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Do all patients with invasive cervical carcinoma need a radical hysterectomy?. Leuven May 2007. Microinvasive Carcinoma of the Cervix FIGO, 1995. Stage IA – can only be diagnosed microscopically IA 1 ≤ < 3 mm invasion; extension no wider than 7 mm

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slide2

Microinvasive Carcinomaof the CervixFIGO, 1995

  • Stage IA – can only be diagnosed microscopically
  • IA1≤ < 3 mm invasion; extension no wider than 7 mm
  • IA2 > 3 mm - 5 mm;extension no wider than 7 mm
slide3

Controversial Areas

  • Cold-knife or loop excision?
  • Mx of microinvasive squamous disease
  • Mx of microadenocarcinoma
  • MX of small volume early invasive disease
issues 1
Histological subtype

Type of cone….cold knife/laser/Leep

Tissue preparation..method/number of sections

Margin Status

LVSI

Issues (1)
slide5

Cold Knife orLoop Excision?

  • Both cheap
  • Both LA / GA
  • Margins are the critical factor
  • When any suggestion of cancer/lesion out of range…cold knife best
pregnancy outcomes and loop excision cone
Sadler,NZ,2004,JAMA…increased PRM with Loop

Kyrgiou,2006,Lancet…RR 2.59 cone and prematurity,1.7 Loop.Laser OK(= RWH data)

Bruinsma et al,2007…both treated and untreated women have increased risk of prematurity

Pregnancy Outcomes and Loop excision/Cone
issues 2
Risk of parametrial spread

Risk of adnexal spread

Risk of nodal spread

What to do after childbirth

Summary recommendations

Issues (2)
specimen processing critical
Radial

Sagittal

Whole specimen

Step section of nodes

Special stains

Specimen ProcessingCritical
slide9
Multiple comparisons of management of CIN111No studies comparing management of microinvasive carcinoma
slide10

Early Stromal Invasion

  • Cone adequate no matter age
figo biannual report 2006
968 Cases Ia1,384 1a2

92% Ia1 treated by surgery, 65% Ia2

FIGO Biannual Report2006
microinvasive carcinoma of the cervix takeshima et al 1999

Microinvasive Carcinomaof the CervixTakeshima et al, 1999

  • n = 402 with < 5 mm invasion
  • LN +ve, 1.2% if 3 mm or less invasion 6.8% if > 3 – 5 mm invasion
  • 4 recurrences, 3 of whom had > 7 mm horizontal spread
  • (Tokyo)
slide14

Microinvasive Disease

1-3 mm risk of nodes +ve ~0.5%

3-5 mm risk of nodes +ve ~3.4%

LVS +ve ~ doubles LN risk

micro invasive squamous disease management
1-3 mm…..treat as if ESI,unless LVS +ve. Consider Hyst if fertility complete

3-5mm…simple hyst and nodes/cone and nodes if fertility an issue

Micro-invasive SquamousDisease Management
conclusions
Meticulous, accurate pathology essential.

Treatment by cone alone is safe treatment in stage 1a1 without LVSI.

The role of cone alone in stage1a2 needs further study (cf,rad trachelectomy/amputation)

Role of lymph node dissection needs further assessment.

Evaluation of the place of sentinel node detection is needed.

Conclusions
rationale for the existence of microadenocarcinoma
All would agree that ACIS exists

Adenoca is HPV related

Morphologically,small lesions exist

There is an inflammatory reaction around the glands

Rationale for the existence of microadenocarcinoma
slide18

Microadenocarcinoma

  • Endocervical
  • Villoglandular
  • Intestinal
  • Endometrioid
  • Clear Cell
  • Adenosquamous
30 years old
Nulliparous

Lesion is 2.4 mm deep,4 mm long

Glandular abnormality

No LVSI

Margins normal

Specimen is a Loop excision

30 years old
would you
Cone

Simple hysterectomy

Cone/Simple hysterectomy and nodes

Radical Hysterectomy

Radical Hysterectomy and Nodes

Radical Trachelectomy and Nodes

Would you?
slide22

Microinvasive Adenocarcinomaof the CervixOstor, 2000

  • Invasion 5 mm or less, complete obliteration of normal endocervical crypts, extension beyond normal glandular field, stromal response.
  • 126/436 – rad hyst – no parametrial involvement
  • 155 cases – no adnexal involvement
  • 5/219 cases – +ve Nodes (2%)
  • 15 recurrences
  • 6 deaths from disease
slide23

