Department of Obstetrics and Gynecology, Saint Barnabas Medical Center, Livingston, New Jersey, USA.
OBJECTIVE: To evaluate endocervical curettage (ECC) and cone margin involvement in the management of adenocarcinoma in situ of the cervix. METHODS: Forty-two women with adenocarcinoma in situ without any associated invasive component underwent 49 cervical conizations. The ECC, cone margin involvement, and residual endocervical glandular disease were evaluated in a retrospective descriptive study. RESULTS: The patients ranged from 18 to 65 years old, with a median of 34 years and a mean of 37 years. Nineteen of 42 (45%) of the women presented with initial cervicovaginal cytology suggesting endocervical glandular abnormality. Twenty-seven patients (64%) had mixed lesions of adenocarcinoma in situ and squamous dysplasia noted in their cervical biopsy, conization, or hysterectomy specimens. Forty ECCs were performed at colposcopy or immediately after conization; 28 patients with ECCs subsequently underwent conization, and 12 underwent hysterectomy. Residual adenocarcinoma in situ was found in 18 (67%) of the 27 patients with negative ECCs and in ten of 13 women with positive ECCs. Residual adenocarcinoma in situ was found in two of seven patients with negative cone margins and seven of ten patients with positive margins. CONCLUSION: We found that negative ECCs and uninvolved cone margins in patients with cervical adenocarcinoma in situ were not reassuring of the absence of residual endocervical glandular disease in subsequent surgical specimens. Conservative management and subsequent surveillance of adenocarcinoma in situ should be undertaken with caution.
Predictors of the residual disease of high-grade lesions and microinvasive squamous cell carcinoma of the cervix following conization.
Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University Hat Yai, Songkhla, Thailand. email@example.com
OBJECTIVE To determine the predictors of residual disease of high-grade lesion (HGL) and microinvasive squamous cell carcinoma of the cervix (MICA) in subsequent hysterectomy following conization. MATERIAL AND METHOD The medical records of women who underwent any conizations diagnosed of HGL and MICA and followed by subsequent hysterectomy within 6 months were retrospectively reviewed. A case and control was defined as whether or not a residual disease of HGL or more was detected in cervical tissue from hysterectomy after conization. Demographic characteristics and pathological features of cases and controls were recorded independently and blindly. Univariate and multivariate analysis were used. The Receiver Operating Characteristics curve of predictors was created using the fitting value obtained from a logistic regression model. RESULTS A total of 185 women were diagnosed during January 1, 1997 and July 31, 2008 including 102 women without a residual disease and 83 with residual disease at cervical tissue from hysterectomy. The multivariate analysis showed that postmenopausal status (OR = 3.5, 95% CI = 1.8-6.7), number of quadrant involvement (OR = 3.8, 95% CI = 1.8-8.3), internal margin involvement (OR = 3.8, 95% CI = 1.7-8.2), severe nuclear atypia (OR = 2.0, 95% CI = 1.1-3.8) and high mitotic activity (OR = 2.1, 95% CI = 1.1-3.7) were the predictors of residual disease in hysterectomy specimens after conization. Three or more predictors involved predicted the detection of residual disease. CONCLUSION The presence of postmenopause, three or four quadrants involved, positive internal margin, severe nuclear atypia and high mitotic activity could be used to predict residual lesions after conization.
Positive margin prevalence and risk factors with cervical specimens obtained from loop electrosurgical excision procedures and cold knife conization.
Department of Obstetrics and Gynecology, Faculty of Medicine, Srinangarind Hospital, Khon Kaen University, Khon Kaen, Thailand.
OBJECTIVES To determine the prevalence and predictive factors of residual disease in the specimens from cold knife conization (CKC) or the loop electrosurgical excision procedure (LEEP) and complication rates of these procedures. DESIGN Descriptive analytical study in Srinangarind Hospital, Khon Kaen, Thailand, of a total of 463 patients with abnormal Pap smears who underwent LEEP or CKC during 2002-2007. METHODS The medical records of 463 women were retrospectively reviewed to ascertain the prevalence, associated factors of positive surgical margin, and complications of LEEP and CKC. The patients' characteristics and pathologic parameters were collected and analyzed. Univariate analysis was based with the chi-square test and the Student's t-test. Multiple logistic regression models were employed to investigate factors associated with cone margin involvement. RESULTS Of the 463 patients, 124 cases had a positive cone margin (26.8%). 53 patients had complications (11.4%), such as bleeding (25) and infection (28). The margin involvement was significantly associated with type of conization, purpose of conization, skill of surgeon, and histological diagnosis. CONCLUSION The prevalence of a positive cone margin is rather high. Physicians who perform conization should take into account risk factors in management of cases with abnormal cytological screening for cervical cancer.
