Cervical Cancer 3
The entity of microinvasive carcinoma of the cervix, is not always as easy to correctly diagnose as you may think, and there are a few rules that need to observed before this diagnosis is made. First of all, it rests on a cone biopsy specimen that needs to adequate with negative margins. If there is a cone with positive margins that show microinvasive carcinoma of the cervix, that does not rule out the possibility that there may be a larger or more invasive lesion somewhere else in the cervix
The diagnosis of microinvasive carcinoma of the cervix also supposes the availability of expert pathology services. These two requirements have world wide not always been present and have led to the continuing kind of confusion and lack of general agreement on what the ideal treatment for these lesions should be. It was recognized shortly after the second world war that there was an entity of invasive carcinoma of the cervix, where the tumors are so small, that more likely than not, less than radical or less than conventional treatment would be sufficient to obtain a cure. You are familiar with this data, but I would like to review them with you here, in the depth of invasion, less than 3 mm are equal to 3 mm, the incidents of positive lymph node metastases is very low, it’s substantially less than 1%, however, if the invasion is between 3 and 5 mm, which is stage IAII category, then the lymph node metastases rate is approximately 5.3%. When you look at recurrences, the recurrence rate is very low with these lesions less than 3 mm invasive, it’s approximately 5.3% when invasion is somewhere between 3 and 5 mm. So one can say that indeed, there are lesions here where the pelvis lymph node metastases rate is very small, where the recurrence rate is very small, but you can also look at it the other way and say well, there are subset of patient’s here who are clearly at a higher risk of having either no disease, or having recurrences, and can we identify them. The issue of lymphovascular space involvement is clearly more controversial as well. This is a compilation of the data here on lesions either less than 3 mm or 3 to 5 mm. Vascular space involvement is very uncommon in these circumstances, but one present in lesions than 3 mm might be associated with an increased risk of pelvic lymph node metastases, although not significant as well as increased risk of recurrences.
Cervical Cancer
Actually in lesions between 3 and 5 mm, you can see that when vascular space involvement was absent, there was actually a higher pelvic lymph node metastases rate than when it was present. On the other hand, recurrences were more frequent when vascular space involvement was present rather than absent. This remains a controversial issue, most gynecologic oncologists in this country continue to feel that lymphovascular space involvement is a factor to be reckoned with at least at the present time, but this may change, is certainly challenged. What are the treatment options, well the treatment options remain as they were before in stage IAI, carcinoma of the cervix, one has the option to perform a simple hysterectomy or a cone biopsy. In stage IAII, one would conduct at least a simple hysterectomy, preferably a modified radical hysterectomy and one should address at the present time, the pelvic lymph node, so a pelvic lymphadenectomy needs to be done. There is a whole host of surgical alternatives that are being proposed in many parts of the world that are actually being tried out in microinvasive carcinoma of the cervix, and they all center on limited resections of the tumor, for instance a cone biopsy for stage IAII, cone combined with a pelvic lymphadenectomy and this pelvic lymphadenectomy can be done through the laparoscope, it can be done in a conventional way. One needs to understand that there are really no good data at the present time to support any of these approaches, and the sad forecast is that because of problems with pathology and with the correct diagnosis of microinvasive carcinoma of the cervix, there is no real expectation that there is going to be any large amount of data in the foreseeable future. In patient’s who are nonsurgical candidates, and who have microinvasive carcinoma, radiation therapy, is then the treatment of choice.
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