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Positive Cytologic Findings in Preclinical Squamous Cell Epithelioma of the Uterine Cervix: Surgical Management
Positive Cytologic Findings in Preclinical Squamous Cell Epithelioma of the Uterine Cervix: Surgical Management KENNETH E. WADDELL, M.D. JOHN S. WELCH, M.D. DAVID G. DECKER, M.D.
THE INTRODUCTION of cytologic examination for the detection of carcinoma of the cervix as a routine part of the gynecologic examination and the institution of extensive screening programs have made almost complete control of carcinoma of the cervix a real possibility. If such a screening program is to succeed, a method for the proper evaluation of a patient who is found to have abnormal cells is an absolute necessity. The patient found by cytodetection methods to have abnormal cervical cells poses problems both in diagnosis and treatment. While adequate treatment is of utmost importance, it is also essential to guard against overtreatment. The effects of overtreatment in these women, who are usually young, may be almost as devastating as continuance of the primary disease. It is as difficult to justify morally the creation of endocrine cripples from routine irradiation in full-cancer dosage of carcinoma in situ of the uterine cervix as it is to say that hysterectomy or radical hysterectomy is the sole surgical approach to this disease. What is needed is an intelligent, modern, informed attitude on the part of the clinician so that treatment may be quantitated to the circumstances. The investigative routine now in use at the Clinic is presented in this paper, together with a general background of information which has led to the adoption of the various steps. The goal, of course, is control of cervical cancer, preferably in a preclinical phase. CYTODETECTION
The cervical smear is an accepted adjunct to the early diagnosis of cervical carcinoma. There are many techniques for sampling the cervical
1025
1026
KENNETH
E. WADDELL, JOHN S. WELCH, DAVID G.
DECKER
cells, including aspiration of the cervical canal or vaginal pool, scraping of the cervix with a wooden spatula or a cotton swab, or imprinting of the cervix against a slide. The method in use at the Clinic at the present is as follows: Under direct vision and strong light, with a warm waterlubricated speculum, an Ayre wooden spatula is inserted into the cervix and vigorously rotated to remove, if possible, cells at the squamocolumnar junction. The material gathered on the spatula is spread evenly on a clean glass slide and fixed immediately without drying in 95 per cent ethanol. Most squamous cell carcinomas seem to start in the region of the squamocolumnar junction, and the pathologists responsible for our cervical cytologic program think that the technique just described, if meticulously followed, will furnish, on a single slide, representative cells to allow the pathologist to suspect cervical carcinoma with a high degree of accuracy. The responsibility for the staining, screening, and interpreting of the smears belongs, of course, to a cytologist who is preferably a gynecologically oriented pathologist. At the Clinic the classification of cervical cytologic smears used is that suggested by Papanicolaou, as follows: Smears classed as group 1 show no abnormal cells; group 2 smears contain atypical, probably benign cells; group 3, suspicious-appearing cells; group 4, cells that are probably malignant, and group 5, malignant cells. It is important to recognize the fact that the words "suspicious-appearing smear" do not constitute a diagnosis, and further procedures are needed to establish the diagnosis. The pathologist's information of necessity is limited in the individual case, as many clinical data, treatment history, and other details which might alter the significance of the predominant cytologic type are not known to him. Actually, at this phase, the pathologist acts as an adviser; full diagnosis awaits an adequate cervical specimen. Properly regarded and properly used, we have come to appreciate the usefulness of the investigation of the cervical smear and its high degree of accuracy. The accuracy of initial cervical smears at the Clinic, as reported by Soule and Dahlin, when compared with the results of tissue biopsy only in the same cases, was as follows: Carcinoma was found in 99 per cent of the cases in which findings in the smears were those of group 5; in 88 per cent of cases in which the smears were of group 4, and in 53 per cent in which they were of group 3. Soule and Dahlin also reported that of all women who were fully investigated from 1954 through 1957 because of "some atypicality in the cervical smear," 70 per cent were found to have carcinoma. lo From the preceding figures, it is obvious that any suspicious-appearing or abnormal smears must be regarded seriously and the cervix investigated fully by other procedures to establish a definite diagnosis. Education of the public to appreciate the usefulness of periodic and repeated smears is of definite value.
