4 dr mario sideri m k

451
-1

Published on

all

Published in: Science
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
451
On Slideshare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
4
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

4 dr mario sideri m k

  1. 1. IEO 2014 Mario Sideri Ginecologia Preventiva IEO Microinvasive and early invasive cervical cancer
  2. 2. IEO 2014 Standard treatment for invasive cervical cancer traditionally includes radical hysterectomy and pelvic limphoadenectomy. The rationale of the treatment is the extirpation of the tumour, with clear margins, and of the lumphatic vessels.
  3. 3. IEO 2014 There are early tumours with a small volume in wihich the removal of the parametrium can be omitted; in addition in some instances the tumour volume can be so small that the risk of lymphnode metastasis is limited, and pelvic lymphadenectomy can also be omitted
  4. 4. IEO 2014 Volume  is expressed as lenght and depth of infiltration of the neoplasia Categories where conservative approach is feasible: IA1 3 mm in depth, 7 mm in lenght, no LVSI IA2 5 mm in depth, 7 mm in lenght, neg. nodes IB1< 2 cm in largest diameter neg. nodes IB1 >2<3 cm in largest diameter, neg. nodes
  5. 5. IEO 2014 Volume  is expressed as lenght and depth of infiltration of the neoplasia The measures that define “micoinvasive” cervical cancer can only be obtained from a surgical specimen containing the whole lesion. Colposcopy is critical to help excise all the lesion in order to define the diagnosis
  6. 6. IEO 2014 Main reasons for cervical cancer declining mortality: • Cervical cancer screening programs • Intraepithelial lesions (CIN) detection • CIN therapy
  7. 7. IEO 2014 Conservative therapy Accurate pre-surgical evaluation of the lesion Chappatte, Gynecol. Oncol. 1991
  8. 8. IEO 2014 Citology,Colposcopy,Histology Key role in: • Grading • Size definition of the lesion • Identification of early invasive disease
  9. 9. IEO 2014 Failure after excisional CIN treatment Incorrect assessment of the lesion Luesley, Br. J. Obstet. Gynecol. 1985 Buxton, Br. J. Obstet. Gynecol. 1991
  10. 10. IEO 2014 END POINT To verify the predictive value of multiple tests in CIN pre-surgical assessment • avoid under/over treatment • schedule proper follow-up • prevent risk for disease persistence
  11. 11. IEO 2014 Clinical characteristic of the 1000 patients treated by cone biopsy Referral Pap smear • LG SIL or less • HG SIL • Susp. Cancer Punch biopsy • Neg/CIN 1 • CIN 2-3 • Cancer (early invasion) n % 262 26.2 722 72.2 16 1.6 107 11.9 786 87.5 5 0.6 Costa et al. 2001
  12. 12. IEO 2014 Clinical characteristic of the 1000 patients treated by cone biopsy Colposcopic features Neg AnTZ 1 AnTZ 2 Visible SCJ Not visible SCJ n % 131 13.1 313 31.3 556 55.6 271 27.1 729 72.9 86,9% Costa et al. 2001
  13. 13. IEO 2014 Clinical characteristic of the 1000 patients treated by cone biopsy Colposcopic features Involved quadrants° 1 2 3 4 °869 positive colposcopy n % 222 25.5 394 45.3 174 20 79 9.1 Costa et al. 2001
