Modern approach to treatment of CIN and micro-invasive

Hans Hinselman
Colposcopy, 1924
George Pappanicolaou
Cytology, 1945

Cervical cancer has become detectable
and curable disease.

Recently, however,
significant controversy
has arisen over several aspects of
the diagnosis and management of
cervical intraepithelial neoplasia

There is no dispute about the need
to treat CIN 3
and few would argue
that CIN 2 should be managed conservatively.

These two grades of CIN (CIN 2 and CIN 3)
are referred to as high-grade lesions
to differentiate them from
the low grade lesions (CIN 1 and HPV changes)

In the spectrum of cervical pathology
the line between premalignant and benign lesions
may be drawn between
CIN 1
CIN 2
CIN 3

L-SIL
High proportion of women affected
Low risk of progression
Significant regression may occur

Management of CIN 1 (L-SIL)
Conservative
Active

Management of L-SIL
Close observation with cytologic
and possibly colposcopic follow-up,
without active treatment
is the preferred management option.

Expectant management of CIN 1
is not totally without some risk...

……. because of the:
potential for a high-grade lesion
to develop during follow-up
already existing high-grade lesion
that was not correctly diagnosed
loss to follow-up

If large lesions or persistent lesions
are present or if the patient is at risk
for being lost to follow-up,
active treatment may be favored

Active management of women with CIN 1 is recommended in the following cases:
Unsatisfactory colposcopy
Large, complex lesions
Persistant CIN 1 (> 18 months)
Women older than 35
Noncompliance for follow up

Women with biopsy confirmed
H-SIL (CIN 2 and 3)
have significant risk of disease progression
to invasive cancer and should be treated.

The expectant management of CIN 2 and 3
with repeat cytology and colposcopy
is not acceptable except for:
pregnant patient
very young patients with CIN 2

Destruction or Excision ?

Management of HSIL
excision recommended
cold-knife
laser conization
LLETZ

Excision is necessary in:
Unsatisfactory examination
Large lesions
Recurrent disease

Unless there are other compelling
reasons for performing a hysterectomy,
this procedure is considered
unacceptable
as primary therapy for CIN 2 and 3.

The finding of invasive cancer after treatment of CIN 3
Conization (n=237)
8.84%
Hysterectomy (n=106)
26.42%
Kesic V, 2004.

Vesna Kesic
Institute of Obstetrics and Gynecology
Clinical Center of Serbia
International Scientific Conference
Prevention of Cervical Cancer: Looking into the Future
Moscow, 31.March-2. April
Microinvasive Cervical Cancer

Treatment of cervical cancer is affected
by the stage of the disease.

FIGO
Montreal,
1994

Microinvasive cervical cancer
Stage I a

MESTWERDT
reported 1947 about 30 small invasive carcinomas.
No evidence for metastases!
In 1953 he called these tumors
„microcarcinomas“
diagnosed neither by palpation
nor with the naked eye
diagnosed only by colposcopy
and microscopically after processing
the material in step serial sections.

Stage l a 1:
Measured stromal invasion of not > 3.0 mm in depth and extension of > than 7.0 mm
Stage I a 2:
Measured stromal invasion of > 3.0 mm and not > 5.0 mm in depth and extension of > than 7.0 mm
Stage I a: Invasive cancer identified only microscopically
Invasive cacinoma of the cervix uteri
(FIGO staging 1994)

Were the microinvasive lesion and its
preinvasive components removed in their
entirety?
What are the dimensions and histologic
characteristics of the lesion?
The diagnosis of stage Ia cervical cancer
should be based on cone biopsy !

The excision margins should be free
of CIN and invasive disease !

If the invasive lesion is excised
but CIN extends to the excision margin
then a repeat excision should be performed
to confirm excision of the CIN
to exclude further invasive disease.
This should be performed even in those cases
planned for hysterectomy
to exclude an occult invasive lesion requiring radical surgery

Histologic Processing of the Cone
Serial sections à 400 μm intervals

Measurement of tumor diameters

Ideally, the management of
microinvasive cancer Stage Ia
should be planned in cooperation
with an experienced pathologist.

Unfavourable prognostic criteria
for microinvasive carcinoma include
Deeper stromal invasion
Capillary-like space involvement
Poor differentiation
Confluent growth pattern

Depth of invasion LVI Risk of node metastases
0-3 - < 1 / 1000
0-3 + 2 / 100
3-5 - 2/ 100
3-5 + 5 / 100
Stage Ia cervical cancer

Each patient with microinvasive cancer
should be evaluated
individually !

If distant spread is very unlikely,
simple but complete excision of the lesion
suffices.
If it is likely that the cancer has spread,
than an extended operation
should be performed.

The reasons of conservative surgery in
microinvasive cervical cancer
To preserve fertility
To prevent the potential complications
of radical treatment.

Management of stage I cervical cancer
Stage I a 1
depth <3 mm
width <7 mm
no lympho-vascular invasion
Conization
Simple hysterectomy in women who do not wish
to retain fertility or if indicated for other reasons

Management of stage I a 2 cervical cancer
Stage I a 2
depth <5 mm
width <7 mm
no lymph vascular invasion
Complete excision (conization or
extrafascial hysterectomy)
Pelvic node dissection ?

Smallest tumor with one pelvic lymph node metastasis
(no vascular invasion)
3 mm depth 17 mm width
F. Girardi et al.: Small FIGO Stage IB Cervical Cancer.
Gynecol Oncol 55, 427-432 (1994)
Local and distant spread
pelvic and/or parametrial node involvement

Treatment options for stage I a
with lympho-vasular invasion
Modified radical hysterectomy (stage Ia1) or
radical hysterectomy (stage Ia2) with pelvic
node dissection
Radical trachelectomy with laparoscopic pelvic
node dissection if fertility desired

Radical vaginal trachelectomy with
laparoscopic pelvic lymphadenectomy

Recurrence rates after trachelectomy
are comparable
to radical hysterectomy (aproximately 4%)
Plante et al. Gynecol Oncol. 2004 ;94:614-23

Radical trachelectomy
Successful pregnancy in 26.5% cases
Plante et al. Gynecol Oncol. 2004 ;94:614-23

Prerequisites for trachelectomy
Strong fertility desire
Patient < 40 years
Tumor < 2 cm (Ia, Ib1)
No lymphovascular invasion
Negative lymphnodes
Favorable histology
Length of cervix > 2 cm

Cervical cancer- survival by FIGO stage
FIGO 25. Annual report, 1996-1998
98.7%
95.9%