The role of loop electrosurgical excisional procedure in the management of adenocarcinoma in situ of the uterine cervix.
Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
OBJECTIVES To evaluate the occurrence of residual or recurrent disease after loop electrosurgical excisional procedure (LEEP) for adenocarcinoma in situ (AIS) of the uterine cervix. STUDY DESIGN Records of 78 patients with a histological diagnosis of AIS of uterine cervix on LEEP who were treated and followed at our center between 1992 and 2008 were, retrospectively, reviewed. RESULTS Of 78 patients who underwent LEEP, 47 had negative and 31 had positive resection margins. Of the 47 patients with negative margins, 30 underwent subsequent hysterectomy and residual AIS, including 1 invasive adenocarcinoma, was present in 17%(5/30) of patients. The remaining 17 had no additional procedures. Of the 31 patients with positive margins, 29 patients underwent subsequent hysterectomy and residual AIS, including 4 invasive adenocarcinomas, was present in 48%(14/29) of patients. The remaining two had no additional procedures. After a mean follow-up time of 28 months (range, 1-74 months), no recurrences were observed among the 19 patients who did not undergo hysterectomy. CONCLUSIONS The incidence of residual disease in patients with negative margins after LEEP for AIS of the uterine cervix is low but not negligible. Therefore, conservative management in these patients seems to be feasible but careful surveillance is required. However, positive resection margin carries a higher risk for residual AIS or occult invasive adenocarcinoma, warranting additional LEEP or hysterectomy in these patients.
Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA. firstname.lastname@example.org
CONTEXT The correct diagnosis and reporting of cervical in situ and invasive carcinoma are essential for the appropriate clinical management of patients with human papillomavirus-associated disease. OBJECTIVES To review common mistakes made in the diagnosis of cervical dysplasia and invasive carcinoma, describe variants and benign mimics of high-grade squamous intraepithelial lesion and adenocarcinoma in situ, and discuss available ancillary studies that can be useful in making the distinctions as well as to review important factors related to prognosis that should be included in the pathology report. DATA SOURCES Review of current literature. CONCLUSIONS There are many mimics and variants of cervical squamous and glandular lesions that can be resolved with ancillary studies and careful histologic examination. Prognostically important features, such as tumor size, presence of vascular invasion, and margin status, should always be included in the pathology report.
Division of Obstetrics, Department of Obstetrics and Gynecology, National Naval Medical Center, 8900 Wisconsin Avenue, Bethesda, MD 20814, USA.
The usefulness of endocervical curettage (ECC) in evaluating women who have abnormal cervical cytology and histopathology has been debated for years; data regarding performance of ECC in the diagnostic evaluations of squamous and glandular lesions are mixed. There are no well-done randomized trials or systematic reviews regarding the usefulness of ECC. The yield on ECC increases in the setting of unsatisfactory colposcopy; in this situation, there seems less controversy regarding performance of an ECC. Reproducibility of ECC-rendered diagnosis is a concern. Data are needed to further define the role of ECC in evaluating women who have cervical disease.
Adenocarcinoma in situ of the uterine cervix: a metaanalysis of 1278 patients evaluating the predictive value of conization margin status.
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Ohio State Medical Center, Columbus, OH 43210, USA. email@example.com
OBJECTIVE We sought to determine the value of conization margin status in predicting residual and recurrent adenocarcinoma in situ (ACIS) of the cervix. STUDY DESIGN In all, 33 studies (1278 patients) were identified. Metaanalysis with pooled Mantel-Haenszel odds ratio (OR) was used to compare the risk of residual and recurrent disease according to margin status. RESULTS A repeated excisional procedure was performed in 607 patients; a positive conization margin was associated with a significant increase in the risk of residual disease (OR, 4.01; 95% confidence interval [CI], 2.62-6.33; P <.001). Of the 671 patients followed up with surveillance only, 2.6% with negative margins and 19.4% with positive margins developed a recurrence (OR, 2.48; 95% CI, 1.05-6.22; P <.001). Invasive adenocarcinoma was more commonly associated with positive margins (5.2%) compared with negative margins (0.1%). CONCLUSION After conization for ACIS, patients with positive margins are significantly more likely to have residual or recurrent disease, whereas those with negative margins may be treated conservatively.
