Oncology / Dysplasia UnitOncology / Dysplasia UnitRoyal Women’s Hospital, Carlton, VictoriaRoyal Women’s Hospital, Carlton, Victoria
Do all patients with invasive Do all patients with invasive cervical carcinoma need a cervical carcinoma need a
radical hysterectomy?radical hysterectomy?
LeuvenLeuven
May 2007May 2007
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
• Stage IA – can only be diagnosed microscopicallyStage IA – can only be diagnosed microscopically
• IAIA11 ≤ < 3 mm invasion; extension no wider than 7 mm≤ < 3 mm invasion; extension no wider than 7 mm
• IAIA22 > 3 mm - > 3 mm - 5 mm; 5 mm; extension no wider than 7 mmextension no wider than 7 mm
Microinvasive CarcinomaMicroinvasive Carcinomaof the Cervixof the Cervix
FIGO, 1995FIGO, 1995
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
• Cold-knife or loop excision?Cold-knife or loop excision?• Mx of microinvasive squamous diseaseMx of microinvasive squamous disease• Mx of microadenocarcinomaMx of microadenocarcinoma• MX of small volume early invasive MX of small volume early invasive diseasedisease
Controversial AreasControversial Areas
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Issues (1)Issues (1)
Histological subtypeHistological subtype Type of cone….cold knife/laser/LeepType of cone….cold knife/laser/Leep Tissue preparation..method/number of Tissue preparation..method/number of
sectionssections Margin StatusMargin Status LVSILVSI
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
• Both cheapBoth cheap• Both LA / GABoth LA / GA• Margins are the critical factorMargins are the critical factor•When any suggestion of When any suggestion of cancer/lesion out of range…cold cancer/lesion out of range…cold knife bestknife best
Cold Knife orCold Knife orLoop Excision?Loop Excision?
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Pregnancy Outcomes and Loop Pregnancy Outcomes and Loop excision/Coneexcision/Cone
Sadler,NZ,2004,JAMA…increased PRM with Sadler,NZ,2004,JAMA…increased PRM with LoopLoop
Kyrgiou,2006,Lancet…RR 2.59 cone and Kyrgiou,2006,Lancet…RR 2.59 cone and prematurity,1.7 Loop.Laser OK(= RWH prematurity,1.7 Loop.Laser OK(= RWH data)data)
Bruinsma et al,2007…both treated and Bruinsma et al,2007…both treated and untreated women have increased risk of untreated women have increased risk of prematurityprematurity
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Issues (2)Issues (2)
Risk of parametrial spreadRisk of parametrial spread Risk of adnexal spreadRisk of adnexal spread Risk of nodal spreadRisk of nodal spread What to do after childbirthWhat to do after childbirth Summary recommendationsSummary recommendations
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Specimen ProcessingSpecimen ProcessingCriticalCritical
RadialRadial SagittalSagittal Whole specimenWhole specimen Step section of nodesStep section of nodes Special stainsSpecial stains
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Multiple comparisons of management of Multiple comparisons of management of CIN111CIN111
No studies comparing management of No studies comparing management of microinvasive carcinomamicroinvasive carcinoma
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
• Cone adequate no matter ageCone adequate no matter age
Early Stromal InvasionEarly Stromal Invasion
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Micro-invasive Carcinoma Micro-invasive Carcinoma Cervix.. Node PositivityCervix.. Node Positivity
(Ostor,1998)(Ostor,1998)
DEPTH NO +VE DEATH ESI 1409 1/66 1
<1 mm 2274 3/267 2
1-3mm 1334 4/333 7
3-5mm 674 14/221 13
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
FIGO Biannual ReportFIGO Biannual Report20062006
