Early Invasive Cervical Carcinoma
Early Invasive Cervical Carcinoma
ABSTRACT & COMMENTARY
Synopsis: Patients with stage IA2 carcinoma of the cervix who have 3-5 mm of invasion present on conization with no invasion in the hysterectomy specimen are at low risk for lymph node metastases, recurrences, or death from cancer.
Source: Creasman WT, et al. Am J Obstet Gynecol 1998;178:62-65.
Creasman and colleagues report the findings of a Gynecologic Oncology Group (GOG) study in which they examined a subset of patients originally treated on a prospective GOG trial involving stage I squamous cell carcinoma. On that trial, conducted between 1981 and 1984, patients underwent radical hysterectomy and pelvic lymphadenectomy. In all patients, the disease was confined to the uterus, with or without microscopically positive lymph nodes. Creasman et al evaluated the risk factors and prognosis of patients with stage IA squamous cell carcinoma of the cervix and 3-5 mm of invasion. Of 188 patients found to have 3-5 mm of invasion, 51 had a cone biopsy with no residual disease identified in the hysterectomy specimen. The status of the cone margins could not be determined in all cases, although none of the results stated that there were positive margins. Vascular space involvement was identified in almost one-fourth of this group and did not appear to correlate with depth of invasion. No recurrences developed, and no patient died of cancer. The progression-free survival at five years was 100%.
Creasman et al conclude that patients with stage IA2 carcinoma of the cervix who have 3-5 mm of invasion and who present on conization with no invasion in the hysterectomy specimen are at low risk for lymph node metastases, recurrences, or death from cancer.
COMMENT BY DAVID M. GERSHENSON, MD
This study represents yet another attempt to clearly define the prognostic significance of early invasive cervical cancer with 3-5 mm invasion. While it does provide some interesting information, it falls short in some areas. First, the study examines a select population of women who had conization with the finding of 3-5 mm invasion and who had a subsequent radical hysterectomy with no residual disease. Eliminated from the study were patients who had a biopsy (not a cone biopsy) with only 3-5 mm invasion (a reasonable group to eliminate) and patients who had both invasive tumor identified in a cone biopsy and residual disease in the hysterectomy specimen. Although Creasman et al found no lymph node metastases or recurrences in their study group, the latter group with conization and residual tumor in the hysterectomy specimen is of great interest. Unfortunately, as Creasman et al point out, not all conization specimens were available for pathology review. Therefore, they were not able to assess the cone margins for tumor-a factor that would allow us to learn the reasons for the residual tumor in the hysterectomy specimen. As a result, we are left with more questions than answers in examining these data for clues about the safety of conization alone in young patients desirous of retaining fertility. Possibly, only a prospective study will provide us with this important information. Nevertheless, cumulative data suggest that the risk of lymph node metastasis in patients with 3-5 mm invasion is less than 5%-probably in the range of 2-3%. Interestingly, Creasman et al found that vascular space involvement, found in approximately 25% of the study group, did not correlate with depth of invasion.
Although this study of a select group of patients provides important information about early invasive cervical cancer, there are still gaps in our knowledge.
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