Reports

Is conization appropriate treatment for cervical cancer in situ?

Brief Reports

B. LAMBERT,* MD, FRCS[C] S. ROUSSEAU,J MD P. BIELMANN,t MD E. LAMOUREUX,§ MD Y. BoIvIN,II MD The recent surge of interest in cryosurgery and laser vaporization for the treatment of carcinoma in situ of the uterine cervix has led clinicians to question the value of conization as a primary mode of treatment for young nulliparous patients. Although some authors still consider conization an excellent tool for both diagnosis and treatment, reporting rates of persistence of the disease after conization of less than 10%,'-5 others have reported persistence rates of 25% to 50%.6-8 This controversy should be resolved, as many patients with cervical intraepithelial neoplasia are of childbearing age.9 We conducted a study to determine the effectiveness of conization as a treatment for cancer in relation to clinical factors such as age, parity and microscopic extension of the disease.'0-'4

Method We reviewed the charts of 142 patients who had undergone a conization that had yielded a pathological diagnosis of carcinoma in situ between 1974 and 1978. Because of poor quality of the cone specimens 31 patients were removed from the study. The mean age of the remaining 111 patients was 38.8 *Associate professor, department of obstetrics and gynecology, University of Montreal tAssistant professor, department of obstetrics and gynecology, H6tel-Dieu de Montreal and hopital Sainte-Justine, Montreal 4:Professor, Institut national de la recherche scientifique, hopital Louis-H. Lafontaine, Montreal §Resident in pathology, H6tel-Dieu de

Montreal IIAssociate professor, department of

pathology, University of Montreal Reprint requests to: Dr. B. Lambert, Departement d'obst6trique et gyn6cologie, H6tel-Dieu de Montreal, 3840, rue St-Urbain, Montr6al, PQ H2W 1T8 1176

the youngest person was 16 and the oldest 66 years. The sample was subdivided into group A, 71 women who desired sterilization and underwent hysterectomy after conization, and group B, 40 women who underwent conization only. The cones were studied as follows: The geographic extension of the disease was determined by cutting open the cone at the 12 o'clock position, marked by a silk stitch, to form a trapezoidal block of given dimensions, as described by Adelman and Hadju.'5 Nine to 13 blocks of tissue 5 mm thick were obtained and divided into three blocks per quadrant, then well oriented serial sections 7 ,um thick were made at 100-,um intervals to determine the circumferential extension of the disease, which was recorded as the number of quadrants invaded (Ql = one, Q2 = two etc.) The longitudinal extension was recorded in relation to the junctional zones (AB = primary junction, BC = secondary junction) and the last gland inside the primary junction. Zone A was formed by normal squamous epithelium, zone B by the transformation or metaplastic region, and zone C by the endocervical canal. Examination for the presence of carcinoma in situ (replacement of the entire thickness of the epithelium by malignant cells)'6 or dysplasia at the borders of the cone determined, proximally and distally, whether the disease had been completely resected; if it had, the cone was referred to as "complete". years;

Results Among the 71 group A patients the cone was complete in 22 and incomplete in 43; 6 patients were found to have vaginal involvement within 2 years after the hysterectomy. Table I shows that hysterectomy was significantly less likely (P < 0.01) to reveal uterine involvement in the patients whose cones were complete than in those whose cones

CMA JOURNAL/MAY 15, 1982/VOL. 126

incomplete. However, in 6 of the 22 whose cones were complete there was uterine involvement, for a persistence rate of 27%. Excluding the 6 patients who had vaginal involvement, 32 (49%) of 65 patients were cured by conization. Table II shows that the patients with vaginal involvement were significantly older than the other two

were

groups.

