Surgery for gynecologic cancer

Surgery is an integral part of staging procedures for ovarian, endometrial, and vulvar cancers, with a move toward surgicopathologic rather than clinical staging in cervical cancer. Morbidity can be reduced without compromising patient cure by individualizing surgery for patients with early vulvar cancer, and reproductive potential can be maintained in some women with early ovarian cancer. The place of prophylactic oophorectomy and primary and secondary surgery in ovarian cancer remain controversial and await prospective study. Recent developments in laparoscopic techniques have been applied to a number of problems in gynecologic cancer surgery, and the feasibility of laparoscopic lymphadenectomy and radical pelvic surgery has been demonstrated. Care must be taken, however, to ensure that the tenets of surgical oncology are not sacrificed in order to offer minimal-access surgery to women with gynecologic cancer.     

Pelvic exenteration in gynecologic oncology: Experience at the Mount Sinai Center, 1975-1992

Thirty-nine patients underwent pelvic exenteration for gynecologic malignancies at The Mount Sinai Medical Center between 1975 and 1992. Surgical techniques, morbidity, survival, and other variables for patients so treated in two periods, 1975-1984 and 1985-1992, were compared. The primary cancer included squamous cell carcinoma of the cervix, 27; adenocarcinoma of the cervix, 1; squamous cell carcinoma of the vagina, 4; adenocarcinoma of the endometrium, 4; squamous cell carcinoma of the vulva, 2; and adenocarcinoma of the rectum, 1. Median survival was 23.1 months, with a median follow-up of 18 months. Survival was significantly related to status of the lymph nodes (p 0.0004) and surgical margins (p 0.0038). There were two postoperative mortalities, one due to pulmonary embolus and another to myocardial infarction. The ability in the second period analyzed, 1985-1992, to integrate a continent urinary reservoir and supralevator exenteration without colostomy yet not induce increased morbidity or decreased survival, has not been previously reported.     

Persisting cyclic ovarian activity in cervical cancer after surgical transposition of the ovaries and pelvic irradiation

The effect of surgical transposition of the ovaries on gonadal function was investigated in ten young women with carcinoma of the uterine cervix, stages I and II. Gonadotrophin-, oestradiol- and progesterone-levels were determined before and during pelvic irradiation. A control group consisted of seven patients with cervical cancer who did not undergo ovaria transposition. In the control group gonadotrophins began to rise after radiation doses of 560-2400 rad (FSH) and 1130-2600 rad (LH) respectively. The excessive secretion was not seen in patients who had ovarian lifting. Ovulatory cycles occurred during or after pelvic irradiation in seven women of the study group, either spontaneously or induced by clomiphene treatment. This indicates that transposition preceding radiotherapy is an effective means of preserving ovarian secretion in young women in whom malignancies of the pelvic region demand irradiation.     

Gynecologic cancer and surgical infectious morbidity

The purpose of this study was to evaluate retrospectively the surgical infectious morbidity in gynecologic cancer. We examined 1,180 gynecologic oncology patients: 608 women had carcinoma of the endometrium, 510 cancer of the cervix, 48 ovarian cancer and 14 vulvar cancer. Thirty-five (6%), 92 (18%), 7 (15%) and 2 (14%) were complicated by infection in carcinoma of the endometrium, cancer of the cervix, ovarian cancer and vulvar cancer, respectively. Our conclusion is that the highest surgical infectious morbidity occurs in patients with cervical cancer and the lowest in patients with carcinoma of the endometrium.     

