The significance of adenosis and clear-cell adenocarcinoma of the genital tract in young females.

Abstract

This report is based in part on available information regarding 100 vaginal and 70 cervical clear-cell adenocarcinomas occurring in females born after 1940. The number of cases reported annually as associated with intrauterine exposure to diethylstilbestrol (DES), or to chemically related compounds, that have been diagnosed since 1961 has increased from 1 to 21 in 1972. There is a definite history of maternal ingestion of a nonsteroidal synthetic estrogen in 95 of 146 cases (65%) completely investigated. In 19 other cases the mothers were treated for high-risk pregnancy with some unidentified drug. In 32 cases (22%) there was no history of such therapy. Rare cases of these cancers had been reported in the pre-DES era so other factors play a role. Dosage or duration of therapy with DES has not been correlated. However, the time of therapy initiation is important as, when recorded, medication has always been before the 18th week of pregnancy. The risk of developing cancer has been estiamted as 4 in 1000 but may be less. The oldest patient with a DES exposure history was 27-years-old at the time of diagnosis, while the youngest was 7-years-old. 91% were 14-years-old or older. Bleeding and discharge were the most common symptoms but 16% had no symptoms. Cytology was positive or suspicious in 65 of 85 cases (76%) in which reports are available. In 18 patients (21%) smears were reported as negative. Surgery or radiation have been employed in therapy. 24 patients have already died and recurrence has occurred in 13 others. A few partial remissions have followed chemotherapeutic agents. Screening examinations are recommended at age 14, or earlier if symptoms occur. Inspection and palpation are important. Biopsies may be needed. The colposcope allows directed biopsies. Adenosis has been found in 1/3 of exposed patients and in another 1/3 areas have failed to stain with an iodine solution. About 90-95% of DES-exposed females show some abnormality of the vagina or cervix. A transition from adenosis to cancer has not been shown. A close follow-up of all DES-exposed females is indicated. Excision of all areas of adenosis is not justified. Destructive treatment is indicated where nuclear atypically or premalignant change in the epithelium is found.