Positive Cytologic Findings in the Uterine Cervix
1027
We believe that false negative smears are relatively unusual, although it is difficult to determine the true accuracy in any practice. Common causes of false negative smears are improper technique in obtaining the smear, faulty preservation or staining, and errors in interpretation. INVESTIGATIVE PROCEDURES
Punch biopsy with or without previous staining with compound solution of iodine (Lugol's solution) is commonly used. One should remember, however, that the pathologist can give only a limited report from a punch biopsy and that the report is indicative only of the tissue examined. Harris and Peterson have shown that 45.5 per cent of their punch biopsies were misleading. If a punch biopsy is reported to show malignancy of a preclinical type, it must be corroborated and clarified by careful removal, with a cold knife, of a cone of the cervix and microscopic examination of the tissue to ascertain the full extent of the lesion and to plan intelligent treatment. Indeed, it is important in the majority of instances to avoid punch biopsy and other cervical trauma, and to rely on a full and adequate specimen for pathologic investigation. It is our current practice, therefore, to recommend that any patient who has a group 3, 4, or 5 cervical smear have an adequate cold knife conization of the cervix. This procedure affords a maximal effort toward an accurate pathologic diagnosis with a minimal risk of gaining a false or incomplete impression of the real cervical disease. With the diagnostic accuracy afforded by an interested pathologist familiar with the fresh-frozen section technique, all essential information may be obtained quickly, and the gynecologist can proceed with the indicated treatment without delay, and without a second trip to the operating room or a second anesthetic. TECHNIQUE OF COLD KNIFE CONIZATION
When a patient whose cervical smear has been found positive for cancer cells is being prepared for cervical conization, particular care should be taken during vaginal preparation so that the cervical epithelium is not traumatized, rubbed away, or destroyed. The tenaculum is applied to the cervix with care also, ,vell away from the squamocolumnar junction and the area to be coned. The cervix is then stained with a compound solution of iodine, for it is important to include all areas in the cervical cone that do not stain. The surgeon should start well out on the cervix. With the point of the knife angled in, he should go well up in the cervical canal; thus the apex of the cone will include the squamocolumnar junction. The specimen should be handled carefully so that the epithelium is not abraded. A typical cone is shown in Figure 1. The cervical cone is sent to the pathology laboratory
1028
KENNETH
E.
WADDELL, JOHN
S.
WELCH, DAVID
G.
DECKER
Fig. 1. a, Typical cervical cone. b, The method of cutting the cervical cone for frozen section.
where at least 12 sections are taken from it at various sites. From study of these sections it is almost always possible to answer two urgent questions: (1) Is cancer present? (2) What is its extent? Further cellular information can be gained from endometrial and endocervical tissue removed by dilatation and curettement which should always follow the conization to prevent cervical epithelial abrasion. After conization in benign conditions or after definitive conization, bleeding may be controlled with cauterization or suturing. A light pack is inserted in the vagina for 48 hours. Periodic office dilatation of the cervix during the ensuing three months prevents possible cervical stenosis. CARCINOMA IN SITU
Carcinoma in situ, also known as stage 0 carcinoma of the cervix or intra-epithelial carcinoma, may be defined as malignant alteration of the cervical epithelial cells, without invasion, that is, with the basal membrane intact. This lesion has the potential to invade, in time, although certainly no one can say that each carcinoma in situ surely leads to invasive disease. It seems reasonable that local destructive measures should suffice for treatment of a lesion limited by definition and by exact pathologic delineation to the epithelial layer of the cervix. The problem, however, is not this simple because the lesion tends to spread superficially and
Positive Cytologic Findings in the Uterine Cervix
1029