Ovarian metastases from cervical carcinomas other than pure adenocarcinomas. A report of 12 cases

Twelve cases of ovarian metastases from cervical carcinomas, most with clinical manifestations of ovarian involvement, are reported. The patients were 23-73 years of age (average, 43 years). The ovarian and cervical tumors were synchronous in eight patients; in three, ovarian tumors were discovered 10 months, 2.5, and 3 years after the detection of a cervical neoplasm. In one patient, the cervical tumor was not discovered until autopsy 7 months after presentation. Four patients had abdominal swelling or distention, three had vaginal bleeding, three had an abnormal Papanicolaou smear, and two had masses discovered during pelvic examination. The ovarian tumors, six of which were bilateral, ranged from 5-17 cm (average, 9.5 cm) in maximal dimension in 11 patients; in the 12th patient, the involved ovary was not enlarged. The cervical tumors were grossly evident in 10 patients. They were usually deeply invasive, often with extracervical extension. Four were squamous cell carcinomas; two, small cell carcinomas; one, a mixed small cell carcinoma and adenocarcinoma; one, a mixed poorly differentiated carcinoid and adenocarcinoma; two, adenosquamous carcinomas; one, a transitional cell carcinoma; and one, an undifferentiated carcinoma. Various features, including bilaterality of the ovarian tumors, the finding that the histologic features of the ovarian tumors typically were unusual for a primary ovarian neoplasm, and the presence of extensive extracervical disease, led to the conclusion that the ovarian tumors were metastatic from the cervix. Although ovarian metastases of cervical carcinoma are uncommon, this series illustrates that, occasionally striking examples with clinical manifestations of ovarian involvement occur.     

Stage IA1 cervical adenocarcinoma: definition and treatment

OBJECTIVE: To propose a definition for stage IA1 cervical adenocarcinoma, based on the International Federation of Gynecology and Obstetrics (FIGO) staging system, and to determine if patients meeting criteria might be candidates for conservative surgery. METHODS: Two hundred women were diagnosed with early-stage cervical adenocarcinoma from 1982 to 1996. Histopathologic sections were reviewed by a gynecologic pathologist. Medical records were reviewed, and patients included in this study had microscopically identifiable lesions, up to 3 mm invasive depth, up to 7 mm tumor width, and negative margins if cone biopsy was performed. RESULTS: Twenty-one patients with microinvasive adenocarcinoma met criteria for FIGO stage IA1 carcinoma of the cervix. The median (range) follow-up was 76 (30-172) months and median (range) patient age was 38 (24-75) years. Definitive treatment included type II or III radical hysterectomy in 16 cases, simple abdominal or vaginal hysterectomy in four cases, and loop electrosurgical excision procedure in one case; one patient received adjuvant pelvic radiation. The histologic subtypes were endocervical adenocarcinoma in 18 cases, adenosquamous carcinoma in two cases, and clear-cell adenocarcinoma in one case. There was no evidence of parametrial invasion or lymph node metastases in any patient who had radical surgery, and there were no disease recurrences. CONCLUSION: Patients with microinvasive adenocarcinoma who met criteria for FIGO stage IA1 cervical carcinoma had disease limited to the cervix, and conservative surgery, such as cone biopsy or simple hysterectomy, might offer them definitive treatment.     

Metastatic adenocarcinoma to the uterine cervix from gastric cancer. A clinicopathologic analysis of 16 cases

BACKGROUND: Metastatic adenocarcinoma to the uterine cervix from gastric cancer is rare, and the clinicopathologic features of this metastasis are unclear. METHODS: A clinicopathologic review of 16 patients with metastatic adenocarcinoma to the uterine cervix from gastric cancer was performed. RESULTS: The ages of the patients ranged from 29 to 57 years, and 81.3% of the patients were premenopausal. Nine of the patients had undergone gastrectomy previously. In 11 patients the histologic type of the gastric cancer was poorly differentiated adenocarcinoma and, in 5 patients, signet ring cell carcinoma. The cervical metastasis was diagnosed 11-121 months (mean, 57.5 months) after the diagnosis of the gastric cancer in 10 of the patients. In six patients, the cervical metastasis was discovered synchronously or before the diagnosis of the gastric cancer. The colposcopic findings were normal in 57.1%, but 56.3% had abnormal cervical smears. In all patients, tumor cells were present in the dilated lymphatics of the cervix. Metastases to the uterine body and bilateral ovaries were common, and half of the patients had metastases to the paraaortic lymph nodes. Extirpation of the cervix was performed in six patients. The prognosis was poor, regardless of the treatment method. CONCLUSIONS: The route of metastasis to the cervix is surmised to be retrograde lymphatic, and this extension is often slow. Periodic gynecologic examinations should be performed indefinitely for premenopausal female patients with advanced gastric cancer.     