The 40 group B patients underwent conization alone because they wished to be able to bear children.'7 They were ineligible for cryosurgery because lesions were not visible or were more than 5 mm beyond the primary junctional zone, because endocervical curettage yielded malignant cells or because there was no correlation between the cytologic, colposcopic and histologic findings. In this group the 17 patients whose cones were incomplete were significantly younger than the 23 whose cones were complete (24.4 v. 28.5 years; F = 6.51, P = 0.025). Follow-up of some patients for at least 1 year showed that of seven with persistent disease three underwent cryosurgery because the cone had been distally incomplete, one underwent a second conization, which completely removed moderately dysplastic tissue, one underwent hysterectomy, which confirmed endocervical and isthmic extension of the disease, one underwent cervicectomy and one Table I-Relation* of completeness of resection of carcinoma in situ of the uterine cervix to findings with subsequent hysterectomy in a group of 71 patients

Hysterectomy finding; no. of patients No tumour Tumour 6 16 Complete 27 16 Incomplete 32 33 Total *X2= 7.34, P < 0.01. tExcluding six patients with vaginal involvement. Resection

was found by a Papanicolaou smear to Younger patients present a different have mild dysplasia but has since had challenge. Conization is now standard whenever the entire lesion cannot be normal smears. Pathological studies showed that in visualized by colposcopy, when more 80% of the cases the lesions were large- than 5 mm of the endocervical canal is cell, nonkeratinized, moderately dif- involved and when endocervical curetferentiated grade 2 cancers; the rest of tage yields malignant cells. Our finding the lesions were large-cell keratinized that completeness of the cone was not a cancers. good index of complete removal of the In group A endocervical involvement tumour may be due to the involvement was found ii. many more of the patients of glands deeper in the endocervical whose cones were incomplete (37 of 43) canal in some of the patients; conversethan of those whose cones were com- ly, the absence of endocervical involveplete (5 of 22), but in group B just 1 ment in some of those with incomplete patient in each subgroup showed long- cones may be attributed to tangential itudinal extension of the disease. On the resection at the very limit of the lesion other hand, among the patients whose in the cervix. Extra care should be taken with very cones were incomplete, circumferential involvement was more pronounced in young and with nulliparous patients, in those of group B, who tended to have whom vertical progression of the lesion four-quadrant invasion, than in those of with age, a tendency noted in this study, group A, who tended to have three- may not be apparent, so that the risk of quadrant invasion. Overall, no particu- incomplete resection is increased. On lar quadrant was involved more than the other hand, the morphologic the others. Neither age nor parity was changes in the cervix due to a past pregnancy could contribute to the lesignificantly related to cone size. sion's resectability. However, extreme caution is needed with nulliparous paDiscussion tients, for whom others favour cryosurgThe literature does not distinguish ery'8 or laser vaporization,'9'20 since conbetween the results of conization in ization among younger patients appears women of childbearing age and the more likely to be incomplete. On the results in those who have completed other hand, in view of the poor theratheir families. In the latter a prediction peutic results of conization in older of complete resectability is not critical patients,"3'6'8 one might consider, to resince most will request hysterectomy, place conization in a prehysterectomy but the possibility of vaginal persistence evaluation, the use of microbiopsy and of disease must be considered. Patients endocervical curettage when feasible 45 years and older should be carefully and when the lesion can be completely evaluated for vaginal involvement by observed by colposcopy. In our opinion colposcopy and possibly biopsy before conization is more a diagnostic than a conization and after hysterectomy, al- therapeutic tool and is most appropriate though colposcopy in that age group is in young primiparas in whom high versometimes unsatisfactory for examina- tical involvement could jeopardize the tion of the cervix because of a high success of interventions such as cryosurgery or laser vaporization. secondary junctional zone. Table Il-Relation of resection status and vaginal involvement to age and parity of all 71 patients Variable Resection Complete Incomplete Vaginal involvement Resection Complete Incomplete

P valuet

Mean . standard error Age (yr)