involve the adjacent vagina and endocervical canal and to dip into and fill the endocervical glands. Also the lesion cannot be considered preinvasive until the entire specimen has been examined. In order for our pathologist to render an opinion, we believe it is essential to deliver to him a freshly removed cervical cone which contains an undisturbed squamocolumnar junction together with an adequate margin of tissue. A minimum of 12 blocks of tissue are examined, using the fresh-frozen technique (a process consuming five to 15 minutes), and during this period it is not unusual for the gynecologist to enter the laboratory to consult and to examine the sections just cut. This joint effort has led at times to a fuller understanding of the individual case and typifies the shared responsibility of the gynecologist and pathologist involved in the final microscopic diagnosis and surgical decision. Typified too are the mutual trust and understanding which each pathologist and gynecologist utilizes in the intelligent treatment, without overtreatment, of the early malignant lesions of the cervix. If the diagnosis of carcinoma in situ of the cervix is made, the question of proper treatment arises. Most authors favor total hysterectomy.!' 2,6,8,9,11 We, too, consider vaginal or abdominal hysterectomy with preservation of the ovaries the treatment of choice. It should be stressed that if this procedure is performed, careful examination of the vaginal cuff by the pathologist at the time of operation is of utmost importance. If the cuff is involved,7 it is important to ascertain that the entire lesion is removed. Several cases of reported recurrence of carcinoma in situ3 , 7 may have been due to incomplete removal at the time of the initial operation. We agree with Kasdon that more radical procedures, such as the Wertheim operation, pelvic lymphadenectomy, the Schauta procedure, or radium and x-ray therapy, are not considered applicable in the usual case of carcinoma in situ. To us this is an early lesion which has not been proved to be metastatic. Certainly it is important to conserve ovarian function in women who are in the younger age group. The sins of overtreatment, on occasion, may be as terrifying as the sequelae of inadequate treatment. In certain instances a less extensive operation is the reasonable choice. This is important in young women who have not completed their families or in a woman who is pregnant. Such patients when cervical smears show abnormalities must have an adequate cone removed, and the multiple sections should be examined by an experienced pathologist to outline the limits of the lesion. If a less radical procedure than hysterectomy is contemplated as definitive treatment, certain criteria should be met: (1) The patient must be intelligent enough to understand the problem and must be willing to share the risk. (2) The patient must be willing and able to have periodic examinations and cervical smears. (3) Pregnancy is present or contemplated in the near future. (4) The
1030
KENNETH
E. WADDELL, JOHN S. WELCH,
DAVID
G.
DECKER
cervical conization must remove the malignant area with a comfortable margin. INVASIVE CARCINOMA
It is not the purpose of this paper to consider lesions beyond a very early stage I, as we are primarily directing attention to the cancer found by cervical smear without an obvious lesion. Complete escape from this problem is not possible, however, since on occasion a tiny area of microscopic invasion is found after conization, or more alarmingly, reported after hysterectomy. If further examinations of tissue following hysterectomy reveal a small area of microscopic invasion, we still believe that treatment has been adequate. Schmitz reported on a group of these patients who were treated by hysterectomy only. None had evidence of recurrence. One of us (Welch), in reviewing the pathologic findings after radical abdominal hysterectomy and excision of lymph nodes carried out at the Clinic in patients who had invasion of no greater than microscopic proportions, found no instances of involvement of the lymph nodes. So interesting is this group that a special study is under way. With frank invasion of more than half of the width of a low-power field, radical abdominal hysterectomy with excision of lymph nodes is the surgical treatment of choice in the majority of these cases. Excellent results may be expected also from adequate radiation therapy, particularly in physiologically old women, obese women, or the patient for whom the surgical risk is high for any other reason. SUMMARY
A practical and effective method of managing a patient who is discovered to have an abnormal uterine cervical smear has been presented. Cytologic study of cervical smears never results in a complete diagnosis of cervical cancer, nor does it always rule out cancer, even though the smear is negative. The finding of a suspicious-appearing smear must be followed by another adequate diagnostic procedure. Only on examination of adequate cervical tissue can a pathologist make a complete diagnosis. A plea is made also for adequate but not excessive treatment of carcinoma in situ. The complications of overtreatment in the form of increased morbidity and loss of ovarian function must be avoided in these young women. REFERENCES 1. Beecham, C. T. and Emich, J. P., Jr.: Carcinoma In Situ. Obst. & Gynec. 13: 653-656 (June) 1959.
