《o all patients with invasive cervical carcinoma need a radical ：所有宫颈浸润癌患者需要一个基》由会员分享，可在线阅读，更多相关《o all patients with invasive cervical carcinoma need a radical ：所有宫颈浸润癌患者需要一个基（46页珍藏版）》请在金锄头文库上搜索。
1、Do all patients with invasive cervical carcinoma need a radical hysterectomy?,Leuven May 2007,Stage IA can only be diagnosed microscopically IA1 3 mm - 5 mm; extension no wider than 7 mm,Microinvasive Carcinoma of the Cervix FIGO, 1995,Cold-knife or loop excision?Mx of microinvasive squamous disease
2、Mx of microadenocarcinomaMX of small volume early invasive disease,Controversial Areas,Issues (1),Histological subtype Type of cone.cold knife/laser/Leep Tissue preparationmethod/number of sections Margin Status LVSI,Both cheapBoth LA / GAMargins are the critical factor When any suggestion of cancer
3、/lesion out of rangecold knife best,Cold Knife or Loop Excision?,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
4、of prematurity,Issues (2),Risk of parametrial spread Risk of adnexal spread Risk of nodal spread What to do after childbirth Summary recommendations,Specimen Processing Critical,Radial Sagittal Whole specimen Step section of nodes Special stains,Multiple comparisons of management of CIN111 No studie
5、s comparing management of microinvasive carcinoma,Cone adequate no matter age,Early Stromal Invasion,Micro-invasive Carcinoma Cervix Node Positivity (Ostor,1998),FIGO Biannual Report 2006,968 Cases Ia1,384 1a2 92% Ia1 treated by surgery, 65% Ia2,n = 402 with 3 5 mm invasion4 recurrences, 3 of whom h
6、ad 7 mm horizontal spread (Tokyo),Microinvasive Carcinoma of the Cervix Takeshima et al, 1999,1-3 mm risk of nodes +ve 0.5% 3-5 mm risk of nodes +ve 3.4% LVS +ve doubles LN risk,Microinvasive Disease,Micro-invasive Squamous Disease Management,1-3 mmtreat as if ESI,unless LVS +ve. Consider Hyst if fe
7、rtility complete3-5mmsimple hyst and nodes/cone and nodes if fertility an issue,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
8、lymph node dissection needs further assessment. Evaluation of the place of sentinel node detection is needed.,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 gl
9、ands,Microadenocarcinoma EndocervicalVilloglandularIntestinalEndometrioidClear CellAdenosquamous,30 years old,Nulliparous Lesion is 2.4 mm deep,4 mm long Glandular abnormality No LVSI Margins normal Specimen is a Loop excision,Would you?,Cone Simple hysterectomy Cone/Simple hysterectomy and nodes Ra
10、dical Hysterectomy Radical Hysterectomy and Nodes Radical Trachelectomy and Nodes,Invasion 5 mm or less, complete obliteration of normal endocervical crypts, extension beyond normal glandular field, stromal response.126/436 rad hyst no parametrial involvement155 cases no adnexal involvement5/219 cas
11、es +ve Nodes (2%)15 recurrences6 deaths from disease,Microinvasive Adenocarcinoma of the Cervix Ostor, 2000,n = 20 IA2 x simple; 14 x radical hyst; 4 conizationNo recurrenceACIS n = 42 n = 20 conizationNo recurrence in conization cases; median follow-up 48 months (UC Irvine),Microinvasive Adenocarci
12、noma McHale et al, 2001,SEER data200 IA1; 286 IA2Simple hyst 48.6%; rad hyst 37.5%1.5% +ve LN (n = 197)Survival 98.5%; 98.6% (Alberquerque),Microinvasive Adenocarcinoma of the Cervix Smith et al, 2001,585 IA1; 358 IA2531 lymphadenectomies 1.3% +veNo significant difference in nodal positivity or surv
13、ival vs stage (Alberquerque),Microinvasive Adenocarcinoma of the Cervix (2) Smith et al, 2002 : Summary Data,131 Stage IA1; 170 Stage IA21/140 had +ve nodes (single)4 tumour related deaths (1 x IA1, 3 x IA2)Overall survival 99.2% IA1; 98.2% IA230% simple + 70% radical ops (Mayo Clinic),Microinvasive
14、 Adenocarcinoma Webb et al, 2001,Microinvasive Adenocarcinoma Poynor e al, 2006,N=3361-2mm;62-3mm;63-4mm;64-5mm No patient of the 16 with neg cone margins had residual ca on the hyst specimen No patient had parametrial spread nor pos nodes,Pathologist criticalLimited dataLymphadenectomy if LVS +veCo
15、nization for 3 mm? Simple hyst and nodes 3-5 mmRe-cone if any doubt,Microadenocarcinoma,What about following pregnancy?,What is the rationale for hysterectomy?,When do we move from minor surgery to major surgery in microinvasive and small cancers of the cervix?,Issues in Small Cancers,How often is t
16、he 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?,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 /=2cm,neg nodes and 10mm invasion,