Factors affecting residual lesion in women with cervical adenocarcinoma in situ after cone excisional biopsy.
Jatupol Srisomboon, Chumnan Kietpeerakool, Prapaporn Suprasert, Sumalee Siriaunkgul, Surapan Khunamornpong, Wiboonwan Prompittayarat
Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand. firstname.lastname@example.org
The objective of this study was undertaken to evaluate the factors affecting residual lesion in women with adenocarcinoma in situ (AIS) on cervical conization specimens. The medical records of women with AIS who had no associated invasive carcinoma after cervical conization and underwent subsequent hysterectomy at Chiang Mai University Hospital were reviewed. During March 1998 and March 2006, 45 women were included for analysis. The mean age was 45.2 years (range, 30-66 years). Thirteen (28.9%) women presented with AIS on Pap smear. Thirty (66.7%) underwent loop electrosurgical excision procedure and the remaining 15 (33.3%) underwent cold-knife conization. Twenty (44.4%) women had mixed lesions of AIS and squamous intraepithelial lesion on cervical specimens. Surgical cone margins were clear in 25 (55.6%) women. Eighteen (40%) and two (4.4%) women had involved and non-evaluable cone margins, respectively. Residual lesion was noted in 14 (31.1%) hysterectomy specimens. There was no residual lesion in women with clear cone margins while 72% and 50% of women with involved and non-evaluable cone margins, had residual lesion, respectively. These differences were statistically significant (P<0.001). No significant association between the ECC results and the residual lesion was noted (P=0.29). In conclusion, approximately one-third of women with AIS on cervical conization have residual lesion on subsequent hysterectomy specimens. Only cone margin status is a significant predictor for residual lesion.
Jennifer L Young, Amir A Jazaeri, Jason A Lachance, Mark H Stoler, William P Irvin, Laurel W Rice, Willie A Andersen, Susan C Modesitt
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Virginia School of Medicine, Charlottesville 22908-0712, USA. email@example.com
OBJECTIVE We evaluated the impact of conization margin status on outcomes of patients diagnosed with cervical adenocarcinoma in situ. STUDY DESIGN A retrospective chart review identified patients at a University hospital from 1988-2006 with adenocarcinoma in situ (AIS) on conization. RESULTS Seventy-four patients were included. Median follow-up was 26 months. Twenty-two of 74 patients (30%) had positive margins, 46 patients (62%) had negative margins, and 6 patients had indeterminate margins. Of patients with positive margins, 55%(12/22) were diagnosed with residual or recurrent disease, including 3 patients diagnosed with adenocarcinoma on hysterectomy. Thirteen percent of patients with negative conization margins (6/46) were diagnosed with residual or recurrent disease, including 2 patients diagnosed with adenocarcinoma during follow-up. Cold knife conization resulted in a significantly higher number of negative margins compared to other conization procedures (P =.013). CONCLUSIONS Even with negative conization margins, women still face a risk of residual, recurrent, or invasive disease.
Shawna L Bull-Phelps, Elizabeth I O Garner, Christine S Walsh, Paola A Gehrig, David S Miller, John O Schorge
Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., J7.124, Dallas, TX 75390-9032, USA.