Positive Cytologic Findings in the Uterine Cervix
1031
2. Carter, B., Cuyler, W. K., Kaufmann, Louise A., Thomas, W. L., Creadick, R. N., Parker, R. T., Peete, C. H., Jr. and Cherny, W. B.: Clinical Problems in Stage 0 (lntraepithelial) Cancer of Cervix. Am. J. Obst. & Gynec. 71: 634650 (March) 1956. 3. Graham, J. B. and Meigs, J. V.: Recurrence of Tumor After Total Hysterectomy for Carcinoma In Situ. Am. J. Obst. & Gynec. 64: 1159-1162 (Nov.) 1952. 4. Harris, J. H. and Peterson, P.: Cold-Knife Conization and Residual Preinvasive Carcinoma of Cervix. Am. J. Obst. & Gynec. 70: 1092-1099 (Nov.) 1955. 5. Kasdon, S. C.: The Laboratory, the Surgeon and In Situ Cancer of Cervix. Obst. & Gynec. 13: 576-590 (May) 1959. 6. Kasdon, S. C. and Udin, M.: The Management of In Situ Cervical Cancer. Bull. Tufts-New England M. Center 4: 122-131 (July-Dec.) 1958. 7. Mussey, Elizabeth and Soule, E. H.: Carcinoma In Situ of Cervix: Clinical Review of 842 Cases. Am. J. Obst. & Gynec. 77: 957-972 (May) 1959. 8. Peterson, Olaf: Spontaneous Course of Cervical Precancerous Conditions. Am. J. Obst. & Gynec. 72: 1063-1071 (Nov.) 1956. 9. Schmitz, H. E.: Opportunity and Cervix Cancer: Third Marlow Lecture. Am. J. Obst. & Gynec. 71: 1283-1290 (June) 1956. 10. Soule, E. H. and Dahlin, D. C.: Cytodetection of Preclinical Carcinoma of Cervix: 10 Years' Experience with Initial Screening and Repeat Cervical Smears. Proc. Staff. Meet., Mayo Clin. 34: 1-8 (Jan. 7) 1959. 11. Te Linde, R. W., Galvin, G. A. and Jones, H. W., Jr.: Therapy of Carcinoma In Situ. Am. J. Obst. & Gynec. 74: 792-799 (Oct.) 1957. 12. Welch, J. S.: Unpublished data.
THE INTRODUCTION of cytologic examination for the detection of carcinoma of the cervix as a routine part of the gynecologic examination and the institution of extensive screening programs have made almost complete control of carcinoma of the cervix a real possibility. If such a screening program is to succeed, a method for the proper evaluation of a patient who is found to have abnormal cells is an absolute necessity. The patient found by cytodetection methods to have abnormal cervical cells poses problems both in diagnosis and treatment. While adequate treatment is of utmost importance, it is also essential to guard against overtreatment. The effects of overtreatment in these women, who are usually young, may be almost as devastating as continuance of the primary disease. It is as difficult to justify morally the creation of endocrine cripples from routine irradiation in full-cancer dosage of carcinoma in situ of the uterine cervix as it is to say that hysterectomy or radical hysterectomy is the sole surgical approach to this disease. What is needed is an intelligent, modern, informed attitude on the part of the clinician so that treatment may be quantitated to the circumstances. The investigative routine now in use at the Clinic is presented in this paper, together with a general background of information which has led to the adoption of the various steps. The goal, of course, is control of cervical cancer, preferably in a preclinical phase. CYTODETECTION
The cervical smear is an accepted adjunct to the early diagnosis of cervical carcinoma. There are many techniques for sampling the cervical
