A~chives of,
Arch Gynecol Obstet (1990) 248:21-23
Gynecology and Obstetrics
© Springer-Verlag1990
Indications for radioisotope bone scanning in staging of cervical cancer P. Hirnle I, K.-P. Mittmann 2, B. Schmidt 1, and K. H. Pfeiffer2 ~Department of Radiooncology, and 2Department of Gynecology and Obstetrics, University of Tfibingen, FRG Received July 4, 1989/Accepted May 15, 1990
Summary. The total of 160 patients with newly diagnosed invasive cancer of the cervix had whole body radioisotope bone scanning during staging of their disease. 51 patients had cancer of the cervix stage I, 63 had stage II, 34 stage III and 12 stage IV (FIGO). Only in 8 of 160 patients did the bone scans indicate possible metastases and this was confirmed by X-ray examination in only one patient with stage IV disease and liver metastases. We conclude that patients with stage I and stage II carcinoma of the cervix do not need to have bone scans.
Key words: Radioisotope bone scanning - Staging examinations - Cervical cancer
Introduction At the University of Tfibingen, radioisotope bone scans are done routinely on patients with newly diagnosed cervical cancer, although metastases are detected in only a few cases. Our study was aimed at identifying cervical cancer patients who should be selected for bone scans.
Patients and methods A retrospective study was made of 160 patients who had a bone scan during staging of newiy diagnosed cervical cancer between 1980 and 1986 in the Dept. of Gynecology of the University of Ttibingen. 51 patients had stage I disease, 63 stage II, 34 stage III and 12 stage IV (FIGO). Total body radionuclide imaging was performed on all patients in the Dept. of Nuclear Medicine of the University of Tiibingen, using a 99mTc.Partial body radionuclide imaging was performed in suspicious body areas. The results obtained were collected and processed by computer.
Offprint requests to: Dr. P. Hirnle, Department of Radiooncology, Hoppe-Seyler-StraBe 3, D-7400 Tfibingen, FRG
22
P. Hirnle et al.
Results
Only in 8 of 160 patients did the bone scans indicate possible metastases. Of these 8 cases, one had clinical stage I disease, five had stage II disease, one had stage III and one had stage IV disease. The X-ray examinations of suspicious areas were negative in all but one case (stage IV). Repeat examinations made 3-9 years later also showed no signs of bone metastases. The one patient with bone metastases had clinical stage IV disease with liver metastases. The primary tumor was a nonkeratizing squamous cell carcinoma, with an adenocarcinoma component. The body scans showed suspicious areas in the humerus, sternum, ribs and cranium, but X-ray examinations showed only a deposit in the sternum. This patient died 14 months after diagnosis.
Discussion
Cervical cancer patients with bone metastases have a very poor prognosis. It was found [1] that 96% of patients with skeletal involvement died within 18 months, while in other series 87% died within 7 months [6]. Our results (showing only one true-positive among 160 body scans) lead us to conclude that a large number of patients are unnecessarily subjected to body scans. Similar doubts arise from a study of the earlier literature what is summarized in Table 1. There is a uniformly low incidence of true-positives, particularly in stage I and II disease. False-positives were more frequent [4, 5, 8]. The 2.5% incidence of skeletal metastases reported by one author [6] in stage I disease is explained by the fact that scans were performed up to 42 months after the initial diagnosis.
Table 1. Summary of literature on bone metastases in different stages of cervical cancer Author
Number of patients examined
Stage I II Katz 1979
Number of cases with metastases confirmed by X-ray
III
79
IV
Stage I II
21 a 163
III
0 62
4
IV 4
Kamath 1983
272
297
3
10
Kim 1987b
285
366
71
80
7
5
1
2
du Toit 1987
105
105
266
64
0
0
2
2
Hirnle 1990
51
63
34
12
0
0
0
6
1
a includes 7 patients with recurrent disease; b includes patients with recurrent disease and repeated body scans
Bone scanning in cervical cancer
23
False positive diagnoses were caused mostly by increased radioactivity from arthritis, old fractures or degenerative bone disease [4]. Among 24 abnormal scans [5] only 4 were verified as being due to malignant disease. This is the same order of magnitude as is found in our own material (1/8). In up to 39.5% cases [8], no pathological changes were found by X-ray examination of scan-positive bones. Among 1,252 patients with cervical cancer, 55 developed bone metastases, but only in one case was this diagnosis made at the time of initial staging [1]. Among the 55 positive cases, only 15 were examined by body scanning. The diagnosis was subsequently confirmed by X-ray examination. The rest were diagnosed by X-ray examination alone. In 44 cases localized pain initiated the search for bone metastases [1]. Among 2, 200 patients suffering from cervical cancer, distant metastases developed in 341, while single bone metastases were found in only 18, in half of whom they occurred in the spine [2]. The lumbar spine was reported as the most common site of bone metastases. These metastases are mostly caused by direct extension from lumbar lymph nodes [1, 3, 4, 6]. Small cell non-keratizing squamous cell carcinoma is suspected of being particularly liable to spread to bone [7]. A relatively high incidence of bone metastases is found only in patients with recurrent disease, and about 10% of scans for bone metastases are positive in this group [4, 8]. Such patients should always have a body scan. In patients with stage III or IV cervical cancer, a body scan should also be performed as part of the staging procedure. We believe that it is not necessary to perform bone scans on patients with stage I and II disease; implementation of such a policy would reduce the number of examinations to one-third of current levels. Acknowledgement. Our grateful acknowledgements go to the Departement of Nuclear Medicine (Director: Prof. Dr. Feine) for performing the body scans.