  14. 14. IEO 2014 Histology on 1000 cone biopsies CONE Histology N° Negative 148 CIN 1 176 CIN 2-3 607 Cancer° 69 °Including 54 Stage IA1, 9 Stage IA2, 3 Stage IB carcinomas, and 3 Adenocarcinomas Costa et al. 2001
  15. 15. IEO 2014 Pap smear by Cone Biopsy Pap smear Cone biopsy Total Neg/CIN 1 N % CIN 2-3 N % Cancer N % LG SIL or less 130 49.6 128 49 4 1.4 262 HG SIL 194 26.9 470 65.1 58 8 722 Cancer 0 9 56 7 44 16 Costa et al. 2001
  16. 16. IEO 2014 CAUTION !!! PAP SMEAR Vs CONE BIOPSY LG SIL 50.4% CIN 2-3/Cancer HG SIL 26.9% Neg/CIN 1 Costa et al. 2001
  17. 17. IEO 2014 CAUTION !!! • > 25 % HSIL in persistent ASCUS/LSIL Gerber S et al., Int J Gynaecol Obstet, 2001; 75:251-5 • > 25% CIN III/Ca. in CIN I-II directed Bx Petry KU et al., Am J Obstet Gynecol, 2002;186:28-34
  18. 18. IEO 2014 Lesion size related to cone biopsy findings Cone biopsy % Lesion Involved quadrants Negative 67.8 1 CIN 1 50.3 1-2 CIN 2-3 78.8 2-3 Cancer 66.2 3-4 Costa et al. 2001
  19. 19. IEO 2014 Cone Punch biopsy biopsy Neg/CIN 1 CIN 2-3 264/201 76.1% Small lesion removed by biopsy Rate of over-estimation of punch biopsy Costa et al. 2001
  20. 20. IEO 2014 Colposcopy by cone biopsy Colposcopy 15 SCJ vis. 131 Neg 116 SCJ not vis. 313 AnTZ 1 869 Pos 556 AnTZ 2 Cone biopsy CIN 2-3 Cancer Total 4 0 4 (0.6%) 37 4 41 (6 %) 163 6 169 (25.1%) 403 59 462 (68.3%) 607 69 676 (100%) Costa et al. 2001
  21. 21. IEO 2014 Punch biopsy by Cone biopsy Punch biopsy* Neg/CIN 1 Neg/CIN 1 63 CIN 2-3 201 Cancer 0 264 Cone biopsy CIN 2-3 Cancer Total 39 5 44 (6.9%) 527 58 585 (92.3%) 3 2 5 (0.8%) 569 65 634 (100%) Costa et al. 2001
  22. 22. IEO 2014 Conclusions 1 No Gold Standard in diagnosis !!! • LG SIL on Pap smear or punch biopsy may hide a HG SIL or Cancer • Punch biopsy may be an inadequate end point by which to judge the severity of the lesion
  23. 23. IEO 2014 Conclusions 2 Limits of colposcopy in Presurgical HG lesion assessment • SCJ not entirely visible 70% • Misleading target biopsy 40% • No lesion 7%
  24. 24. IEO 2014 H-SIL and microinvasive cervical cancers
  25. 25. IEO 2014
  26. 26. IEO 2014
  27. 27. IEO 2014
  28. 28. IEO 2014
  29. 29. IEO 20140173621
  30. 30. IEO 20140184901
  31. 31. IEO 20140196521
  32. 32. IEO 20140196522
  33. 33. IEO 20140196523
  34. 34. IEO 20140196524
  35. 35. IEO 20140198641
  36. 36. IEO 2014310781
  37. 37. IEO 2014310782
  38. 38. IEO 2014314291
  39. 39. IEO 2014319421
  40. 40. IEO 2014319422
  41. 41. IEO 2014
  42. 42. IEO 2014
  43. 43. IEO 2014
  44. 44. IEO 2014
  45. 45. IEO 2014
  46. 46. IEO 2014 Open Question In stage Ib1 cervical cancer is the removal of parametria always necessary even in case of minimal involvement?
  47. 47. IEO 2014
  48. 48. IEO 2014 HSG experience in Cervical Cancer (1982 - 1986) Stage Ib1, Class I vs Class III 0 20 40 60 80 100 0 1 2 3 4 5 6 7 8 9 10years % Class I Class III p: 0.1 Landoni et all. I.G.C.S. 1989
  49. 49. IEO 2014 0 20 40 60 80 100 0 1 2 3 4 5 6 7 8 9 10years % Class I Class III p: 0.9 Landoni et all. I.G.C.S. 1989 HSG experience in Cervical Cancer (1982 - 1986) Stage Ib1 < 3 cm, Class I vs Class III
  50. 50. IEO 2014 German Experience Surgery* Pts 5yrs Wertheim - Meigs 108 72.3 % Galvin – Te Linde 102 78.5 % * adjuvant RT ~ 50% in both groups Stark G.:Geburt. und Frauen. 47(1), 45-8,1987