1025
1026
KENNETH
E. WADDELL, JOHN S. WELCH, DAVID G.
DECKER
cells, including aspiration of the cervical canal or vaginal pool, scraping of the cervix with a wooden spatula or a cotton swab, or imprinting of the cervix against a slide. The method in use at the Clinic at the present is as follows: Under direct vision and strong light, with a warm waterlubricated speculum, an Ayre wooden spatula is inserted into the cervix and vigorously rotated to remove, if possible, cells at the squamocolumnar junction. The material gathered on the spatula is spread evenly on a clean glass slide and fixed immediately without drying in 95 per cent ethanol. Most squamous cell carcinomas seem to start in the region of the squamocolumnar junction, and the pathologists responsible for our cervical cytologic program think that the technique just described, if meticulously followed, will furnish, on a single slide, representative cells to allow the pathologist to suspect cervical carcinoma with a high degree of accuracy. The responsibility for the staining, screening, and interpreting of the smears belongs, of course, to a cytologist who is preferably a gynecologically oriented pathologist. At the Clinic the classification of cervical cytologic smears used is that suggested by Papanicolaou, as follows: Smears classed as group 1 show no abnormal cells; group 2 smears contain atypical, probably benign cells; group 3, suspicious-appearing cells; group 4, cells that are probably malignant, and group 5, malignant cells. It is important to recognize the fact that the words "suspicious-appearing smear" do not constitute a diagnosis, and further procedures are needed to establish the diagnosis. The pathologist's information of necessity is limited in the individual case, as many clinical data, treatment history, and other details which might alter the significance of the predominant cytologic type are not known to him. Actually, at this phase, the pathologist acts as an adviser; full diagnosis awaits an adequate cervical specimen. Properly regarded and properly used, we have come to appreciate the usefulness of the investigation of the cervical smear and its high degree of accuracy. The accuracy of initial cervical smears at the Clinic, as reported by Soule and Dahlin, when compared with the results of tissue biopsy only in the same cases, was as follows: Carcinoma was found in 99 per cent of the cases in which findings in the smears were those of group 5; in 88 per cent of cases in which the smears were of group 4, and in 53 per cent in which they were of group 3. Soule and Dahlin also reported that of all women who were fully investigated from 1954 through 1957 because of "some atypicality in the cervical smear," 70 per cent were found to have carcinoma. lo From the preceding figures, it is obvious that any suspicious-appearing or abnormal smears must be regarded seriously and the cervix investigated fully by other procedures to establish a definite diagnosis. Education of the public to appreciate the usefulness of periodic and repeated smears is of definite value.
Positive Cytologic Findings in the Uterine Cervix
1027
We believe that false negative smears are relatively unusual, although it is difficult to determine the true accuracy in any practice. Common causes of false negative smears are improper technique in obtaining the smear, faulty preservation or staining, and errors in interpretation. INVESTIGATIVE PROCEDURES
Punch biopsy with or without previous staining with compound solution of iodine (Lugol's solution) is commonly used. One should remember, however, that the pathologist can give only a limited report from a punch biopsy and that the report is indicative only of the tissue examined. Harris and Peterson have shown that 45.5 per cent of their punch biopsies were misleading. If a punch biopsy is reported to show malignancy of a preclinical type, it must be corroborated and clarified by careful removal, with a cold knife, of a cone of the cervix and microscopic examination of the tissue to ascertain the full extent of the lesion and to plan intelligent treatment. Indeed, it is important in the majority of instances to avoid punch biopsy and other cervical trauma, and to rely on a full and adequate specimen for pathologic investigation. It is our current practice, therefore, to recommend that any patient who has a group 3, 4, or 5 cervical smear have an adequate cold knife conization of the cervix. This procedure affords a maximal effort toward an accurate pathologic diagnosis with a minimal risk of gaining a false or incomplete impression of the real cervical disease. With the diagnostic accuracy afforded by an interested pathologist familiar with the fresh-frozen section technique, all essential information may be obtained quickly, and the gynecologist can proceed with the indicated treatment without delay, and without a second trip to the operating room or a second anesthetic. TECHNIQUE OF COLD KNIFE CONIZATION
When a patient whose cervical smear has been found positive for cancer cells is being prepared for cervical conization, particular care should be taken during vaginal preparation so that the cervical epithelium is not traumatized, rubbed away, or destroyed. The tenaculum is applied to the cervix with care also, ,vell away from the squamocolumnar junction and the area to be coned. The cervix is then stained with a compound solution of iodine, for it is important to include all areas in the cervical cone that do not stain. The surgeon should start well out on the cervix. With the point of the knife angled in, he should go well up in the cervical canal; thus the apex of the cone will include the squamocolumnar junction. The specimen should be handled carefully so that the epithelium is not abraded. A typical cone is shown in Figure 1. The cervical cone is sent to the pathology laboratory
1028
KENNETH
E.
