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ABSTRACT & COMMENTARY
Synopsis: Patients with stage IA2 cervical cancer have a significant risk of lymph node metastases and should be treated by radical hysterectomy and pelvic lymphadenectomy.
Source: Buckley SL, et al. Gynecol Oncol 1996;63:4-9.
Buckley and associates retrospectively reviewed the combined experience at four institutions with 94 patients with stage IA2 squamous cell carcinoma (invading the cervical stroma > 3-5 mm with 7 mm or less in horizontal spread) treated from 1963 to 1993 by radical hysterectomy and pelvic lymphadenectomy. Depth and lateral extent of stromal invasion were verified using an ocular micrometer. Cell type and lymph vascular invasion (LVSI) were recorded in each case. Those patients with lymph node metastases were offered postoperative radiation. The mean duration of follow-up was 6.9 years (range, 0.4-23.5 years). Seven of 94 patients (7.4%) had lymph node metastases. Five patients had one positive node, one patient had two positive nodes, and one patient had three positive nodes. Five patients developed recurrent cancer, and four died of disease. LVSI was present in 31 cases (33%). Tumor recurrence was significantly increased in patients with positive LVSI (9.7% vs 3.2%). The five-year survival rate of patients with LVSI was 89% vs. 98% in patients without this finding (P = 0.058). The five-year survival rate of all stage IA2 cervical cancer patients was 95%.
The authors conclude that patients with stage IA2 cervical cancer have a significant risk of lymph node metastases and should be treated by radical hysterectomy with pelvic lymphadenectomy. They further conclude that LVSI is an important prognostic variable in these patients.
COMMENT BY DAVID M. GERSHENSON, MD
In 1994, the Cancer Committee of the International Federation of Obstetrics and Gynecology (FIGO) revised the classification system for stage IA cervical cancer, subdividing it into stage IA1, in which the tumor invades the cervical stroma to a depth of 3 mm or less, and stage IA2, in which the tumor invades the cervical stroma to a depth of more than 3-5 mm and has a horizontal spread of 7 mm or less. LVSI was not included as part of these definitions. There are no prospective, randomized studies involving this patient population. A survey of the literature containing a few large retrospective studies indicates that the risk of lymph node metastasis in this group of patients is in the range of 4-7%. There is no consensus regarding treatment for women with these lesions. With the risk of lymph node metastasis this high, pelvic lymphadenectomy would seem to be an appropriate part of the treatment strategy. The approach to the central lesion, however, is less clear. The authors recommend a classical radical hysterectomy. Might not modified radical hysterectomy (with a more limited resection of the paracervical and uterosacral ligaments) or even simple extrafascial hysterectomy be considered? We really don't know the answer because it has never been formally studied. My own bias is to employ modified radical hysterectomy in conjunction with bilateral pelvic lymphadenectomy in order to limit morbidity, chiefly postoperative bladder atony. Unfortunately, the study of FIGO stage IA2 cervical cancer is hampered by the fact that most institutions lack accurate pathology. Even many expert gynecologic pathologists do not report the precise extent of horizontal spread. And some do not even note whether LVSI is present. While this study adds significantly to our information about this entity, many questions remain unanswered, including the optimal treatment. Clearly, we require reporting of other large series to resolve these issues. Accurate and meticulous pathological review will be critical. It is very unlikely that we will witness a prospective, randomized study in this area because of physician bias.