Positive Margins After Conization and Risk of Persistent Lesion
abstract & commentary
Synopsis: Cytology and colposcopy follow-up in cases of positive conization margins may help to establish justification for the choice of reoperation, thereby limiting morbidity following repeated surgery.
Source: Narducci F, et al. Gynecol Oncol 2000;76: 311-314.
Narducci and associates investigated a method to reduce the frequency of uterine reoperation with no persistent lesion and to identify factors predictive of persistent or recurrent lesions. Of 505 conizations performed by the same surgeon, 71 had positive margins (average patient age = 35.7 ± 7.7 years). The patients underwent either immediate reoperation or monitoring with a Pap smear and colposcopy. Histologic assessment of the cervical cone after conization showed positive margins in 14.1% of cases (endocervical and exocervical margins affected in 50 of 505 [9.9%] and 21 of 505 [4.2%] cases, respectively). Of 59 of these patients (83.1%) who underwent follow-up monitoring over an average of 35.2 months, 12 patients (average age = 40.8 ± 6.4 years) underwent immediate hysterectomy and 47 (average age = 34.0 ± 7.4 years) benefited from monitoring first (secondary discovery of 19 persistent lesions within 6 months and 9 recurrences within 18 months on average [range, 8.8-48 months]). Of the nine patients with recurrent lesions, seven underwent reintervention and two monitoring. Of the 19 patients with persistent lesions, 18 underwent reintervention and one monitoring. Normal histology was observed in 29.4% of patients undergoing secondary reoperation for an abnormal smear compared with 66.7% of patients undergoing immediate reoperation (P = 0.04). Severity of lesion and age of patients could not be used to predict the incidence of a persistent or recurrent lesion. Seventy-nine percent of conizations had positive endocervical margins in patients with a recurrent or persistent lesion compared with 48% in patients with normal follow-up (P = 0.03). Narducci et al conclude that cytology and colposcopy follow-up in cases of positive conization margins may help to establish justification for the choice of reoperation, thereby limiting morbidity following repeated surgery.
Comment by David M. Gershenson, MD
What is the appropriate management for a patient with positive margins of a conization specimen? As highlighted in this article from France, there is no single management option. In general, options include either reoperation—repeat conization or, more often, hysterectomy—or close follow-up with Pap smears and colposcopy. There are no definite criteria for selecting one course over another. Factors that should be considered include the type of positive margin (cervical intraepithelial neoplasia [CIN] vs microinvasion), extensiveness of positive margin (focal vs multifocal or diffuse), patient age, patient reliability for follow-up, and the patient’s desire for future fertility and attitude about reoperation vs. follow-up. In this article, 10 of the 12 patients who underwent immediate reoperation (an average of 2.8 months after the initial conization) had microinvasion on the initial conization specimen; most were older, and all underwent hysterectomy. Not unexpectedly, in 67% of the subsequent specimens, there was no residual disease. For the patients who were followed after initial conization, Narducci et al found no difference between patients with normal follow-up and those who had a recurrent or persistent lesion with respect to age or severity of lesion. Other investigators have found age, lesion severity, and smoking to be predictors for recurrence. In conclusion, I agree with Narducci et al that close follow-up is preferable to reoperation, except in cases of microinvasion at the margins, adenocarcinoma in situ, poor compliance with follow-up, or women who have completed childbearing and who desire definitive surgery.
Which of the following circumstances would be the least indicative for reoperation (repeat conization or hysterectomy) rather than follow-up after conization with positive margins?
a. Microinvasion at the margin.
b. Poor compliance with follow-up.
c. Adenocarcinoma in situ at the margin.
d. CIN 3 at the margin.
e. Completion of childbearing.
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