WADDELL, JOHN
S.
WELCH, DAVID
G.
DECKER
Fig. 1. a, Typical cervical cone. b, The method of cutting the cervical cone for frozen section.
where at least 12 sections are taken from it at various sites. From study of these sections it is almost always possible to answer two urgent questions: (1) Is cancer present? (2) What is its extent? Further cellular information can be gained from endometrial and endocervical tissue removed by dilatation and curettement which should always follow the conization to prevent cervical epithelial abrasion. After conization in benign conditions or after definitive conization, bleeding may be controlled with cauterization or suturing. A light pack is inserted in the vagina for 48 hours. Periodic office dilatation of the cervix during the ensuing three months prevents possible cervical stenosis. CARCINOMA IN SITU
Carcinoma in situ, also known as stage 0 carcinoma of the cervix or intra-epithelial carcinoma, may be defined as malignant alteration of the cervical epithelial cells, without invasion, that is, with the basal membrane intact. This lesion has the potential to invade, in time, although certainly no one can say that each carcinoma in situ surely leads to invasive disease. It seems reasonable that local destructive measures should suffice for treatment of a lesion limited by definition and by exact pathologic delineation to the epithelial layer of the cervix. The problem, however, is not this simple because the lesion tends to spread superficially and
Positive Cytologic Findings in the Uterine Cervix
1029
involve the adjacent vagina and endocervical canal and to dip into and fill the endocervical glands. Also the lesion cannot be considered preinvasive until the entire specimen has been examined. In order for our pathologist to render an opinion, we believe it is essential to deliver to him a freshly removed cervical cone which contains an undisturbed squamocolumnar junction together with an adequate margin of tissue. A minimum of 12 blocks of tissue are examined, using the fresh-frozen technique (a process consuming five to 15 minutes), and during this period it is not unusual for the gynecologist to enter the laboratory to consult and to examine the sections just cut. This joint effort has led at times to a fuller understanding of the individual case and typifies the shared responsibility of the gynecologist and pathologist involved in the final microscopic diagnosis and surgical decision. Typified too are the mutual trust and understanding which each pathologist and gynecologist utilizes in the intelligent treatment, without overtreatment, of the early malignant lesions of the cervix. If the diagnosis of carcinoma in situ of the cervix is made, the question of proper treatment arises. Most authors favor total hysterectomy.!' 2,6,8,9,11 We, too, consider vaginal or abdominal hysterectomy with preservation of the ovaries the treatment of choice. It should be stressed that if this procedure is performed, careful examination of the vaginal cuff by the pathologist at the time of operation is of utmost importance. If the cuff is involved,7 it is important to ascertain that the entire lesion is removed. Several cases of reported recurrence of carcinoma in situ3 , 7 may have been due to incomplete removal at the time of the initial operation. We agree with Kasdon that more radical procedures, such as the Wertheim operation, pelvic lymphadenectomy, the Schauta procedure, or radium and x-ray therapy, are not considered applicable in the usual case of carcinoma in situ. To us this is an early lesion which has not been proved to be metastatic. Certainly it is important to conserve ovarian function in women who are in the younger age group. The sins of overtreatment, on occasion, may be as terrifying as the sequelae of inadequate treatment. In certain instances a less extensive operation is the reasonable choice. This is important in young women who have not completed their families or in a woman who is pregnant. Such patients when cervical smears show abnormalities must have an adequate cone removed, and the multiple sections should be examined by an experienced pathologist to outline the limits of the lesion. If a less radical procedure than hysterectomy is contemplated as definitive treatment, certain criteria should be met: (1) The patient must be intelligent enough to understand the problem and must be willing to share the risk. (2) The patient must be willing and able to have periodic examinations and cervical smears. (3) Pregnancy is present or contemplated in the near future. (4) The
1030
KENNETH
E. WADDELL, JOHN S. WELCH,
DAVID
G.