968 Cases Ia1,384 1a2968 Cases Ia1,384 1a2 92% Ia1 treated by surgery, 65% Ia2 92% Ia1 treated by surgery, 65% Ia2
Oncology / Dysplasia UnitOncology / Dysplasia UnitRoyal Women’s Hospital, Carlton, VictoriaRoyal Women’s Hospital, Carlton, Victoria
• n = 402 with < 5 mm invasionn = 402 with < 5 mm invasion
• LN +ve,LN +ve, 1.2% if 3 mm or less invasion1.2% if 3 mm or less invasion6.8% if > 3 – 5 mm invasion6.8% if > 3 – 5 mm invasion
• 4 recurrences, 3 of whom had > 7 mm4 recurrences, 3 of whom had > 7 mm horizontal spread horizontal spread
(Tokyo)(Tokyo)
Microinvasive CarcinomaMicroinvasive Carcinomaof the Cervixof the CervixTakeshima et al, 1999Takeshima et al, 1999
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
1-3 mm risk of nodes +ve ~0.5%1-3 mm risk of nodes +ve ~0.5%3-5 mm risk of nodes +ve ~3.4%3-5 mm risk of nodes +ve ~3.4%LVS +ve ~ doubles LN riskLVS +ve ~ doubles LN risk
Microinvasive DiseaseMicroinvasive Disease
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Micro-invasive SquamousMicro-invasive SquamousDisease ManagementDisease Management
• 1-3 mm…..treat as if ESI,unless LVS +ve. 1-3 mm…..treat as if ESI,unless LVS +ve. Consider Hyst if fertility completeConsider Hyst if fertility complete
• 3-5mm…simple hyst and nodes/cone and 3-5mm…simple hyst and nodes/cone and nodes if fertility an issuenodes if fertility an issue
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
ConclusionsConclusions
Meticulous, accurate pathology essential.Meticulous, accurate pathology essential. Treatment by cone alone is safe treatment in Treatment by cone alone is safe treatment in
stage 1a1 without LVSI.stage 1a1 without LVSI. The role of cone alone in stage1a2 needs The role of cone alone in stage1a2 needs
further study (cf,rad further study (cf,rad trachelectomy/amputation)trachelectomy/amputation)
Role of lymph node dissection needs further Role of lymph node dissection needs further assessment.assessment.
Evaluation of the place of sentinel node Evaluation of the place of sentinel node detection is needed.detection is needed.
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Rationale for the existence of Rationale for the existence of microadenocarcinomamicroadenocarcinoma
All would agree that ACIS existsAll would agree that ACIS exists Adenoca is HPV related Adenoca is HPV related Morphologically,small lesions existMorphologically,small lesions exist There is an inflammatory reaction There is an inflammatory reaction
around the glands around the glands
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
MicroadenocarcinomaMicroadenocarcinoma
• EndocervicalEndocervical• VilloglandularVilloglandular• IntestinalIntestinal• EndometrioidEndometrioid• Clear CellClear Cell• AdenosquamousAdenosquamous
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
30 years old30 years old
NulliparousNulliparous Lesion is 2.4 mm deep,4 mm longLesion is 2.4 mm deep,4 mm long Glandular abnormalityGlandular abnormality No LVSINo LVSI Margins normalMargins normal Specimen is a Loop excisionSpecimen is a Loop excision
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Would you?Would you?
ConeCone Simple hysterectomySimple hysterectomy Cone/Simple hysterectomy and nodesCone/Simple hysterectomy and nodes Radical Hysterectomy Radical Hysterectomy Radical Hysterectomy and NodesRadical Hysterectomy and Nodes Radical Trachelectomy and NodesRadical Trachelectomy and Nodes
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
• Invasion 5 mm or less, complete obliteration ofInvasion 5 mm or less, complete obliteration of normal endocervical crypts, extension beyond normal endocervical crypts, extension beyond normal glandular field, stromal response. normal glandular field, stromal response.
