Do all patients with invasive cervical carcinoma need a radical hysterectomy?

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Do all patients with invasive cervical carcinoma
need a radical hysterectomy?

• Leuven
• May 2007

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Microinvasive Carcinomaof the CervixFIGO, 1995

• Stage IA can only be diagnosed
  microscopically
• IA1 lt 3 mm invasion extension no wider
  than 7 mm
• IA2 gt 3 mm - 5 mm extension no wider than 7
  mm

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Controversial Areas

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

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Issues (1)

• Histological subtype
• Type of cone.cold knife/laser/Leep
• Tissue preparation..method/number of sections
• Margin Status
• LVSI

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Cold Knife orLoop Excision?

• Both cheap
• Both LA / GA
• Margins are the critical factor
• When any suggestion of cancer/lesion out of
  rangecold knife best

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Pregnancy Outcomes and Loop excision/Cone

• Sadler,NZ,2004,JAMAincreased PRM with Loop
• Kyrgiou,2006,LancetRR 2.59 cone and
  prematurity,1.7 Loop.Laser OK( RWH data)
• Bruinsma et al,2007both treated and untreated
  women have increased risk of prematurity

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Issues (2)

• Risk of parametrial spread
• Risk of adnexal spread
• Risk of nodal spread
• What to do after childbirth
• Summary recommendations

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Specimen ProcessingCritical

• Radial
• Sagittal
• Whole specimen
• Step section of nodes
• Special stains

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Multiple comparisons of management of
CIN111No studies comparing management of
microinvasive carcinoma
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Early Stromal Invasion

• Cone adequate no matter age

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Micro-invasive Carcinoma Cervix.. Node
Positivity (Ostor,1998)
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FIGO Biannual Report2006

• 968 Cases Ia1,384 1a2
• 92 Ia1 treated by surgery, 65 Ia2

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Microinvasive Carcinomaof the CervixTakeshima
et al, 1999

• n 402 with lt 5 mm invasion
• LN ve, 1.2 if 3 mm or less invasion 6.8
  if gt 3 5 mm invasion
• 4 recurrences, 3 of whom had gt 7 mm
  horizontal spread
• (Tokyo)

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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
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Micro-invasive SquamousDisease Management

• 1-3 mm..treat as if ESI,unless LVS ve. Consider
  Hyst if fertility complete
• 3-5mmsimple hyst and nodes/cone and nodes if
  fertility an issue

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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.

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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

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• Microadenocarcinoma
• Endocervical
• Villoglandular
• Intestinal
• Endometrioid
• Clear Cell
• Adenosquamous

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30 years old

• Nulliparous
• Lesion is 2.4 mm deep,4 mm long
• Glandular abnormality
• No LVSI
• Margins normal
• Specimen is a Loop excision

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Would you?

• Cone
• Simple hysterectomy
• Cone/Simple hysterectomy and nodes
• Radical Hysterectomy
• Radical Hysterectomy and Nodes
• Radical Trachelectomy and Nodes

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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

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Microinvasive Adenocarcinoma McHale 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)

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Microinvasive Adenocarcinomaof the Cervix Smith
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)

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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)

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Microinvasive Adenocarcinoma Webb 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)

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Microinvasive AdenocarcinomaPoynor e al, 2006

• N336lt/1mm,9gt1-2mm6gt2-3mm6gt3-4mm6gt4-5mm
• No patient of the 16 with neg cone margins had
  residual ca on the hyst specimen
• No patient had parametrial spread nor pos nodes

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Microadenocarcinoma

• Pathologist critical
• Limited data
• Lymphadenectomy if LVS ve
• Conization for lt 3 mm
• ? Simple hyst and nodes 3-5 mm
• Re-cone if any doubt

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What about following pregnancy?

• What is the rationale for hysterectomy?

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When do we move from minor surgery to major
surgery in microinvasive and small cancers of the
cervix?
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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?

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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
  lt/2cm,neg nodes and lt10mm invasion

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Parametrial involvement in small cancers

• Stegeman et al,2007
• N103
• 2cm or less,lt10mm infiltration,neg pelvic nodes
• Two cases of parametrial spread (0.43)
• Both LVSI ve

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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 lt32weeks gestation
• 3 recurrences of cancer and one death

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Radical Trachelectomy

• ?An operation with no indication

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Conisation for Stage 1B diseaseRob et al,2007

• MRI/USG..lt2cm/lt10mm deep
• Lap sentinal nodesif neglympadenectomy
• 7 days later cone/trachelectomy
• No cerclage

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Rob et al,2007Results

• 6x 1a2/20x1b1
• 7 cones/15 trachelectomies
• 4 x pos nodesn22
• 11/15 pregnant,8/11 delivered
• 1 x Intra-abdominal pregnancy
• 1 x Recurrence (1b1/8x7mm/lvsi/27-ve nodes)

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CUFF OF VAGINA
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• Small Cancers of the Cervix
• Role of radical trachelorrhaphy not
• established but probably safe in
• lesions lt/ 2 cm recurrence rates
  5,delivery rate 60

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Time to think of Cervical Amputation

• A MORE RATIONAL OPERATION

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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

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THANK YOU