OBJECTIVES Cervical adenocarcinoma in situ (AIS) is a precursor of invasive disease that is increasing in incidence primarily among reproductive-age women of low parity. Conization is an alternative to hysterectomy that allows future pregnancy, but has an inherent risk of residual AIS. The purpose of this study was to determine the outcomes of patients treated by this fertility-sparing strategy over an extended period of surveillance. METHODS Women diagnosed with cervical AIS who underwent primary fertility-sparing surgery with either loop excision or cold knife conization between 1993 and 2001 were identified at three institutions. A retrospective medical record review was performed. Patients 40 years of age and older and those undergoing hysterectomy within 12 months of diagnosis were excluded. RESULTS A total of 101 women underwent cone biopsy and expectant management. The median age was 29 years. Fifty-seven percent were nulliparous and 23% primiparous. Cold knife conization was most commonly performed (69 vs. 32 procedures) and had a higher efficacy of achieving negative margins (72% vs. 47%; P=0.036). Thirty-five women had a total of 49 pregnancies during a mean follow-up of 51 months. Thirty-five gestations were delivered at term. There were two preterm births, eight spontaneous miscarriages, three elective terminations, and one ectopic pregnancy. Thirty-six patients had a repeat cone biopsy. Five ultimately underwent hysterectomy. No invasive cervical adenocarcinomas were observed during the study interval. CONCLUSION Fertility-sparing surgery enables women with cervical AIS to achieve pregnancy with minimal risk of developing invasive disease during surveillance.
Cold knife versus laser cone biopsy for adenocarcinoma in situ of the cervix--a comparison of management and outcome.
Sydney Gynaecologic Oncology Group, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia. firstname.lastname@example.org
Eighty-two patients with adenocarcinoma in situ of the cervix managed at Royal Prince Alfred Hospital were reviewed and data were collected on those treated by cold knife cone biopsy (n= 38) and laser cone biopsy (n= 44). No differences were found in patient age, cytologic or referral history, or outcomes. Having laser excision did not compromise margin status or subsequent management. Invasive disease was found in 24 patients, 16 of whom were managed conservatively with good outcome. Twelve of these were in the laser cone group. In those patients from both groups managed conservatively, there was only one recurrence, squamous preinvasive disease after 8 years. Laser cone biopsy is as effective as cold knife cone biopsy with no compromise of outcome for these patients.
Other papers by authors:
Department of Obstetrics and Gynecology, Saint Barnabas Medical Center, Livingston, New Jersey 07039, USA. email@example.com
BACKGROUND: Periumbilical extension of midline incision often results in an irregular, unaesthetic scar with beveled edges. TECHNIQUE: An Allis clamp is placed at the lateral margin of the umbilicus with subsequent medial traction. This straightens the proposed periumbilical incision, resulting in a symmetrical scar. EXPERIENCE: We have used this technique extensively over the past several years with excellent results and no adverse sequelae. CONCLUSION: This simple technique results in the symmetrically curvilinear, nonbeveled periumbilical extension of a midline incision.
Modified Le Fort partial colpocleisis with Kelly urethral plication and posterior colpoperineoplasty in the medically compromised elderly: a comparison with vaginal hysterectomy, anterior colporrhaphy, and posterior colpoperineoplasty.
Department of Obstetrics and Gynecology, Saint Barnabas Medical Center, Livingston, NJ 07039, USA.
Bolus mitomycin C and 5-FU with sequential radiation for poor-prognosis locally advanced cervical cancer.
Department of OBstetrics and Gynecology, Saint Barnabas Medical Center, Livingston, New Jersey 07039, USA.
Forty patients with locally advanced cervical carcinoma were entered into a protocol utilizing the bolus administration of both mitomycin C (10 or 15 mg) on Day 1 and 5-fluorouracil (400 mg) on Day 1-5 followed by sequential pelvic irradiation on Day 6 between September 1980 and October 1985. All patients had poor-prognosis FIGO stage IB, IIB, IIIB, or IVA disease. Only patients with poor prognosis factors such as bulky tumor masses of 5 cm or greater noted on the initial physical exam (37 patients) or poorly differentiated histology (3 patients) were eligible for this study. There were three severe side effects seen in the 24 patients receiving 15 mg mitomycin C. One patient developed thrombocytopenia, one patient developed acute radiation enteritis, and the third patient developed radiation proctitis requiring laser therapy. Only 1 of 16 patients receiving 10 mg mitomycin C developed a complication (thrombocytopenia). Neutropenia was mild in all patients. No infections were seen. Thrombocytopenia never warranted platelet transfusion. No patients developed therapy-related bowel obstruction or fistulae. Median follow-up was 11.3 years with a range of 6.2-14.2 years. A complete response rate of 63%, a local control rate of 58%, and a 5-year survival rate of 44% were obtained. This does not appear to offer any benefit over radiation alone. This present study supports the superiority of higher dose concurrent infusional chemotherapy and radiation over low-dose sequential bolus chemotherapy and radiation.