• 126/436 – rad hyst – no parametrial involvement126/436 – rad hyst – no parametrial involvement
• 155 cases – no adnexal involvement155 cases – no adnexal involvement
• 5/219 cases – +ve Nodes (2%)5/219 cases – +ve Nodes (2%)
• 15 recurrences15 recurrences
• 6 deaths from disease6 deaths from disease
Microinvasive AdenocarcinomaMicroinvasive Adenocarcinomaof the Cervixof the Cervix
Ostor, 2000Ostor, 2000
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
• n = 20 IAn = 20 IA
• 2 x simple; 14 x radical hyst; 4 conization2 x simple; 14 x radical hyst; 4 conization
• No recurrenceNo recurrence
• ACIS ACIS n = 42 n = 42 n = 20 conization n = 20 conization
• No recurrence in conization cases; medianNo recurrence in conization cases; median follow-up 48 months follow-up 48 months (UC Irvine)(UC Irvine)
Microinvasive AdenocarcinomaMicroinvasive Adenocarcinoma McHale et al, 2001McHale et al, 2001
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
• SEER dataSEER data
• 200 IA200 IA11; 286 IA; 286 IA22
• Simple hyst 48.6%; rad hyst 37.5%Simple hyst 48.6%; rad hyst 37.5%
• 1.5% +ve LN (n = 197)1.5% +ve LN (n = 197)
• Survival 98.5%; 98.6%Survival 98.5%; 98.6%
(Alberquerque)(Alberquerque)
Microinvasive AdenocarcinomaMicroinvasive Adenocarcinomaof the Cervixof the Cervix
Smith et al, 2001Smith et al, 2001
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
• 585 IA585 IA11; 358 IA; 358 IA22
• 531 lymphadenectomies – 1.3% +ve531 lymphadenectomies – 1.3% +ve
• No significant difference in nodal positivity orNo significant difference in nodal positivity or survival vs stage survival vs stage
(Alberquerque) (Alberquerque)
Microinvasive AdenocarcinomaMicroinvasive Adenocarcinomaof the Cervix (2)of the Cervix (2)
Smith et al, 2002 : Summary DataSmith et al, 2002 : Summary Data
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
• 131 Stage IA131 Stage IA11; 170 Stage IA; 170 Stage IA22
• 1/140 had +ve nodes (single)1/140 had +ve nodes (single)
• 4 tumour related deaths (1 x IA4 tumour related deaths (1 x IA11, 3 x IA, 3 x IA22))
• Overall survival 99.2% IAOverall survival 99.2% IA11; 98.2% IA; 98.2% IA22
• 30% simple + 70% radical ops30% simple + 70% radical ops(Mayo Clinic)(Mayo Clinic)
Microinvasive AdenocarcinomaMicroinvasive Adenocarcinoma
Webb et al, 2001Webb et al, 2001
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Microinvasive AdenocarcinomaMicroinvasive AdenocarcinomaPoynor e al, 2006Poynor e al, 2006
N=33…6</=1mm,9>1-2mm;6>2-N=33…6</=1mm,9>1-2mm;6>2-3mm;6>3-4mm;6>4-5mm3mm;6>3-4mm;6>4-5mm
No patient of the 16 with neg cone No patient of the 16 with neg cone margins had residual ca on the hyst margins had residual ca on the hyst specimenspecimen
No patient had parametrial spread nor No patient had parametrial spread nor pos nodespos nodes
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
• Pathologist criticalPathologist critical
• Limited dataLimited data
• Lymphadenectomy if LVS +veLymphadenectomy if LVS +ve
• Conization for <Conization for < 3 mm3 mm
• ? Simple hyst and nodes 3-5 mm? Simple hyst and nodes 3-5 mm
• Re-cone if any doubtRe-cone if any doubt
MicroadenocarcinomaMicroadenocarcinoma
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
What about following pregnancy?What about following pregnancy?
What is the rationale for hysterectomy?What is the rationale for hysterectomy?
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
When do we move from minor When do we move from minor surgery to major surgery in surgery to major surgery in
microinvasive and small cancers microinvasive and small cancers of the cervix?of the cervix?
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Issues in Small CancersIssues in Small Cancers
How often is the parametrium involved?How often is the parametrium involved? Is there a surrogate for parametrial Is there a surrogate for parametrial
involvement such as LVSI?involvement such as LVSI? Is parametrial involvement embolic or Is parametrial involvement embolic or
by direct infiltration?by direct infiltration? Is there a difference between squamous Is there a difference between squamous
and glandular lesions?and glandular lesions?