Microinvasive AdenocarcinomaMcHale et al, 2001

  • n = 20 IA
  • 2 x simple; 14 x radical hyst; 4 conization
  • No recurrence
  • ACIS  n = 42  n = 20 conization
  • No recurrence in conization cases; median follow-up 48 months(UC Irvine)
slide24

Microinvasive Adenocarcinomaof the CervixSmith et al, 2001

  • SEER data
  • 200 IA1; 286 IA2
  • Simple hyst 48.6%; rad hyst 37.5%
  • 1.5% +ve LN (n = 197)
  • Survival 98.5%; 98.6% (Alberquerque)
slide25

Microinvasive Adenocarcinomaof the Cervix (2)Smith et al, 2002 : Summary Data

  • 585 IA1; 358 IA2
  • 531 lymphadenectomies – 1.3% +ve
  • No significant difference in nodal positivity or survival vs stage (Alberquerque)
slide26

Microinvasive AdenocarcinomaWebb et al, 2001

  • 131 Stage IA1; 170 Stage IA2
  • 1/140 had +ve nodes (single)
  • 4 tumour related deaths (1 x IA1, 3 x IA2)
  • Overall survival 99.2% IA1; 98.2% IA2
  • 30% simple + 70% radical ops (Mayo Clinic)
microinvasive adenocarcinoma poynor e al 2006
N=33…6</=1mm,9>1-2mm;6>2-3mm;6>3-4mm;6>4-5mm

No patient of the 16 with neg cone margins had residual ca on the hyst specimen

No patient had parametrial spread nor pos nodes

Microinvasive AdenocarcinomaPoynor e al, 2006
slide28

Microadenocarcinoma

  • Pathologist critical
  • Limited data
  • Lymphadenectomy if LVS +ve
  • Conization for <3 mm
  • ? Simple hyst and nodes 3-5 mm
  • Re-cone if any doubt
slide30
When do we move from minor surgery to major surgery in microinvasive and small cancers of the cervix?
issues in small cancers
How often is the parametrium involved?

Is there a surrogate for parametrial involvement such as LVSI?

Is parametrial involvement embolic or by direct infiltration?

Is there a difference between squamous and glandular lesions?

Issues in Small Cancers
covens et al 2002
842 patients with 1A1/1A2/1B1Cancers

8 patients has pos parametrial nodes and 25 pos parametrial infiltration

Only 0.6% had parametrial infiltration if </=2cm,neg nodes and <10mm invasion

Covens et al, 2002
parametrial involvement in small cancers
Stegeman et al,2007

N=103

2cm or less,<10mm infiltration,neg pelvic nodes

Two cases of parametrial spread (0.43%)

Both LVSI +ve

Parametrial involvement in small cancers
worldwide context
3 major centres- Lyons, Toronto, Barts/RMH

500 worldwide

10 years= 105 at Barts/Royal Marsden

43 pregnancies in 28 women

26 live births, 6 <32weeks gestation

3 recurrences of cancer and one death

Worldwide Context
radical trachelectomy

Radical Trachelectomy

?An operation with no indication

conisation for stage 1b disease rob et al 2007
MRI/USG..<2cm/<10mm deep

Lap sentinal nodes…if neg…lympadenectomy

7 days later cone/trachelectomy

No cerclage

Conisation for Stage 1B diseaseRob et al,2007
rob et al 2007 results
6x 1a2/20x1b1

7 cones/15 trachelectomies

4 x pos nodes…n=22

11/15 pregnant,8/11 delivered

1 x Intra-abdominal pregnancy

1 x Recurrence (1b1/8x7mm/lvsi+/27-ve nodes)

Rob et al,2007Results
slide43

Small Cancers of the Cervix

  • Role of radical trachelorrhaphy not

established but probably safe in

lesions </= 2 cm …recurrence rates 5%,delivery rate 60%

time to think of cervical amputation

Time to think of Cervical Amputation

A MORE RATIONAL OPERATION

choice of surgery
The need for a rational approach to very early malignancies is a product of screening programmes

The artificial cut-offs of 5 x 7 mm which lead to a huge change in radicality need some more thought

More thorough pathological assessment should lead to safer and more conservative therapy

Choice of surgery