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FW: Dysplasia questionFrom: Elrod Darryl G MAJ 48 MDOS/SGOBO (Darryl.elrod@LAKENHEATH.AF.MIL)Tue Apr 12 17:59:54 2005
I am emailing this scenario for one of my partners. He wanted to know what "my group's" thoughts were on the issue. For the record, I suggested doing another cone. I have come across another difficult dysplasia case. 45 y/o female with HGSIL pap, inadequate colpo, + ecc with CIN II. I did a cone on her last week (1.5 cm depth) which went well. Her pathology came back CIN III with extensive glandular involvement, negative endo and ectocervical margins but + ECC. I went and looked at the slides with Dr. The dysplasia is infiltrating the glands a lot but the margins are well clear. The ECC is mostly B9 but there is 1 fleck of high grade dysplasia in it. I don't know how I could have contaminated the ECC but it is mostly B9. I got all the articles I could find. There is a Koback (Green 1995, The role of endocervical curettage at cervical conizaton for high-grade dysplasia) seems to be the best. They report 40% residual dysplasia with + ECC and neg margins. All the cases of occult cancer were in patients with + ECC and + endocervical margins. The Kobak article recommends a repeat CKC then Hyst if both + ECC and + margins but doesn't say if just + ECC. My partners are divided - 1 said do another CKC and another said do a hyst. Being a minimalist I wanted to offer her a f/u pap + ecc in 3 months with hyst if still positive. My rational is 60% of + ecc have no residual dz. Given her volume of dysplasia on the ECC I think her odds are even better. Having looked at the specimens I really think the + ECC looks like a contaminant since it is only a fleck - but I can't know for sure. I would also like to offer her a hyst now due to the risk of residual dysplasia and the + ecc. I realize there is a small risk she will have occult cancer and then could need a rad hyst. And that is the reason to repeat the cone before the hyst. It just seems morbid to do cone - cone - hyst for this lady after looking at the specimen and the little fleck making my ecc positive. Any words of wisdom? Thanks, Glen
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