The human interleukin 18 gene IL18 maps to 11q22.2-q22.3, closely linked to the DRD2 gene locus and distinct from mapped IDDM loci

OBJECTIVE: To report a laparoscopic technique for placement of a transabdominal cervicoisthmic cerclage. DESIGN: Detailed case report of one of three patients undergoing described procedure. SETTING: University hospital. PATIENT: A 39-year-old infertile patient with a history of cervical adenocarcinoma in situ and two cone biopsies, resulting in an essentially absent exocervix. INTERVENTION(S): Laparoscopic transabdominal cervicoisthmic cerclage placement, as an interval procedure, followed by ET of cryopreserved donor oocyte-derived embryos. MAIN OUTCOME MEASURE(S): Clinical outcome. RESULT(S): Establishment of a pregnancy delivered at 38 1/2 weeks of gestation by elective cesarean section. CONCLUSION(S): Patients believed to require a transabdominal cerclage may undergo a laparoscopic interval procedure, obviating the need for a laparotomy before or during pregnancy.     

Anatomical anterior exenteration with urethral and vaginal preservation: illustrated surgical method

PURPOSE: We describe in detail a method for urethral and vaginal preservation in women considering orthotopic urinary tract reconstruction after bladder removal. MATERIALS AND METHODS: We retrospectively reviewed the pathological reports of patients treated with anterior exenteration at our hospital between 1984 and 1997 for specific evidence of urethral, vaginal, cervical or uterine involvement by the primary bladder tumor. Based on our findings we describe our approach to anterior exenteration in 6 patients. RESULTS: A total of 46 patients were treated at our center with en bloc anterior exenteration and pelvic lymphadenectomy for primary bladder cancer between 1984 and 1997. In 7 patients (15%) pathological review of the surgical specimen documented urethral involvement by the primary tumor. In 1 patient (2%) microscopic evidence of tumor was identified in the cervix and 1 (2%) had tumor extension to the vagina documented in the final pathology report. CONCLUSIONS: The observed rates of vaginal and urethral involvement agree with those reported by others, and suggest that in the majority of women treated with anterior exenteration sacrifice of the urethra and vagina is usually not necessary from an oncological perspective. This procedure is particularly appropriate in women concerned with postoperative sexual function and those considering orthotopic reconstruction of the lower urinary tract after exenterative bladder cancer surgery.     

The postpubertal change in the playful defense of male rats depends upon neonatal exposure to gonadal hormones

Only 19 cases of metastases at the cannula insertion site after laparoscopy for gynecological malignancy have been reported in the literature. One case has been diagnosed with cervical squamous cell carcinoma, whereas the others have been diagnosed with ovarian cancer and borderline ovarian tumor. We present a novel case of laparoscopy-site abdominal wall metastasis from endometrial cancer after laparoscopic-assisted vaginal hysterectomy (LAVH). The 56-year-old female patient exhibited metastases of an abdominal wall trocar site and a perineal site after undergoing LAVH and laparoscopic-assisted (LA) bilateral pelvic lymph node sampling as well as LA para-aortic lymph node sampling for treating endometrial carcinoma, surgical staging IIIC, G3. The interval between the surgical extirpation of endometrial carcinoma and diagnosis of the tumor recurrence was 6 months, suggesting that overmanipulation of the diseased organ during laparoscopic surgery may have resulted in tumor spillage, intraperitoneal dissemination, and wound contamination. Although this procedure has been proven beneficial to patients with benign disease or early-stage gynecologic malignancies, laparoscopic-assisted vaginal hysterectomy may not be efficacious to eradicate advanced gynecological malignancy.     

