data are available about treatment of women under 30 years, in whom the least invasive treatment is very important in order to prevent adverse pregnancy outcomes [13, 14]. In this study we describe a specif- ic group of patients: young women with ACIS who desire future fertility. The aim of this study is to compare the effectiveness of loop conization in select young women with small colposcopic lesions of ACIS and a small cervix versus cold knife conization in women aged 30 years and younger with a diagnosis of ACIS. Gynecologic Oncology xxx (2011) xxx–xxx ⁎ Corresponding author at: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, 75 Francis street, Boston, MA, 02115, USA. Fax: +1 617 738 5124. E-mail address: sfeldman@partners.org (S. Feldman). YGYNO-974233; No. of pages: 6; 4C: 0090-8258/$ – see front matter © 2011 Published by Elsevier Inc. doi:10.1016/j.ygyno.2011.09.006 Contents lists available at SciVerse ScienceDirect Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno Please cite this article as: van Hanegem N, et al, Fertility-sparing treatment in younger women with adenocarcinoma in situ of the cervix, Gynecol Oncol (2011), doi:10.1016/j.ygyno.2011.09.006