Volume 153 Number 2

Discussion DR.JOHN L. POWELL, Springfield, Massachusetts (By

invitation). The literature on diagnosis, management, and prognosis of microinvasive or "superficially inva­sive" carcinoma of the cervix creates confusion and dilemma. Although most reports indicate that stage 0 cervical carcinoma (carcinoma in situ) may be treated by conservative means, considerable controversy exists in regard to the diagnosis and management of Stage IA cervical cancer. Most agree that it is the earliest stage in the transition of cervical intraepithelial neoplasia to invasive carcinoma and represents little or no threat of metastasis. With respect to treatment, the crux of the problem seems to be how much infiltration into the stroma is permissible, so that simple methods may be used rather than the radical operation or radiation therapy required for a more advanced carcinoma.

Unfortunately, the International Federation of Gy­necology and Obstetrics ( FIGO) definition of microin­vasive carcinoma (Stage IA) is of limited clinical value, since the precise depth of stromal invasion is not spec­ified.' In a review of numerous reports on microinva­sive carcinoma of the cervix, since this concept was first proposed by Mestwerdt,2 in 1947, we have noted nu­merous definitions of this entity. Nelson et al. 3 report 18 definitions, and Lohe4 lists 20 synonyms and 16 dif­ferent parameters for the definition of size of cervical microcarcinoma. Criteria for diagnosis have varied, with most authors using one or more of the following: (I) depth of invasion varying from I to 9 mm, with most authors using 5 mm or less; (2) blood or lymphatic space invasion; (3) confluency of invasive area; (4) mul­ticentricity of foci; (5) tumor volume of less than 420 or 500 mm'.

Definitions of confluency often are not uniform among separate investigators. Although most reports indicate that vascular or lymphatic involvement is rea­son to exclude a patient from Stage IA and place her in Stage IB, others have stated that up to 41.7% of cases serially step-sectioned may exhibit this phenomenon, and, therefore, question its importance.5 Symmonds6

thinks that multicentric foci, that is, areas of invasion found in multiple blocks, indicate a more serious dis­ease, and warrant inclusion of the patient under the category of Stage IB.

In an attempt to define this lesion better, in 1973, the Committee on Nomenclature of the Society of Gy­necologic Oncologists proposed that microinvasive car­cinoma be defined as a lesion which invades the cervical stroma to a depth of 3.0 mm or less below the base of the epithelium, and in which there is no evidence of lymph-vascular space invasion. This statement, how­ever, was not accepted unanimously.

A combined study by Averette, at the University of Miami, and Nelson, from Downstate Medical Center, and their colleagues, reported in 1976, noted no lymph node metastases among 162 patients treated by radical hysterectomy and pelvic lymphadenectomy when pen­etration was less than I mm without vascular or lym-

Carcinoma of cervix 171

phatic invasion, and none of the patients developed recurrent cancer. 7 Their literature review of 198 pa­tients with invasion to 5 mm revealed a 3.5% incidence of nodal metastases.

In 1983, Van Nagell et al.,8 at the University of Ken­tucky, published data on 177 patients with cervical squa­mous cell cancer that invaded the stroma to a depth of 5 mm or less. Accurate measurements were made with calibrated optics, and 84 patients were treated by radical hysterectomy and pelvic lymphadenectomy. Among 52 patients with stromal penetration of 3 mm or less and no capillary-lymphatic space involvement; none was found to have lymph node metastases. How­ever, three of 32 patients (9.4%) with stromal penetra­tion from 3.1 to 5 mm had lymph node metastases. Fifty-one patients were treated primarily by vaginal hysterectomy, and 42 by total abdominal hysterectomy. After therapy, all patients were followed from 2 to 14 years, and none was lost to follow-up. Among 145 pa­tients with lesions that invaded the stroma to a depth of 3.0 mm or less, only two developed recurrences, and both were intraepithelial. Among the 32 cases of car­cinoma that invaded the stroma 3.1 to 5 mm, there were three invasive recurrences and two deaths:

In discussing Dr. Van Nagell et al.'s article, Dr. Av­erette reported a patient with only 0.2 mm of stromal invasion and lymph-vascular spaces involvement who had grossly clinically positive pelvic lymph nodes.

I must emphasize that anyone who elects to treat invasive cervical cancer by simple surgical means must be as thorough in his or her evaluation of the histo­pathologic findings as were the authors. The 1979 na­tionwide study of microinvasive carcinoma conducted by the Gynecologic Oncology Group clearly demon­strated errors that can occur in diagnosis.9 Case reports and slides from 19 United States institutions, including Duke, were reviewed, and of 265 patients considered, 132 were rejected because there was no invasion in 99, invasion in excess of 5 mm in 18, inadequate cone bi­opsy in nine, and protocol violations in six. Clearly, if medical centers interested in the study of microinvasive carcinoma fail to make the proper diagnosis fifty per­cent of the time, special attention with appropriate con­sultation must be given to every woman who is assigned a diagnosis of Stage IA microinvasive carcinoma ..