F value

43.8 . 2.10 40.5 . 1.55

1.53

NS

5.47

0.025

0.05

NS

1 Vaginal 4.33 . 1.01) involvement *.termin. by analysis of variance. tNS = not significant.

I. BOYES DA, WORTH AJ, FIDLER HK: The results of treatment of 4389 cases of preclinical cervical squamous

carcinoma. J Obste: Gynaecol Br Commonw 1970; 77: 769-780 2. CREASMAN WI, RUTLEDGE F: Carcinoma in situ of the cervix; analysis of 861 patients. Obstet Gynecol 972; 39: 373-380 3. AHLGREN NI, INGEMARSSON I, LtNDBERG LG, NORDQvtST SRB: Conization as treatment of carcinoma in situ of the uterine cervix. Obstet Gynecol 1975; 46: 135-139 4. KOLSTAD P. KLEM V: Long term follow-up of 1121 cases of carcinoma in situ. Obste: Gynecol 1976; 48: 125-129 5. JONES HW itt. BULLER RE: The treatn.ent of cervical intraepithelial neoplasia by cone biopsy. Am J Obsiet Gynecol 1980; 137: 882-886 6. GARCIA RL, BIGELOW B, DEMOPOULOS RI, BECKMAN EM: Evaluation of cone biopsy in the management of carcinoma in situ of the cervix. Gynecol Oncol 1975; 3: 32-39 7. NISHtMURA A, TSUKAMOTA N, SUGIMORI H, HAMASAKI Y, MATSUYAMA A, KASHIMURA M, TAKI I: Evaluation of the colposcopically directed biopsy and the cone biopsy. Gynecol Oncol 1978; 6: 229-235 8. CRISP WE, SHALANTA H, BENNETT WA: Shallow conization of the cervix. Obstet Gynecol 1968; 31: 775-758 9. LAMBERT B: An etiological survey of clinical factors in cervical intra-epithelial neoplasia (CIN). J Reprod Med 1980; 24: 26-31 10. POITOUT P. TRUC JB, PANIEL BJ, PETIT C, MUSSET R: Epithlliome intra-epithllial du col utdrin. Diagnostic et traitement: 124 cas [with Eng abstri. Nouv Presse Med 1978:7:1459-1461 II. MCCANN SW, MICKAL A, CRAPANZANO JT: Sharp conization of the cervix. Observations of 501 consecutive patients. Obstet Gynecol 1969; 33: 470-475 12. ENTERLINE HI, ARyAN DA, DARVIS RE: The predictability of residual carcinoma in situ from study of cervical cone. Am J Obsiet Gynecol 1963; 85: 940-946 13. DORAN TA, SHIER CB: Conization of the cervix. Review at the Toronto General HospiGfl (1956-1961).

Am J Obsiet Gynecol 1964; 88: 367-374 14. SCHIFFER MA, GREENE HJ, POMERANCE W, MOTz A: Cervical conization for diagnosis and treatment of carcinoma in situ. Am J Obstet Gynecol 1965; 93: 889-895 15. ADELMAN HC, HADJU SI: Role of conization in the treatment of tervical carcinoma in situ. Am J Obstet Gynecol 1968; 93: 755-758

16. BURGHARDT E: Early Histological Diagnosis of Cervical Cancer, Saunders, Philadelphia, 1973: 206-231

51.0 . 4.35 ) Parity 2.95 . 0.47 2.81 . 0.36

References

17. BJERRE B, ELIASSON G, LINELL F, SODERBERG H, SJOBERG NO: Conization as only treatment of carcinoma in situ of the uterine cervix. Am J Obstet Gynecol 1976; 125: 143-1 52 18. RICHART RM, TOWNSEND DE, CRISP W, DEPETRILLO A, FERENCZY A, JOHNSON G, L1CKRISH G, ROY M, VILLA SANTA U: An analysis of long term follow-up results in patients with cervical intraepithelial neoplasia treated by cryotherapy. Am J Obstet Gynecol 1980; 137: 823-826 19. BAGGISH MS: High-power-density carbon dioxide laser therapy for early cervical neoplasia. Am J Obstet Gynecol 1980; 136: 117-125

1.02

NS 20. MASTERSON BJ, KRANTZ KE, CALKINS JW, MAGRINA JF, CARTER RP: The carbon dioxide laser in cervical intraepithelial neoplasia: a five-year experience in treating 230 patients. Am J Obstet Gynecol 1981; 39: 565-567

CMA JOURNAL/MAY 15, 1982/VOL. 126 1177