DECKER
cervical conization must remove the malignant area with a comfortable margin. INVASIVE CARCINOMA
It is not the purpose of this paper to consider lesions beyond a very early stage I, as we are primarily directing attention to the cancer found by cervical smear without an obvious lesion. Complete escape from this problem is not possible, however, since on occasion a tiny area of microscopic invasion is found after conization, or more alarmingly, reported after hysterectomy. If further examinations of tissue following hysterectomy reveal a small area of microscopic invasion, we still believe that treatment has been adequate. Schmitz reported on a group of these patients who were treated by hysterectomy only. None had evidence of recurrence. One of us (Welch), in reviewing the pathologic findings after radical abdominal hysterectomy and excision of lymph nodes carried out at the Clinic in patients who had invasion of no greater than microscopic proportions, found no instances of involvement of the lymph nodes. So interesting is this group that a special study is under way. With frank invasion of more than half of the width of a low-power field, radical abdominal hysterectomy with excision of lymph nodes is the surgical treatment of choice in the majority of these cases. Excellent results may be expected also from adequate radiation therapy, particularly in physiologically old women, obese women, or the patient for whom the surgical risk is high for any other reason. SUMMARY
A practical and effective method of managing a patient who is discovered to have an abnormal uterine cervical smear has been presented. Cytologic study of cervical smears never results in a complete diagnosis of cervical cancer, nor does it always rule out cancer, even though the smear is negative. The finding of a suspicious-appearing smear must be followed by another adequate diagnostic procedure. Only on examination of adequate cervical tissue can a pathologist make a complete diagnosis. A plea is made also for adequate but not excessive treatment of carcinoma in situ. The complications of overtreatment in the form of increased morbidity and loss of ovarian function must be avoided in these young women. REFERENCES 1. Beecham, C. T. and Emich, J. P., Jr.: Carcinoma In Situ. Obst. & Gynec. 13: 653-656 (June) 1959.
Positive Cytologic Findings in the Uterine Cervix
1031
2. Carter, B., Cuyler, W. K., Kaufmann, Louise A., Thomas, W. L., Creadick, R. N., Parker, R. T., Peete, C. H., Jr. and Cherny, W. B.: Clinical Problems in Stage 0 (lntraepithelial) Cancer of Cervix. Am. J. Obst. & Gynec. 71: 634650 (March) 1956. 3. Graham, J. B. and Meigs, J. V.: Recurrence of Tumor After Total Hysterectomy for Carcinoma In Situ. Am. J. Obst. & Gynec. 64: 1159-1162 (Nov.) 1952. 4. Harris, J. H. and Peterson, P.: Cold-Knife Conization and Residual Preinvasive Carcinoma of Cervix. Am. J. Obst. & Gynec. 70: 1092-1099 (Nov.) 1955. 5. Kasdon, S. C.: The Laboratory, the Surgeon and In Situ Cancer of Cervix. Obst. & Gynec. 13: 576-590 (May) 1959. 6. Kasdon, S. C. and Udin, M.: The Management of In Situ Cervical Cancer. Bull. Tufts-New England M. Center 4: 122-131 (July-Dec.) 1958. 7. Mussey, Elizabeth and Soule, E. H.: Carcinoma In Situ of Cervix: Clinical Review of 842 Cases. Am. J. Obst. & Gynec. 77: 957-972 (May) 1959. 8. Peterson, Olaf: Spontaneous Course of Cervical Precancerous Conditions. Am. J. Obst. & Gynec. 72: 1063-1071 (Nov.) 1956. 9. Schmitz, H. E.: Opportunity and Cervix Cancer: Third Marlow Lecture. Am. J. Obst. & Gynec. 71: 1283-1290 (June) 1956. 10. Soule, E. H. and Dahlin, D. C.: Cytodetection of Preclinical Carcinoma of Cervix: 10 Years' Experience with Initial Screening and Repeat Cervical Smears. Proc. Staff. Meet., Mayo Clin. 34: 1-8 (Jan. 7) 1959. 11. Te Linde, R. W., Galvin, G. A. and Jones, H. W., Jr.: Therapy of Carcinoma In Situ. Am. J. Obst. & Gynec. 74: 792-799 (Oct.) 1957. 12. Welch, J. S.: Unpublished data.