Department of Obstetrics and Gynecology, St. Barnabas Medical Center, Livingston, New Jersey.
Extrarenal Wilms' tumors (nephroblastomas) are considered rare, with only 36 cases reported to date. A primary Wilms' tumor of the uterus has been reported on two previous occasions. A third case is presented and the histologic features and histogenesis of the tumor discussed.
Aggressive management of incomplete or inevitable abortion. Report of 1002 septic and aseptic patients.
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Int J Gynaecol Obstet. 2012 Aug 29;: 22939281
Predictive value of negative cone margin status for risk of residual disease among women with cervical adenocarcinoma in situ.
Chumnan Kietpeerakool, Surapan Khunamornpong, Jatupol Srisomboon, Ajchara Kasunan, Narisa Sribanditmongkol, Sumalee Siriaungkul
Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
OBJECTIVE: To determine the value of negative cone margins in predicting residual disease in women with adenocarcinoma in situ (ACIS). METHODS: Data were retrospectively analyzed from 60 women with ACIS who underwent conization at Chiang Mai University Hospital between March, 1998, and December, 2010. Negative margin status was defined as absence of neoplastic epithelium at all margins, coupled with presence of normal cervical epithelium. The association between the incidence of residual lesions and cone margin status was analyzed via χ(2) or Fisher exact test. RESULTS: When adjusted for age and completeness of visualization of the cervical squamocolumnar junction during colposcopy, women who underwent loop electrosurgical excision procedure were 4 times more likely to have positive cone margins than those who underwent cold-knife conization (95% CI, 1.13-16.43). Residual disease was not found among 26 women who had negative cone margins, but was observed in 17 (65.4%) of 26 women with positive cone margins (P<0.001). CONCLUSION: Women with ACIS who had negative cone margins were found to have a notably low risk of residual disease. Adherence to the standard method of cone sampling and criteria for negative margin status might contribute to a high predictive value of negative cone margins.
Gynecol Oncol. 2012 Jul 26;: 22842126
Utility of Conization with Frozen Section for Intraoperative Triage Prior to Definitive Hysterectomy.
Fabio Martinelli, Kathleen M Schmeler, Chelsea Johnson, Jubilee Brown, Elizabeth D Euscher, Pedro T Ramirez, Michael Frumovitz
Department of Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy.
OBJECTIVE: To review our experience with conization with intraoperative frozen section analysis and to compare results from our tertiary cancer center with those from 2 community hospitals. METHODS: The records of all women who underwent conization with intraoperative frozen section analysis from January 1, 1997, through April 30, 2011, at The University of Texas MD Anderson Cancer Center and 2 community hospitals-The Woman's Hospital of Texas and St. Luke's Episcopal Hospital-were reviewed. Findings on pathologic analysis of frozen sections, permanent loop electrosurgical excisional procedure/conization specimens, and hysterectomy specimens were compared for each patient, and results from the cancer center were compared to those from the community hospitals. RESULTS: One hundred fifty-three patients met the inclusion criteria. Rates of accuracy of conization with frozen section analysis in predicting definitive pathologic findings were as follows: cervix with no residual disease after prior extirpative procedure 96.5%(95% CI 86.9-100%); cervical squamous carcinoma in situ, 95.4%(95% CI 84.5-100%); cervical adenocarcinoma in situ, 98.7%(95% CI 92.7-100%); microinvasive carcinoma, 97.4%(95% CI 90.1-100%); and invasive carcinoma≥3mm, 100%. Most importantly, conization with frozen section analysis was 100% accurate for triaging patients to simple or radical hysterectomy. Finally, this approach performed equally well in the cancer center with subspecialized pathologists and the 2 community hospitals with general pathologists. CONCLUSION: Conization with frozen section analysis is an effective technique for intraoperative triage of patients to immediate simple or radical hysterectomy and can be accurately performed in both academic and community hospitals.
Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
OBJECTIVE Modified radical hysterectomy has been advocated for the definitive treatment of patients with cervical adenocarcinoma in situ (ACIS) with positive conization margins due to the risk of a co-existing invasive cervical adenocarcinoma (ICA). We sought to identify patients who can be safely managed with an extrafascial hysterectomy based on predictors of invasion in the conization specimen. METHODS Between 1996 and 2010, we identified 33 patients who had definitive surgical management for cervical ACIS following conization with positive margins and/or positive endocervical curettage (ECC). Demographic and pathologic characteristics were collected by chart review. Statistical analysis was performed using Fisher's exact test. RESULTS Among 33 patients, 4 (12%) had ICA in the hysterectomy specimen. Predictors of ICA included pathologic suspicion of invasion (PSI) in the conization specimen and positive ECC. In patients with ICA at hysterectomy, PSI and ACIS-positive ECC were found in 75%(p=0.32) and 100%(p=0.09) respectively. When PSI was present and the ECC was positive, the positive predictive value (PPV) for ICA was 33%(2 of 6). When PSI was absent, the negative predictive value (NPV) for ICA was 94%(1 of 16). When both PSI and ECC were negative, the NPV for ICA was 100%(0 of 6). CONCLUSIONS Women with cervical ACIS have the highest risk for ICA in the setting of positive cone margins, positive ECC, and presence of PSI in the conization specimen. Extrafascial hysterectomy remains a viable option for women with positive cone margins when ECC is negative and PSI is absent.
J Low Genit Tract Dis. 2012 Feb 1;: 22302130
Francesco Sopracordevole, Vincenzo Canzonieri, Giorgio Giorda, Giovanni De Piero, Emilio Lucia, Elio Campagnutta
Departments of 1Gynecologic Oncology, and 2Pathology, Centro di Riferimento Oncologico-National Cancer Institute, Aviano, Pordenone, Italy.
OBIECTIVE: This study aimed to evaluate the safety of conservative treatment in women desiring preservation of fertility with stage IA adenocarcinoma of the cervix. MATERIALS AND METHODS: Clinical report of all women with stage IA adenocarcinoma of the cervix, endocervical subtype, with clear margins on cone biopsy, diagnosed in our cancer center inclusive between January 1995 and December 2007, were evaluated, after either conservative therapy or hysterectomy. All diagnoses were reviewed by a pathologist expert in gynecologic oncology. Follow-up methods include at least cervical cytology, colposcopy with direct biopsy if indicated, and cervical curettage. RESULTS: Of 783 laser cone biopsy specimens, 7 were diagnostic for microinvasive adenocarcinoma, endocervical subtype (6 stage IA1 lesions and 1 stage IA2 lesion) with clear margins. No lymphovascular space invasion was seen. No residual invasive disease was observed in the specimens of 2 patients treated with hysterectomy after conization. Five women treated with laser cone biopsy only are free of invasive disease at 44, 66, 72, 86 and 100 months; 1 patient was found to have persistent adenocarcinoma in situ on endocervical cytology. CONCLUSIONS: Cone biopsy as definitive therapy is safe in women with stage IA1 adenocarcinoma of the cervix, endocervical subtype, with clear margins and no lymphovascular space invasion. Because of the low reliability of follow-up techniques (cytology, colposcopy, and endocervical curettage), conservative treatment should be reserved only for women strongly desiring to preserve fertility and accepting the risk of recurrent disease.
Factors predicting the outcome of conservatively treated adenocarcinoma in situ of the uterine cervix: an analysis of 166 cases.
Silvano Costa, Simona Venturoli, Giovanni Negri, Mario Sideri, Mario Preti, Martina Pesaresi, Adriana Falasca, Daniela Barbieri, Marialuisa Zerbini, Donatella Santini, Maria Teresa Sandri, Bruno Ghiringhello, Nadia Caroppo Venturini, Stina Syrjänen, Kari Syrjänen
Department of Obstetrics and Gynecology, S.Orsola-Malpighi University Hospital, Bologna, Italy.