Laparoscopic ovarian suspension before irradiation

OBJECTIVE: To evaluate a technique of lateral ovarian transposition by laparoscopy. DESIGN: Case report. SETTING: Tertiary care center. PATIENT(S): A 34-year-old woman with rectal carcinoma. INTERVENTION(S): Laparoscopic ovarian transposition. MAIN OUTCOME MEASURE(S): Return of normal menstruation after irradiation. RESULT(S): Lateral ovarian transposition could be done by laparoscopy. However, division of the ovarian ligament was needed. The location of the ovaries after surgery was outside the radiation field. CONCLUSION(S): Lateral ovarian transposition can be done by laparoscopy. Contrary to a previous report, division of the ovarian ligament is required.     

Description of a laparoscopic technique for treating patients with ovarian remnant syndrome

OBJECTIVE: A retroperitoneal approach for laparoscopic treatment of ovarian remnant syndrome was developed. DESIGN: Clinical study. SETTING: Department of Gynecology, Friedrich-Schiller-University Jena. PATIENT(S): During a 29-month period, seven consecutive patients with ovarian remnant syndrome were treated by laparoscopy. Patients were not preselected and preoperative, intraoperative, and postoperative data were registered prospectively. INTERVENTION(S): For removal of remnant ovaries we used a laparoscopic retroperitoneal approach that included complete dissection of the pelvic course of the ureter and coagulation and dissection of the infundibulopelvic ligament and of the uterine vessels. RESULT(S): In the first patient's case, the right ureter was injured during dissection, which was initiated too far distally between ovary and external iliac vessels. Thereafter, we changed our technique to start the dissection of the ureter at the pelvic brim. No subsequent patient had an intraoperative or postoperative complication. All patients reported fewer preoperative complaints and were free of recurrence by sonographic examination. CONCLUSION(S): Using a retroperitoneal approach laparoscopic resection of a remnant ovary may be a safe and effective technique.     

Screening for intracranial aneurysms in patients with isolated polycystic liver disease

BACKGROUND/PURPOSE: Cloacal exstrophy can now be managed with excellent survival rates and reasonable long-term outcomes with many of these patients living into their late teens and early adulthood. In this report, the authors describe for the first time the association of large ovarian cysts with cloacal exstrophy. METHODS: From 1974 to 1996, 12 patients with cloacal exstrophy have been treated at C.S. Mott Children's Hospital. Massive ovarian cysts developed in four of these. These patients represent the subjects of this study. RESULTS: All four patients have been followed up beyond puberty and massive ovarian cysts have developed, which have caused significant morbidity. Three patients have required surgical intervention. All the patients had reached menarche before the development of the cysts. In all cases, the presentation was severe pelvic pain. Urinary tract obstruction from the large pelvic cysts developed in three of the four. The cysts were bilateral in three of four patients and measured 8 to 10 cm in diameter on ultrasound scan or computed tomography (CT). Cyst aspiration was attempted in two cases and was unsuccessful. Three of the four patients have required bilateral salpingo-oophorectomy. The indications for surgery were uncontrollable pelvic pain in one and urinary obstruction and uncontrollable pelvic pain in two. Surgical findings demonstrated massive thin-walled cysts with essentially no normal ovarian tissue in association with duplicated mullerian structures. The pathology findings were corpus luteal cyst in two and mucinous cystadenoma in one. The fourth patient with an 8- x 10-cm unilateral cyst is being followed up. CONCLUSIONS: The authors have described, for the first time, the association of massive ovarian cysts with cloacal exstrophy. These cysts can lead to severe pelvic pain and urinary tract obstruction. Bilateral oophorectomy has been required in most of these patients.     