References 1. Blythe JG, Ptacek JJ, Buchsbaum HJ, Latourette HB (1975) Bony metastases from carcinoma of cervix. Occurence, diagnosis and treatment. Cancer 36:475-484 2. Carlson V, DeMos L, Fletcher GH (1967) Distant metastases in squamous cell carcinoma of the uterine cervix. Radiology 88:961-966 3. Fisher MS (1980) Lumbar spine metastasis in cervical carcinoma: a characteristic pattern. Radiology 134:631-637 4. Kamath CRV, Maruyama Y, DeLand FH, van Nagell JR (1983) Role of bone scanning f o r evaluation of carcinoma of the cervix. Gynecol Oncol 15:171-185 5. Katz RD, Alderson PO, Rosenshein NB, Bowerman JW, Wagner HNJr (1979) Utility of bone scanning in detecting occult skeletal metastases from cervical carcinoma. Radiology 133:469-472 6. Kim RY, Weppelmann B, Salter MM, Brascho DJ (1987) Skeletal metastases from cancer of the uterine cervix: frequency, patterns, and radiotherapeutic significance. Int J Radiat Oncol Biol Phys 13:705 7. Okamura S, Okamoto Y, Maeda T, Sano T, Ueki M, Sugimoto O, Sakata T, Yamasaki K, Akagi H (1985) A study of bone metastasis of cervical carcinoma by bone scintigraphy. Nippon Sanka Fujinka Gakkai Zasshi 37:603-610 8. Du Toit JP, Grove DV (1987) Radioisotope bone scanning for the detection of occult bony metastases in invasive cervical carcinoma. Gynecol Oncol 28:215-219
Arch Gynecol Obstet (1990) 248:21-23
Gynecology and Obstetrics
© Springer-Verlag1990
Indications for radioisotope bone scanning in staging of cervical cancer P. Hirnle I, K.-P. Mittmann 2, B. Schmidt 1, and K. H. Pfeiffer2 ~Department of Radiooncology, and 2Department of Gynecology and Obstetrics, University of Tfibingen, FRG Received July 4, 1989/Accepted May 15, 1990
Summary. The total of 160 patients with newly diagnosed invasive cancer of the cervix had whole body radioisotope bone scanning during staging of their disease. 51 patients had cancer of the cervix stage I, 63 had stage II, 34 stage III and 12 stage IV (FIGO). Only in 8 of 160 patients did the bone scans indicate possible metastases and this was confirmed by X-ray examination in only one patient with stage IV disease and liver metastases. We conclude that patients with stage I and stage II carcinoma of the cervix do not need to have bone scans.
Key words: Radioisotope bone scanning - Staging examinations - Cervical cancer
Introduction At the University of Tfibingen, radioisotope bone scans are done routinely on patients with newly diagnosed cervical cancer, although metastases are detected in only a few cases. Our study was aimed at identifying cervical cancer patients who should be selected for bone scans.
Patients and methods A retrospective study was made of 160 patients who had a bone scan during staging of newiy diagnosed cervical cancer between 1980 and 1986 in the Dept. of Gynecology of the University of Ttibingen. 51 patients had stage I disease, 63 stage II, 34 stage III and 12 stage IV (FIGO). Total body radionuclide imaging was performed on all patients in the Dept. of Nuclear Medicine of the University of Tiibingen, using a 99mTc.Partial body radionuclide imaging was performed in suspicious body areas. The results obtained were collected and processed by computer.
Offprint requests to: Dr. P. Hirnle, Department of Radiooncology, Hoppe-Seyler-StraBe 3, D-7400 Tfibingen, FRG
22
P. Hirnle et al.
Results
Only in 8 of 160 patients did the bone scans indicate possible metastases. Of these 8 cases, one had clinical stage I disease, five had stage II disease, one had stage III and one had stage IV disease. The X-ray examinations of suspicious areas were negative in all but one case (stage IV). Repeat examinations made 3-9 years later also showed no signs of bone metastases. The one patient with bone metastases had clinical stage IV disease with liver metastases. The primary tumor was a nonkeratizing squamous cell carcinoma, with an adenocarcinoma component. The body scans showed suspicious areas in the humerus, sternum, ribs and cranium, but X-ray examinations showed only a deposit in the sternum. This patient died 14 months after diagnosis.