OBJECTIVE The present study assessed the clinical outcome of patients conservatively treated for cervical adenocarcinoma in situ (AIS) and their predictive factors using univariate and multivariate population averaged (PA) generalized estimating equation (GEE) model in a longitudinal setting. METHODS A series of 166 consecutive women (mean age 39.8 yrs; range 23-63 yrs) underwent conservative treatment of AIS as the primary treatment and were followed-up (mean 40.9 mo) using colposcopy, PAP-smear, biopsy and HPV-testing with Hybrid Capture 2. RESULTS Hysterectomy was performed as part of the primary management in 47 patients, who were excluded from the follow-up (FU) analysis. Out of 119 women closely followed-up, additional therapeutic procedures were performed in 69. At study conclusion, 7 patients (5.9%) showed persistent disease, while 8 (6.7%) had progressed to invasive adenocarcinoma (AC). Positive HR-HPV test was the only independent predictor of disease recurrence (adjusted OR=2.72; 95%CI 1.08-6.87), and together with free cone margins (OR=0.20; 95%CI 0.04-0.92), HR-HPV positivity was also the single most powerful predictor of disease progression to AC, with OR=3.74; 95%CI 1.84-7.61 (p=0.0001) in multivariate PA-GEE. CONCLUSIONS These results suggest that testing HR-HPV positive at any time point during FU is the most significant independent predictor of progressive disease, while showing free margins in cone has a significant protective effect against progression to AC. Furthermore, because 4.3% women with persistent, recurrent or progressive disease experienced a late (5th and 6th FU) diagnosis of HG-CGIN or microinvasive AC, a close surveillance should be scheduled for at least three years in conservatively treated AIS patients.
Correlation of cone biopsy with findings at radical hysterectomy and use of adjuvant radiation therapy.
UT Southwestern Medical Center, Department of Ob/Gyn, Division of Gynecologic Oncology, Dallas, TX 75390, USA. Todd.firstname.lastname@example.org
OBJECTIVE To determine if pathologic findings in cone biopsy specimens correlate with residual invasive disease in radical hysterectomy specimens and the need for adjuvant chemo-radiation therapy. STUDY DESIGN We identified 65 patients who underwent a cone biopsy and subsequent radical hysterectomy. Clinico-pathologic parameters in the cone specimens were correlated with the presence of residual invasive disease in the radical hysterectomy specimens and the need for adjuvant chemo-radiation. RESULTS A positive endocervical margin, a positive deep margin, a positive post-cone ECC, and positive LVSI were significantly associated with the presence of residual disease in the radical hysterectomy specimen, while positive LVSI, a positive ECC, a positive deep cone margin, and greater than 1 positive margin were significantly associated with the use of adjuvant chemo-radiation therapy. CONCLUSION Pathologic parameters in cone biopsy specimens can estimate the risk of residual invasive disease in radical hysterectomy specimens and the use of adjuvant chemo-radiation.
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA.
OBJECTIVE For women who have completed childbearing, the treatment of choice for adenocarcinoma in situ (ACIS) of the cervix is hysterectomy. In women who desire future fertility, however, conservative therapy is an acceptable alternative. In this study we compare the outcomes for young women who underwent loop conization or were treated with cold knife conization. METHODS We performed a retrospective analysis in 112 patients with ACIS, age 30 or younger, treated with cold knife conization or loop conization between 1998 and 2010. Decision to perform office loop conization was based on the size of the cervix and the colposcopic lesion. Main outcomes were negative margins after the procedure and recurrence of ACIS. RESULTS Fifty-eight patients (52%) were treated with cold knife conization and 54 (48%) underwent loop conization. The odds ratio for cold knife conization to achieve negative cone margins compared with loop conization was 1.4 (95% CI 0.6-3.5). We observed no difference in residual or recurrent ACIS between patients treated with loop conization versus cold knife conization. CONCLUSIONS In select young patients who desire future fertility, loop conization and cold knife conization have equivalent rates of negative margins and negative follow-up. For optimal results, patients must have a lesion which can be removed in one pass of a loop, confirmed by expert colposcopy. Loop excision should be considered the treatment of choice in this specific group of patients.
J Reprod Med. ;56 (9-10):376-80 22010519
Risk for residual adenocarcinoma in situ or cervical adenocarcinoma in women undergoing loop electrosurgical excision procedure/conization for adenocarcinoma in situ.
