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

1. Do all patients with invasive cervical carcinoma need a radical hysterectomy? Leuven May 2007

2. 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

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

4. Histological subtype Type of cone….cold knife/laser/Leep Tissue preparation..method/number of sections Margin Status LVSI Issues (1)

5. 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

6. 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

7. Risk of parametrial spread Risk of adnexal spread Risk of nodal spread What to do after childbirth Summary recommendations Issues (2)

8. Radial Sagittal Whole specimen Step section of nodes Special stains Specimen ProcessingCritical

9. Multiple comparisons of management of CIN111No studies comparing management of microinvasive carcinoma

10. Early Stromal Invasion • Cone adequate no matter age

11. Micro-invasive Carcinoma Cervix.. Node Positivity(Ostor,1998)

12. 968 Cases Ia1,384 1a2 92% Ia1 treated by surgery, 65% Ia2 FIGO Biannual Report2006

13. 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)

14. 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

15. 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

16. 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

17. 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

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

19. Nulliparous Lesion is 2.4 mm deep,4 mm long Glandular abnormality No LVSI Margins normal Specimen is a Loop excision 30 years old

21. Cone Simple hysterectomy Cone/Simple hysterectomy and nodes Radical Hysterectomy Radical Hysterectomy and Nodes Radical Trachelectomy and Nodes Would you?

22. 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

23. 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)

24. 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)

25. 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)

26. 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)

27. 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

28. 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

29. What is the rationale for hysterectomy? What about following pregnancy?

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

34. 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

35. 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

36. 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

37. 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

38. Radical Trachelectomy ?An operation with no indication

39. 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

40. 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

42. CUFF OF VAGINA

43. Small Cancers of the Cervix • Role of radical trachelorrhaphy not established but probably safe in lesions </= 2 cm …recurrence rates 5%,delivery rate 60%

44. Time to think of Cervical Amputation A MORE RATIONAL OPERATION

45. 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

46. THANK YOU