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Covens et al, 2002Covens et al, 2002
842 patients with 1A1/1A2/1B1Cancers842 patients with 1A1/1A2/1B1Cancers 8 patients has pos parametrial nodes 8 patients has pos parametrial nodes
and 25 pos parametrial infiltrationand 25 pos parametrial infiltration Only 0.6% had parametrial infiltration if Only 0.6% had parametrial infiltration if
</=2cm,neg nodes and <10mm </=2cm,neg nodes and <10mm invasioninvasion
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Parametrial involvement in small Parametrial involvement in small cancerscancers
Stegeman et al,2007Stegeman et al,2007 N=103N=103 2cm or less,<10mm infiltration,neg 2cm or less,<10mm infiltration,neg
pelvic nodespelvic nodes Two cases of parametrial spread Two cases of parametrial spread
(0.43%)(0.43%) Both LVSI +ve Both LVSI +ve
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Worldwide ContextWorldwide Context
3 major centres- Lyons, Toronto, 3 major centres- Lyons, Toronto, Barts/RMHBarts/RMH
500 worldwide 500 worldwide 10 years= 105 at Barts/Royal Marsden10 years= 105 at Barts/Royal Marsden 43 pregnancies in 28 women43 pregnancies in 28 women 26 live births, 6 <32weeks gestation 26 live births, 6 <32weeks gestation 3 recurrences of cancer and one death3 recurrences of cancer and one death
Oncology / Dysplasia UnitOncology / Dysplasia UnitRoyal Women’s Hospital, Carlton, VictoriaRoyal Women’s Hospital, Carlton, Victoria
Radical TrachelectomyRadical Trachelectomy
?An operation with no indication?An operation with no indication
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Conisation for Stage 1B diseaseConisation for Stage 1B diseaseRob et al,2007Rob et al,2007
MRI/USG..<2cm/<10mm deepMRI/USG..<2cm/<10mm deep Lap sentinal nodes…if neg…Lap sentinal nodes…if neg…
lympadenectomylympadenectomy 7 days later cone/trachelectomy7 days later cone/trachelectomy No cerclageNo cerclage
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Rob et al,2007Rob et al,2007ResultsResults
6x 1a2/20x1b16x 1a2/20x1b1 7 cones/15 trachelectomies7 cones/15 trachelectomies 4 x pos nodes…n=224 x pos nodes…n=22 11/15 pregnant,8/11 delivered11/15 pregnant,8/11 delivered 1 x Intra-abdominal pregnancy1 x Intra-abdominal pregnancy 1 x Recurrence (1b1/8x7mm/lvsi+/27-1 x Recurrence (1b1/8x7mm/lvsi+/27-
ve nodes)ve nodes)
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
CUFF OF VAGINA
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Small Cancers of the CervixSmall Cancers of the Cervix
• Role of radical trachelorrhaphy notRole of radical trachelorrhaphy not
established but probably safe in established but probably safe in
lesions </= 2 cm …recurrence rates lesions </= 2 cm …recurrence rates 5%,delivery rate 60%5%,delivery rate 60%
Oncology / Dysplasia UnitOncology / Dysplasia UnitRoyal Women’s Hospital, Carlton, VictoriaRoyal Women’s Hospital, Carlton, Victoria
Time to think of Cervical Time to think of Cervical AmputationAmputation
A MORE RATIONAL OPERATIONA MORE RATIONAL OPERATION
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
Choice of surgeryChoice of surgery
The need for a rational approach to very early The need for a rational approach to very early malignancies is a product of screening malignancies is a product of screening programmesprogrammes
The artificial cut-offs of 5 x 7 mm which lead The artificial cut-offs of 5 x 7 mm which lead to a huge change in radicality need some to a huge change in radicality need some more thoughtmore thought
More thorough pathological assessment More thorough pathological assessment should lead to safer and more conservative should lead to safer and more conservative therapytherapy
Oncology / Dysplasia UnitOncology / Dysplasia UnitThe Royal Women’s Hospital, Carlton, VictoriaThe Royal Women’s Hospital, Carlton, Victoria
THANK YOUTHANK YOU
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