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kentucky Markey Cancer Center, 333 Whitney-Hendrickson Building, 800 Rose Street, Lexington, KY 40536-0298, USA. email@example.com
To evaluate the risk for residual adenocarcinoma in situ (AIS) or cervical adenocarcinoma in women undergoing loop electrosurgical excision procedure (LEEP)/conization as the initial management for AIS. A retrospective chart study was conducted from 1990 to 2005. Patients with AIS were identified from a pathology database. Forty-three patients were identified with AIS of the cervix who were initially treated with LEEP/conization. Twelve cases of invasive adenocarcinoma (28%) were identified on LEEP/conization. Margin status was available for 41 patients. Twenty (49%) patients had a positive margin, and 21 (51%) patients had a negative margin. Nineteen women with positive margins underwent definitive surgical therapy; 68% had residual AIS. Eleven women with negative margins underwent hysterectomy; 45% had residual AIS. Women with positive and negative margins were compared and found to differ significantly in regard to diagnosis of adenocarcinoma on LEEP/conization. Women status post-LEEP/conization for AIS have a high risk of residual AIS, even with negative conization margins. If definitive hysterectomy is deferred, close follow-up is mandatory.
Evaluation of cervical conization as a definitive treatment for microinvasive cervical carcinoma and cervical intraepithelial neoplasia grade 3.
Noriko Takeda, Takahiro Suzuki, Miwa Suzuki, Motoki Matsuura, Ryoichi Tanaka, Miho Fujii, Eiki Ito, Tsuyoshi Saito
Department of Obstetrics and Gynecology, Sapporo Medical University, South 1 West16 chuo-ku, Sapporo, Hokkaido 060-8556, Japan.
PURPOSE The aim of the study was to evaluate disease persistence after conization of CIN3 and microinvasive cervical carcinoma. METHODS Medical records from a total of 231 patients were reviewed. The prevalence of CIN3 and cervical carcinoma diagnosed by means of conization were analyzed. All conizations were performed under lumbar anesthesia using a laser technique. RESULTS Of the 231 patients, 25 had margin involvement with CIN3 or microinvasive carcinoma. Among these 25 patients, 10 underwent hysterectomy. Two of these 10 patients had CIN3 and eight had microinvasive carcinoma. Residual disease was observed in hysterectomy specimens from 9 of the 10 patients. Of the eight patients diagnosed with microinvasion from post-cone hysterectomy specimens, four had CIN3 and three had microinvasive carcinoma. The three patients with microinvasion were found to have a larger area of residual disease as compared with other patients with margin involvement. CONCLUSIONS Conization alone seems to be a reasonable treatment for patients with CIN1, 2, 3, and microinvasive carcinoma. For adenocarcinoma, in situ treatment with conization alone is possible but requires careful follow-up. Hysterectomy appears to be a safe treatment option for microinvasive adenocarcinoma, although follow-up by cytology is sometimes possible in cases with negative surgical margins.
J Reprod Med. ;55 (3-4):129-33 20506673
Predictive value of endocervical curettage at cervical conization and provider practices in management of high-grade cervical dysplasia.
Department of Gynecology and Obstetrics, Johns Hopkins Hospital, 600 North Wolfe Street, Phipps 281, Baltimore, MD 21287, USA. firstname.lastname@example.org
OBJECTIVE To determine the utility of endocervical curettage (ECC) at cervical conization for predicting residual or recurrent dysplasia and to evaluate differences in management between general gynecologists and gynecologic oncologists. STUDY DESIGN From February 1999 to November 2007, 192 patients with high-grade dysplasia on conization were retrospectively identified. Data were analyzed for 54 patients who underwent repeat conization or hysterectomy to evaluate predictors of disease. Data for all patients were analyzed based on provider. RESULTS Among patients who underwent secondary procedures, 68.5%(37/54) had residual or recurrent disease. Eighty-six percent of patients with a positive ECC had residual or recurrent disease compared to 48% of patients with a negative ECC (OR 6.91, CI 1.595-30.00, p=0.01). Among all patients, 77%(148/192) were managed by a generalist, and 23%(44/192) by a gynecologic oncologist. Oncologists were significantly more likely to perform a hysterectomy (45.5% vs. 14.2%, OR 5.04, CI 2.38-10.69, p<0.0001). CONCLUSION Endocervical curettage at the time of conization with high-grade dysplasia is a simple and reliable predictor of residual or recurrent disease and should be performed routinely. Gynecologic oncologists are more likely than general gynecologists to perform a hysterectomy in the management of high-grade dysplasia on conization.