Management of the adolescent girl exposed in utero to DES

Attention in this discussion of the management of the adolescent girl exposed "in utero" to diethylstilbestrol (DES) is directed to the following: history; scope of the problem; pathogenesis/embryology; management; future fertility; squamous cell carcinoma; and male factors. In the late 1940s and early 1950s, estrogen deficiency was thought to play a role in the high fetal death rate among pregnant diabetic women. DES was 1st used in diabetics and soon thereafter in patients who were threatening to miscarry, who had previous stillbirths, and previous spontaneous abortions. Estrogens were used by some physicians through the late 1960s. In 1970 Herbst and Scully reported 7 carcinomas of the vagina in young women. On careful review, it was found that the mothers of these young women with clear-cell cancer had been treated with DES at various stages of their pregnancies. Subsequent investigation led to the discovery of the condition of vaginal adenosis in many young women exposed "in utero" to DES. It is estimated that 80-90% of patients exposed to intrauterine DES will show gross and microscopic evidence of vaginal and cervical adenosis. It is now felt by most authorities that adenosis coexists with the clear-cell cancer rather than preceding the tumor. A clear-cell tumor registry has been established and, to date, over 400 cases have been registered. The age-range of DES-exposed clear-cell carcinoma is between 7 and 31 years of age. The care of a girl exposed to DES begins when the physician is informed that the patient's mother either received the medication or there was any possibility of such medication. If bleeding occurs before the menarche, the patient should be hospitalized and examined under anesthesia. In the women of menstrual age, management has been somewhat controversial. The use of the colposcope has allowed careful initial examination of the cervix and vagina as well as providing an excellent means of follow-up. The colposcope has been very helpful in delineating the changes caused by DES. There are numerous gross findings that represent adenosis. These include the cervical changes of the "cockscomb" or anterior cervical ridge or "hood," a cervix within a cervix, and a hermicervix. With the colposcope, the areas of adenosis are seen as grape-like projections which, on biopsy, represent columnar epithelium. Areas of metaplastic squamous tissue are easily identified. On occasion dysplasia can occur in areas of adenosis. Of equal importance is the digital examination of the vagina. At this time it is felt that adenosis requires no other treatment than observations. The treatment of clear-cell carcinoma of the vagina or cervix is best determined by a gynecologic oncologist. 80% of DES patients have had live births.     

Reduced sensitivity to ethanol of Gs alpha and Gi/o alpha in the cerebral cortex of alcoholic patients

CA125 is a coelomic epithelial antigen which is widely used to monitor residual disease in patients undergoing chemotherapy for ovarian cancer. Interpretation of serum CA125 levels has been based on a normal value of 35 U/ml which was derived by screening a young, general population of blood donors which included women with intact reproductive systems. This study addresses the issue of what constitutes a normal serum CA125 level following successful surgical therapy for gynecologic malignancy. Three hundred ninety-three CA125 values were measured in 145 patients after an elapsed time of at least 1 year following completion of surgical therapy for early-stage endometrial or cervical adenocarcinoma. All patients were without evidence of recurrent disease. The mean duration of followup was 4.3 years with a median of 3.7 years. Sixty-seven percent of the CA125 values were less than 10 U/ml; 95% were less than or equal to 20 U/ml. The median value for this patient population was 7.5 U/ml with a mode of 7.1 U/ml. There was no correlation between patient age and CA125 levels. These data suggest that the normal value for CA125 used for patient follow-up after treatment for gynecologic adenocarcinoma needs to be redefined. Our data support an upper limit of normal of 20 U/ml and encourage further study on the clinical impact of this new definition.     

Port-site recurrences following laparoscopic operations for gynaecological malignancies

