File:CIN 3 with Glandular Involvement and Underlying Invasive Squamous Carcinoma (6076189889).jpg

This cold knife cone is from a middle-aged woman who has record of high-grade SIL going back at least to 2002. I do not know if/how it was treated at that time. She recently presented with HSIL on Pap and subsequent cervical biopsy. Fortunately, the gynecologist elected to do a cold-knife conization, which disclosed an additional invasive component.

Had a LEEP been done instead, I think there would have been substantial risk of missing the invasive component. Note that the invasive foci are not connected to the surface or intraglandular in-situ component and lie fairly deep.

As I understand currently accepted practice, this tumor does not qualify as microinvasive or "miminally invasive" carcinoma. While the depth of invasion (measured from the nearest involved gland to the deepest invasive focus) is only 3 mm, the horizontal extent of the invasive tumor (estimated from the number of radial slices involved) is 8 mm, which surpasses the 7-mm threshold criterion for frankly invasive squamous carcinoma. From my review of the literature, though, it appears there remains controversy as to what constitutes minimally invasive carcinoma.

From an "art of medicine" standpoint (translation: "just my opinion, which I cannot scientifically back up") I do not like the looks of this tumor, and if the patient were my loved one, I would urge her to ask for aggressive treatment.