λ-Carrageenan br Discussion br Risk of recurrence

4. Discussion
Risk of recurrence in early stage cervical cancer varies depending on stage of disease, nodal status (added to the FIGO 2018 staging system), and certain pathologic risk factors [2–6]. Identifying patients who are most likely to benefit from surgery alone may help reduce morbidity from surgery and adjuvant radiation therapy. When occult tumors are present, conization may be performed prior to radical surgery. As recur-rence risk is affected by tumor size, LVSI, and depth of stromal invasion, it is unclear if the conization pathologic features influence the final hys-terectomy pathology, which may potentially affect the recommenda-tions for adjuvant therapy.
There are few studies that have evaluated several pathologic factors in patients who underwent conization followed by radical hysterec-tomy with lymphadenectomy for cervical cancer. In regards to margin status, a series of 297 patients, negative conization margins were asso-ciated with no residual disease in the hysterectomy in ~98% of cases [13]. Diaz et al. evaluated the predictive value of positive conization margin status, which was associated with residual disease in the final pathology specimen [14]. Similarly, our results noted that 100% of pa-tients with intermediate risk final pathology had positive margin status
Table 2
Impact of lymphovascular space invasion on conization specimen with final pathology.
High risk + Margins + Lymph nodes + Parametria
Fig. 2. Recurrence-free survival of patients in the low and intermediate risk groups and the high risk group.
on conization as did 94.7% of high risk cases. This is in λ-Carrageenan to only 48% of patients with low risk disease. Not surprisingly, patients who had no residual disease had negative margins in 100% of cases. In patients with IB1 disease (FIGO 1995 staging), Kim and colleagues noted that a depth of invasion (N5 mm) correlated with parametrial in-volvement in 15.3% and lymph node metastases in 23% [5]. Depth of stromal invasion was similar across patients with low, intermediate, or high risk disease. Our study did report the finding of larger conization tumor size was associated with intermediate risk (median 1.7 cm) and high risk (median 1.5 cm) compared to low risk (median 0.9 cm) criteria.
While there was no correlation with depth of invasion or additive tumor size to final pathology high risk features, our study did indicate an association of LVSI on conization and lymph node metastases. In this study, 41 (39.4)% of patients were noted to have positive LVSI in the conization specimen. Strikingly, when LVSI was noted in the conization specimen, the presence of positive lymph node metastases was detected in 29% of the cases. On the contrary, when conization LVSI was not present, only 2% of patients were noted to have any one of the high risk criteria. However, it should be noted that 26% of low risk patients also had LVSI on the conization specimen. Bidus and col-leagues evaluated cervical biopsy or conization specimens prior to de-finitive surgery and noted that the pre-hysterectomy sampling had poor sensitivity and low negative predictive value for the presence of LVSI in the final specimen [15]. In another series, it was reported that the sensitivity of conization margin status to predict LVSI in the final hysterectomy specimen was only 70%; however, they did not directly comment on LVSI in the conization specimen [13]. Though the lymph node metastases rate was not reported, Kim and colleagues noted that depth of invasion, which was associated with the high risk criteria of parametrial involvement, also correlated with the presence of LVSI (55.3%) in the conization specimen [5]. In addition to a correlation with lymph node positivity, a prior study from our institution also re-ported that presence of LVSI in the conization specimen was significantly associated with positive parametrial involvement [16]. Therefore, the presence of LVSI in the conization specimen may represent the presence of high risk criteria (parametrial or lymph node involvement) in final pa-thology and may influence the treatment approach.