Abstract

Background: Minimal deviation adenocarcinoma (MDA, also reported as Adenoma Malignum) of the cervix is a rare variant of cervical carcinoma. It is thought to represent about 1% to 3% of all cervical adenocarcinomas. The symptoms can be multifarious and aspecific, however the most peculiar and recurrent is a persistent watery-mucoid vaginal discharge. Because of the symptoms, patients are often referred to a general gynecologist and invariably further examinations are carried out, but not always a precise diagnosis is obtained. Thus, the patients are usually candidated for a surgical non-conservative treatment, mainly to relief the symptoms. Albeit its rareity this cancer is highly aggressive, hence the need for oncologically appropriate approach. Since extremely low incidence of this cancer the majority of general gynecologist will fail in recognise “hints symptoms” and therefore cannot offer a correct treatment.

Case presentation: We present a case of a caucasian patient, aged 45 years old, multipara and with profused watery vaginal discharge since half an year. According to anamnestic fitting, gynecological examinations were negative and a recent pap smear was reported as negative. Ultrasound scans described few cysts compatible with Nabothian cysts within an otherwise normal uterus and cervix. MRI of the pelvis confirmed the presence of the cystic morphology of the cervix. In view of the persistent symptomatology without a raised suspect of malignancy, the patient underwent an extrafascial hysterectomy and consensual bilateral salpingooophorectomy because of her age. Histopathology reported differential diagnosis among lobular endocervical glandular hyperplasia versus adenoma Malignum of the cervix. Patient has been therefore referred to the Gynecological Oncology service at our hospital. Histopathology review confirmed MDA of the cervix with a maximum size of 23 mm, negative margins and without lymph-vascular invasion. Multidisciplinary Tumor Board suggested two equivalent options for appropriate treatment: adjuvant external beam radiotherapy of the pelvis with vaginal brachytherapy versus robotic bilateral parametrectomy and lymphnodal pelvic dissection for a proper staging. Further surgical approach has been performed and histopathology confirmed a stage FIGO Ib1. Patient has been therefore sent for routine follow-up and after 10 months she is cancer free.

Conclusion: Referring to tertiary hospitals a rare malignancy as MDA for primary treatment is the best practise. However even in case of incidental finding or misdiagnosis, an early and timely referring can hopefully reduce errors and morbidity in the primary treatment.