I would like Dr. Creasman to comment on (I) the importance of cell type and grade of tumor as prog­nostic factors in this stage and (2) the length of follow­up in his cases. Since the FIGO committee is currently suggesting a volume definition, has he done any vol­umetric analysis of the Duke experience?

REFERENCES

l. American Joint Committee for Cancer Staging and End­Results Reporting.

2. Mestwerdt G. Probeexzision and Kolposkopie in der Fruhdiagnose des Portiokaszinomas. Zentralbl Gynaekol 1947;4:326.

3. NelsonJH, Averette HE, Richart RM. Dysplasia, carcinoma

Creasman et al.

in-situ, and early invasive cervical carcinoma. CA 1984; 34:306.

4. Lohe KJ. Diagnosis and treatment of microinvasive cervical cancer. Surgery in gynecological oncology, Boston: Mar­tinus Nijhoff Publishers, 1984:94.

5. Tarkington CN, Tweeddale DN, Roddicks JW. Microin­vasive carcinoma of the cervix. South Med J 1969;62: 1000.

6. Symmonds RE. Morbidity and complications of radical hys­terectomy with pelvic lymph node dissection. AM J 0BSTET GYNECOL l 966;94:663.

September 15, 1985 Am J Obstet Gynecol

7. Averette HE, Nelson JH Jr, Ng AB, et al. Diagnosis and management of microinvasive (Stage IA) carcinoma of the uterine cervix. Cancer 1976;38:414.

8. Van NagellJRJr, Greenwell N, Powell DF, et al. Microin­vasive carcinoma of the cervix. AM J 0BSTET GYNECOL 1983;145:982.

9. Sedlis A, Tsukada Y, Park R, et al. Microinvasive carcinoma of the uterine cervix: a clinical-pathologic study. AM J OB­STET GYNECOL 1979; 133:64.

Reconstructive pelvic operations for in vitro fertilization

Jairo E. Garcia, M.D., Howard W. Jones, Jr., M.D., Anibal A. Acosta, M.D., and Mason C. Andrews, M.D.

Norfolk, Virginia

Lysis of adhesions, bilateral salpingectomy, and ovarian suspension were carried out in 54 normal

ovulatory patients with long-standing infertility that was associated with severe pelvic adhesions after multiple liiparotomies for reimplantation of the fallopian tubes, salpingostomy, lysis of adhesions, or severe endometriosis. Ovulation was induced in 39 patients after laparotomy for in vitro fertilization, with the use of human menopausal gonadotropin, pure follicle-stimulating hormone, and human chorionic gonadotropin.

Oocyte retrieval by laparoscopy was accomplished in 37 patients, and embryo transfer was carried out in 36. Pregnancy after in vitro fertilization and embryo transfer occurred in 14 patients. Although severe

adhesions recurred in four patients, a significant improvement was obtained after the procedure in the others. (AM J OBSTET GYNECOL 1985;153:172-8.)

Key words: In vitro fertilization, reconstruction operations, adhesions, endometriosis

One of the general criteria for the selection of pa­tients for basic in vitro fertilization has been accessibility of the ovaries by laparoscopy.' Even though ultrasound­guided follicular aspiration seems to be emerging as an alternative to laparoscopy, a group of patients still exists in which a reliable ultrasound procedure is not feasible because of the presence of hydrosalpinx, bowel adhe­sions, ovaries prolapsed into the cul-de-sac, etc. 2

"

The present report describes the procedure and re­sults of reconstructive pelvic operations for in vitro fer­tilization at the Norfolk program.

Material and methods

A total of 54 patients was selected to undergo a pre­liminary laparotomy, prior to admission into our in vitro fertilization program, during January, 1980, and September, 1984.

From The Howard and Georgeanna Jones Institute for Reproductive Medicine, Eastern Virginia Medical School.

Presented by invitation at the Forty-seventh Annual Meeting of The South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, January 27-30, 1985.

Reprint requests: Dr. Jairo E. Garcia, Women's Hospital Fertility and /VF Center, Greater Baltimore Medical Center, 6701 North Charter St., Baltimore, MD 21204.

172

Table I. Indications for reconstructive pelvic operations for in vitro fertilization

Block ovaries <50% Ovaries available Dominant ovary unavailable Bilateral hydrosalpinx Ectopic pregnancy after in vitro fertilization

37 II 3 2 1

A routine screening laparoscopy carried out in those patients showed blocked ovaries and pelvis in 3 7 pa­tients, ovaries partially available (less than 50% each) in 11 patients, bilateral hydrosalpinx interfering with a reliable ultrasound procedure in two patients, and ectopic pregnancies (after in vitro fertilization) associ­ated with severe pelvic adhesions in one patient. Finally, although three patients had two ovaries, one of the ovaries was covered by adhesions, and it was this one which was always the so-called dominant ovary when the patients were stimulated (Table 1).

Pelvic adhesions were classified as severe (thick and vascular), moderate, and mild (filmy and avascular), in 44, six, and four patients, respectively.

Procedures. All patients underwent laparotomy un-