OBJECTIVE: To determine the frequency of port-site recurrences following laparoscopic surgical treatment of gynaecological malignancies metastatic at the time of surgery. DESIGN: Retrospective review of metastatic primary and recurrent gynaecological malignancies. RESULTS: Twenty-five women were studied. Twenty-four had metastatic disease at the time of laparoscopic surgery, 22 in association with a primary malignancy (cervix: n = 12, ovary: n = 7, endometrium: n = 3), and two in association with recurrent ovarian cancer; all received pelvic or extended field radiation or chemotherapy after surgery. One woman with Stage IIIC ovarian cancer, disease-free at the completion of neoadjuvant chemotherapy following laparotomy by a general surgeon, was included; she developed scalene node metastases 18 months after definitive laparoscopic surgery. Seventy-one 5 mm trocars and fifty 10 mm trocars (total n = 121) were used for surgery; thirty-one 10 mm trocar sites and forty-four 5 mm sites (total n = 75) received post-operative treatment with chemotherapy (n = 49) or radiation (n = 26). Four women (16%) developed recurrences in association with endometrial (n = 2) and cervical (n = 2) cancer at six trocar sites. All recurrences were associated with abdominopelvic and/or distant metastases, and all occurred at untreated 5 mm trocar sites. The difference in recurrence rates between 5 mm and 10 mm trocar sites (chi(2) = 6; P < 0.025), and between treated and untreated trocars (chi(2) = 5; P < 0.05) were both statistically significant (McNemar's test), but the effects of treatment and trocar size on the port-site recurrence rate were confounded. CONCLUSIONS: Port-site recurrences are local manifestations of disseminated disease that result from the enhancement of tumour growth characteristic of healing tissues and can be prevented by appropriate post-operative therapy.     

Abdominal radical trachelectomy: a new surgical technique for the conservative management of cervical carcinoma

Traditionally radical hysterectomy has formed the mainstay of treatment for early stage cervical carcinoma. More recently radical trachelectomy and laparoscopic lymphadenectomy have been introduced to allow preservation of fertility. We present a new approach to fertility-sparing surgery, namely abdominal radical trachelectomy. The technique is similar to a standard radical hysterectomy and lymphadenectomy. In our technique the ovarian vessels are not ligated and, following lymphadenectomy and skeletonisation of the uterine arteries, the cervix, parametrium and vaginal cuff are excised. The residuum of the cervix is then sutured to the vagina and the uterine ateries re-anastomosed.     

Results of laparoscopic treatments of ovarian endometriomas: laparoscopic ovarian fenestration and coagulation

OBJECTIVE: To determine the long-term results of laparoscopic fenestration and coagulation of ovarian endometriomas and to compare them with the results of ovarian cystectomy performed by either laparotomy or laparoscopy. DESIGN: Case-control study. SETTING: Two university-affiliated hospitals. PATIENT(S): One hundred fifty-six premenopausal women with ovarian endometriomas of at least 3 cm in diameter (stage 3 and 4 endometriosis, revised American Fertility Society classification). INTERVENTION(S): Laparoscopic ovarian fenestration and coagulation (group 1, 80 patients); laparoscopic ovarian cystectomy (group 2, 23 patients); and ovarian cystectomy by laparotomy and microsurgical technique (group 3, 53 patients). MAIN OUTCOME MEASURE(S): Operative findings, recurrence rate, and cumulative clinical pregnancy rate (PR) over a 36-month follow-up period. RESULT(S): The mean (+/-SD) time to first pregnancy was significantly shorter in group 1 (1.4+/-0.2 years) than in group 2 (2.2+/-0.5 years) or group 3 (2.4+/-0.5 years). The difference between the cumulative clinical PR between the three groups was not statistically significant after 36 months of follow-up. The difference in the recurrence rate among groups 1, 2, and 3 was not statistically significant. CONCLUSION(S): Laparoscopic ovarian fenestration and coagulation of endometriomas leads to faster conception than ovarian cystectomy by laparotomy. Laparoscopic ovarian fenestration and coagulation of endometriomas is associated with cumulative clinical PRs and recurrence rates over 36 months that are similar to those associated with ovarian cystectomy.     

Primary surgery for stage IB-IIA cervical cancer, including short-term and long-term morbidity and treatment in pregnancy

Radical hysterectomy and pelvic lymphadenectomy are indicated for the treatment of cervical carcinoma that is localized clinically to the cervix and upper vagina. Intraoperative complications have been reported in 1.1%-7.4% of patients. Long-term complications include bladder dysfunction (2% at 3 years), urinary fistula (vesical, 0.8%; ureteral, 1.2%), stress urinary incontinence (29%), ureteral stricture (1%), rectal dysfunction (80%), severe constipation (5.3%), lymphocysts (20% by ultrasonography; 2% clinically), and lymphedema (10%). The operative mortality is 0.7%. The 5-year survival rate for patients with stage IB disease is 85.7% and for stage IIA is 69.6%. The recurrence rate is 27.2%. Recurrences are distributed equally between the pelvis and extrapelvic sites. Radical hysterectomy is the treatment of choice for pregnant patients with early cervical cancer. It affords termination or delivery of the pregnancy at the same time that the treatment is provided. For patients with stage I disease treated with radical hysterectomy, the survival rate is 92.1%.     