Discussion
Cervical cancer patients with bone metastases have a very poor prognosis. It was found [1] that 96% of patients with skeletal involvement died within 18 months, while in other series 87% died within 7 months [6]. Our results (showing only one true-positive among 160 body scans) lead us to conclude that a large number of patients are unnecessarily subjected to body scans. Similar doubts arise from a study of the earlier literature what is summarized in Table 1. There is a uniformly low incidence of true-positives, particularly in stage I and II disease. False-positives were more frequent [4, 5, 8]. The 2.5% incidence of skeletal metastases reported by one author [6] in stage I disease is explained by the fact that scans were performed up to 42 months after the initial diagnosis.
Table 1. Summary of literature on bone metastases in different stages of cervical cancer Author
Number of patients examined
Stage I II Katz 1979
Number of cases with metastases confirmed by X-ray
III
79
IV
Stage I II
21 a 163
III
0 62
4
IV 4
Kamath 1983
272
297
3
10
Kim 1987b
285
366
71
80
7
5
1
2
du Toit 1987
105
105
266
64
0
0
2
2
Hirnle 1990
51
63
34
12
0
0
0
6
1
a includes 7 patients with recurrent disease; b includes patients with recurrent disease and repeated body scans
Bone scanning in cervical cancer
23
False positive diagnoses were caused mostly by increased radioactivity from arthritis, old fractures or degenerative bone disease [4]. Among 24 abnormal scans [5] only 4 were verified as being due to malignant disease. This is the same order of magnitude as is found in our own material (1/8). In up to 39.5% cases [8], no pathological changes were found by X-ray examination of scan-positive bones. Among 1,252 patients with cervical cancer, 55 developed bone metastases, but only in one case was this diagnosis made at the time of initial staging [1]. Among the 55 positive cases, only 15 were examined by body scanning. The diagnosis was subsequently confirmed by X-ray examination. The rest were diagnosed by X-ray examination alone. In 44 cases localized pain initiated the search for bone metastases [1]. Among 2, 200 patients suffering from cervical cancer, distant metastases developed in 341, while single bone metastases were found in only 18, in half of whom they occurred in the spine [2]. The lumbar spine was reported as the most common site of bone metastases. These metastases are mostly caused by direct extension from lumbar lymph nodes [1, 3, 4, 6]. Small cell non-keratizing squamous cell carcinoma is suspected of being particularly liable to spread to bone [7]. A relatively high incidence of bone metastases is found only in patients with recurrent disease, and about 10% of scans for bone metastases are positive in this group [4, 8]. Such patients should always have a body scan. In patients with stage III or IV cervical cancer, a body scan should also be performed as part of the staging procedure. We believe that it is not necessary to perform bone scans on patients with stage I and II disease; implementation of such a policy would reduce the number of examinations to one-third of current levels. Acknowledgement. Our grateful acknowledgements go to the Departement of Nuclear Medicine (Director: Prof. Dr. Feine) for performing the body scans.
References 1. Blythe JG, Ptacek JJ, Buchsbaum HJ, Latourette HB (1975) Bony metastases from carcinoma of cervix. Occurence, diagnosis and treatment. Cancer 36:475-484 2. Carlson V, DeMos L, Fletcher GH (1967) Distant metastases in squamous cell carcinoma of the uterine cervix. Radiology 88:961-966 3. Fisher MS (1980) Lumbar spine metastasis in cervical carcinoma: a characteristic pattern. Radiology 134:631-637 4. Kamath CRV, Maruyama Y, DeLand FH, van Nagell JR (1983) Role of bone scanning f o r evaluation of carcinoma of the cervix. Gynecol Oncol 15:171-185 5. Katz RD, Alderson PO, Rosenshein NB, Bowerman JW, Wagner HNJr (1979) Utility of bone scanning in detecting occult skeletal metastases from cervical carcinoma. Radiology 133:469-472 6. Kim RY, Weppelmann B, Salter MM, Brascho DJ (1987) Skeletal metastases from cancer of the uterine cervix: frequency, patterns, and radiotherapeutic significance. Int J Radiat Oncol Biol Phys 13:705 7. Okamura S, Okamoto Y, Maeda T, Sano T, Ueki M, Sugimoto O, Sakata T, Yamasaki K, Akagi H (1985) A study of bone metastasis of cervical carcinoma by bone scintigraphy. Nippon Sanka Fujinka Gakkai Zasshi 37:603-610 8. Du Toit JP, Grove DV (1987) Radioisotope bone scanning for the detection of occult bony metastases in invasive cervical carcinoma. Gynecol Oncol 28:215-219
