Radiation Oncology/Cervix/IA

Prognostic Factors Depth of stromal invasion (measured from base membrane of cervical epithelium) <3 mm (IA1): Parametrial invasion rate 0 - 2.3%, LN mets rate 0 - 5.3% >3 mm (IA2): Parametrial invasion rate 0 - 3.3%, LN mets rate 1.3 - 13.8% (average ~8%) Lymphovascular space invasion Clinical significance is controversial Strong correlation with depth of invasion and tumor volume; literature unclear if it is an independent prognostic factor Nevertheless, many GYN/ONC do not consider patients with LVSI+ to be Stage IA (including SGO and JSOG definitions) Tumor volume Clinical significance is controversial in IA Some data support volumetric measurement, but technique is slow and imprecise Confluence of invasive foci There appears to be no difference (FIGO vs. JSOG data) Grade Four studies did not find grade an independent prognostic variable Treatment Overview IA1 and LVSI- Historically total hysterectomy a gold standard Demonstration of minimal risk of parametrial spread and LN+, with significant morbidity, resulted in shift to conization Cervical conization primary treatment today Brachytherapy alone probably a reasonable option in non-surgical candidates, based on the 2 series below NCCN.org: Extrafascial hysterectomy or Cone + observe if negative margins or Modified radical + PLND if LVSI+ IA2 or LVSI+ Some form of hysterectomy to evaluate parametrial space and LNs NCCN.org: Radical hysterectomy + PLND +/- aortic LN dissection or Pelvic RT + brachytherapy (75-80 Gy to Point A) Radical trachelectomy + LND if fertility preservation desired Surgical Series Milan, 2005 (Italy) 15670302 -- "Prognostic factors in microinvasive cervical squamous cell cancer: long-term results." (Raspagliesi F, Int J Gynecol Cancer. 2005 Jan-Feb;15(1):88-93.) Retrospective. 67 patients with IA1 treated with conization. Mean F/U 10 years Invasive recurrences: 4 patients (6%) Predictive factors: LVSI+, cone apical margin distance <10mm Italian CTF, 2003 (Italy) 14658592 -- "The clinical outcome of patients with stage Ia1 and Ia2 squamous cell carcinoma of the uterine cervix: a Cooperation Task Force (CTF) study." (Gadducci A, Eur J Gynaecol Oncol. 2003;24(6):513-6.) Retrospective, multi-institutional. 166 patients with IA (143 patients IA1, 23 patients IA2), treated with conization alone (18%, all IA1), total hysterectomy (49%), or radical hysterectomy (33%). Pelvic LN status: 0/67 LN+ Recurrence: 5% intraepithelial and 2% invasive. IA1 recurrence 6%, IA2 recurrence 13%. Cone alone 10% (but none invasive), total hysterectomy 5%, radical hysterectomy 9% Conclusion: Conization can be a definitive treatement for Stage IA1. For Stage IA2, extrafascial hysterectomy might be adequate, need for LN dissection is questionable Oslo, 1989 2722048 -- "Follow-up study of 232 patients with stage Ia1 and 411 patients with stage Ia2 squamous cell carcinoma of the cervix (microinvasive carcinoma)." (Kolstad P, Gynecol Oncol. 1989 Jun;33(3):265-72.) Retrospective. 643 patients with IA. Follow up 3-17 years Surgery: recurrence 15/496 (3%). All salvaged with further surgery Brachytherapy alone: recurrence 0/136 (0%) Radiotherapy Series Washington University, 1991 (1959-1986) 1905690 -- "Radiotherapy alone for medically inoperable carcinoma of the cervix: stage IA and carcinoma in situ." (Grigsby PW, Int J Radiat Oncol Biol Phys. 1991 Jul;21(2):375-8.) Retrospective. 21 patients with CIS and 34 patients with IA. RT for IA: BT alone (13 patients) to average 55 Gy to Point A, BT + Whole Pelvis (21 patients) to 14 Gy WP + 23.5 Gy parametrial boost with midline block + BT to 52 Gy to Point A Recurrence: 0/21 CIS, 1/34 IA in pelvis. No DM. Toxicity: severe complications 6%, in those getting WPRT + BT Conclusion: BT alone excellent treatment for both CIS and IA Oslo, 1989 2722048 -- "Follow-up study of 232 patients with stage Ia1 and 411 patients with stage Ia2 squamous cell carcinoma of the cervix (microinvasive carcinoma)." (Kolstad P, Gynecol Oncol. 1989 Jun;33(3):265-72.) Retrospective. 643 patients with IA. Follow up 3-17 years Surgery: recurrence 15/496 (3%). All salvaged with further surgery Brachytherapy alone: recurrence 0/136 (0%) Review Milan, 2003 14693337 -- "Microinvasive squamous cell cervical carcinoma." (Raspagliesi F, Crit Rev Oncol Hematol. 2003 Dec;48(3):251-61.)