Radical hysterectomy with pelvic lymphadenectomy in patients with carcinoma of the uterine cervix--3 years' experience

INTRODUCTION: Almost all patients with invasive cervical carcinoma can be treated with either primary irradiation therapy or primary surgery. Some patients are appropriately treated with the combination of irradiation and surgery. Chemotherapy is not effective as primary treatment of invasive cervical cancer but may be used as additional therapy and when the disease is recurrent or persistent. There are some important advantages of primary extensive surgery over irradiation. The findings at operation and that from the careful pathologic examination of surgical specimens can be very helpful in selection of patients for supplementary postoperation irradiation therapy or chemotherapy, or both [1-6]. AIM OF THE STUDY: The aim of the study was to compare pretreatment clinical evaluations with surgical and postsurgical pathohistological findings. METHODS: Extensive hysterectomy and bilateral pelvic lymphadenectomy were used in the treatment of 251 patients with early invasive cervical cancer. The patients were treated at the Department of Obstetrics and Gynaecology of the Clinical Centre of Serbia in Belgrade, between 1993 and 1995. Cervical cancer was detected by clinical examination, colposcopic and cytologic (Pap smear) findings, colposcopically directed biopsy or conisation and pathological findings, sonography, chest radiography, blood and urine analyses. In some cases we had to make other examinations (cystography, cystoscopy, intravenous pyelography, sygmoidoscopy, rectoscopy, CT scanning and magnetic resonance). The surgical treatment of invasive carcinoma of the cervix was limited to those patients in whom the disease was confined to the cervix or vaginal fornix (stage Ia, stage Ib or stage IIa), and who were in high surgical risk. RESULTS: Over a three year period (1993-1995) there were 251 patients with invasive cervical cancer, treated by primary surgery (radical hysterectomy and bilateral pelvic lymphadenectomy sec. Werthein-Meigs), average age 42 years. Most of the patients demonstrated invasive cervical cancer, clinically classified in Ib st. (81.67%). Some characteristics of pathologic findings, such as parametric width, number of removed lymph nodes, percentage of lymph nodes metastases and correlation with clinical stage of invasive cervical cancer, histologic grade of cervical cancer with lymph node metastasis, pathologic findings after surgical treatment, correlation between clinical and surgical staging, were already presented in tables. DISCUSSION: In the last decades the incidence of invasive cervical cancer and death rate have been decreased. Progress in reducing mortality is primarily attributed to the introduction of cervical cancer screening as part of regular gynaecologic examinations. Regular testing with Papanicolaou (Pap) smear and colposcopy have an important role in this problem [1]. Extensive hysterectomy and bilateral pelvic lymphadenectomy were used in the treatment of 251 patients with early invasive cervical cancer. We found that the clinical diagnosis of disease extent was correct in 67.7% of patients who underwent extensive surgery for early invasive cervical cancer. Sensitivity of clinical findings was 75.8% and positive predictive value was 86.2%. Lymph node metastasis was detected in 17% patients. Brodman at al. [14] found that clinical examinations, including CT scanning and magnetic resonance, were correct in only 62.5% of cases. It is very difficult to detect parametric involvement and lymph node metastasis by clinical examinations. Irradiation therapy was used in the postoperative period as additional treatment of extensive hysterectomy and bilateral pelvic lymphadenectomy in 89.7% of patients. CONCLUSION: The findings at operation and that from the careful pathologic examination of surgical specimens are absolutely irreplaceable and important in grading invasive cervical cancer and selection of patients for supplementary postoperate irradiation therapy.