  51. 51. IEO 2014 Pts N+(%) P+(%) Landoni ’89 189 32 (17) 20 (10) Covens ‘01 842 45 ( 6) 33 ( 4) (8 PMLN & 25 PT) tumor size < 2cm/nodesNeg/depth inv.< 10mm (0.6) Winter ’01 (N-) 351 44 (12) Steed ’06 110 13(12) 5 ( 5) Benedetti ‘00 49 15 (31) Parametrial involvement in Early Stage Cervical Cancer
  52. 52. IEO 2014 Recurrences 2%
  53. 53. IEO 2014 Recurrences 30%
  54. 54. IEO 2014 Recurrences  Size < 2 cm 1.9%  Size > 2 cm 20%
  55. 55. IEO 2014 26 patients with stage IA2 (6) - IB1 (20) cervical cancer  4 patients had radical surgery due to nodes pos.(16.7%)  1/22 conservative surgery patients had a pelvic recurrence (isthmic part of the uterus) 14 mts after initial treatment (NED at 30 mts after CT/RT)  No Deaths  Conception rate 71%  Term Deliveries 42% OUTCOMES from VAGINAL TRACHELECTOMY and LAPAROSCOPIC PLND Robb L. et all. Int. J.Gyn. Cancer, 2006
  56. 56. IEO 2014 Simple trachelectomy Leep
  57. 57. IEO 2014 IEO Study Design Conservative treatment for Stage IA2-IB1 cervical cancer patients
  58. 58. IEO 2014 IEO Study design Patients will be stratified in two categories based on the tumor diameter Patients with tumor diameter < 2cm Patients with tumor diameter >2cm<3cm
  59. 59. IEO 2014  Histologically confirmed diagnosis FIGO stage IA2-IB1 squamous/adenosquamous/adeno  Cervical tumor diameter < 3 cm on MRI or on cervical specimen after cone  Distance between OUI and tumor > 1 cm on MRI  No evidence of pelvic lymph nodes involvement and distant metastasis on CT scan/PET Adequate hematological, liver and renal function  Absence of any psycological, familial, sociological, condition potentially hampering compliance with the study protocol and follow-up schedule  Signed informed consent INCLUSION CRITERIA
  60. 60. IEO 2014  First step: cone biopsy and laparoscopically pelvic lymphadenectomy  No evidence of RISK FACTORS on the cervical specimen and negative pelvic lymph nodes: FOLLOW-UP  Presence of RISK FACTORS on the cervical specimen: LVS Involvement & invasion > 10mm – CT Free Margins < 3mm – SURGERY  Presence of pelvic lymph nodes metastases: RADICAL TREATMENT Treatment A ( < 2 cm)
  61. 61. IEO 2014  36 patients IB1 < 2 cm  Conization & LND  66 months follow up (range 18 -168) Single case of pelvic recurrence 34 months after treatment - squamous - G3 - LVSI
  62. 62. IEO 2014 21 preganacies in 17 patients  3 preterm (27-32 and 33 weeks)  3 first trimester abortions  1 second trimester abortion  1 ectopic pregnancy; 1 FID genetic anomalies Obsterical Outcomes Cervical conization is a possible conservative management in stage FIGO IB1< 2 cm, in very selected patients with negative lymphnodes
  63. 63. IEO 2014  First step: laparoscopic pelvic lymphadenectomy NEGATIVE NODES  Second step: NACHT for 3 cycles every 21 days  Third step: cone biopsy after clinical and radiologic evaluations Treatment B (> 2 < 3 cm)
  64. 64. IEO 2014 BEFORE
  65. 65. IEO 2014 AFTER
  1. Gostou de algum slide específico?

    Recortar slides é uma maneira fácil de colecionar informações para acessar mais tarde.

×