FROM THE DEPARTMENT OF DIAGNOSTIC RADIOLOGY, UNIVERSITY HOSPITAL, INSELSPITAL, CH-3008 BERNE, SWITZERLAND.
LY.MPHOGRAPHY IN CARCINOMA OF THE UTERINE CERVIX W. A. FUCHS and G. SEILER-RoSENBERG Lymphography has become a routine procedure in patients with carcinoma of the uterine cervix. Several groups of authors have reported their results and experiences concerning the diagnostic accuracy of the method, its clinical indications and possible implications in the prognosis. In 1964 FUCHS & BOOK-HEDERSTROM presented a report on the accuracy and the clinical indications of the method based on a material of 60 patients. Comparison of these results with those of the present investigation 10 years later, covering a different case material, might yield some further information and demonstrate the advances of lymphography.
Methods and Material. A total of 158 patients with carcinoma of the uterine cervix were examined between 1963 and 1972. The ages ranged from 28 to 81 years (mean: 51 years). The patients were clinically graded into four groups according to the FIGO classification (1971), 37 being classified as stage I, 66 as stage II, 42 as stage III, 7 as stage IV, and 6 as undetermined, stage III to IV (Table I). The therapy consisted of hysterectomy and postoperative irradiation in 81 cases and radiation therapy only in 73. Two patients were treated only by operation and two cases with advanced tumor received chemotherapy alone. The main techniques for irradiation were as follows: High kilovoltage irradiation (6000 rad) in 131 cases, complemented with local radium therapy in 81 cases. Submitted for publication 6 September 1973. 23-755836 Acta Radiologica Diagnosis Vol. 16 (1975)
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353
354
W. A. FUCHS AND G. SEILER-ROSENBERG
Table 1 Metastases revealed by lymphography in 158 patients with carcinoma of the uterine cervix
Stage
No. of cases
I II
III IV Undetermined (III-IV) Total
No. of lymphographies
37 66 42 7
Primary tumour Recurrence
Total
+
+
6
6 164
?
3 9 9 2
3 5 1
31 47 26 4
1 4 3
4
2
4
23
9
108
12
12
35
39 68 44 7
158
+
?
?
4 (10%) 13 (19 %) 12 (27 %) 2
4 5 1
3 5 1
35 52 27 4
9
120
2
+ = metastases present ? = uncertain - = no metastases
The actuarial method of BERKSON & GAGE (1950) was used to evaluate the survival rate. Altogether 164 lymphographies were carried out on 158 patients: in 134 cases a combination of lymphography, cavography and urography and in 30 cases lymphography and urography. In 18 cases the lymphography was conducted only unilaterally because of technical difficulties; in 6 patients it was repeated during the course of the disease. In 78 cases lymphography was performed initially, in 62 cases during Table 2 Accuracy of lymphographic diagnosis in 135 cases with carcinoma of the uterine cervix
Stage
I II
III IV Undetermined (III-IV) Total
No. of lyrnphographies
36 55 32
Correct
False positive
False negative
Operative Clinical and course histologic findings
Histology Clinical course
Histology Clinical course
28 27 2
5 21 24
6
4
6 135
4 59 58 117(86.7%)
2
2 2 (1.5 %)
1 2
2 3 6 (2 uncertain) 1
1 13 3 16 (11.8 %)
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LYMPHOGRAPHY IN CARCINOMA OF THE UTERINE CERVIX
355
Fig. I. Solitary filling defect of 10 mm diameter due to metastasis within a medial external iliac lymph node of normal size in a 42-year-old patient. Obliteration of the intermediary sinuses confirmed by histology.
the first days of treatment and in 24 cases when a recurrence was suggested. At lymphography a positive diagnosis of malignant metastatic involvement was made only when solitary or multiple well-demarcated filling defects of at least 10 mm diameter in regional lymph nodes were present (Figs 1, 2). Obstruction of the lymphatic circulation was an additional finding indicating malignant involvement of the lymphatic system (Fig. 3). Results
Thirtyfive (21 per cent) of the 164 lymphographic examinations in the 158 cases were considered pathologic, 9 (5.5 per cent) possibly pathologic, and 120 (73 per cent) normal. Four positive findings (10 per cent) were encountered in stage I (n = 39); 13 (19 per cent) in stage II (n =68); and 18 (31.5 per cent) in the advanced stages III (n = 44) and IV (n = 7) (undetermined stage III to IV: n = 6) (Table I). In 23 lymphographies (66 per cent) the external iliac lymph nodes alone were invaded by metastases, in 5 (14 per cent) the aortic lymph nodes alone, and in 4 (11 per cent) both the iliac and aortic lymph nodes. In I case with infiltration of the vulva the inguinal lymph nodes were involved, 2 cases had iliac and inguinal metastases, and 2 cases had microscopically confirmed metastases in obturator lymph nodes. Malignant tissue was found in the supraclavicular lymph nodes in a patient with aortic lymph node involvement. The accuracy of the lymphographic diagnosis was evaluated in 135 cases; operative
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356
W. A. FUCHS AND G. SEILER-ROSENBERG
Fig. 2. Multiple confluent filling defects within enlarged left aortic lymph nodes due to metastases in a 42-yearold patient. Slight displacement of the left ureter. Fig. 3. Large confluent filling defects in lymph nodes and obstruction of the lymphatic circulation in the right aortic area in a 61-year-old patient. No displacement of the right ureter. Fig. 2
Fig. 3
and histologic findings were available in 62 of these, and in 73 the clinical course of the disease was considered to confirm the evaluation. Twenty-three patients had died within two years following the initial treatment and were therefore not included. A correct lymphographic diagnosis was made in' 87 per cent, a false positive diagnosis in 1.5 per cent, and a false negative in 12 per cent (Table 2). The overall failure rate was therefore approximately 14 per cent. In 9 cases the lymphographic diagnosis was not conclusive, and only suggestive of malignancy; in 2 cases microscopy revealed a negative result. The clinical course of the disease was uneventful in 2 cases, but malignant spread was suggested in 2 cases. In 3 patients the observation time was too short for evaluation. Cavography did not reveal abnormality in all the 103 cases of stages I and II. In advanced stages III and IV pathology was present in about 25 per cent of the cases. In one patient metastatic spread to the right aortic lymph nodes was diagnosed only by cavography. The survival rate of carcinoma of the uterine cervix was estimated in 129 patients of all clinical stages with malignant disease at first presentation (86 cases stages I and II, 36 cases stage III, 7 cases stage IV). The 2-year survival rate was 79 per cent, the 5-year survival rate 69 per cent, for the 105 cases with negative lymphography. For the 24 patients with abnormal lymphography the 2-year and 5-year survival rates were 48 and 40 per cent, respectively (Fig. 4). In clinical stage I and II carcinoma (n = 86) the survival rate of patients with negative lymphography (n = 73) was for two years 92 per cent and for five years 80 per cent. Patients with positive lympho-
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357
LYMPHOGRAPHY IN CARCINOMA OF THE UTERINE CERVIX
%
SURVIVAL RATE
SURVIVAL RATE
100
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
%
··············0
0
I
234
567
89m
2
3
4
5
SURVIVAL TIME IN YEARS
Fig. 4. Survival rates of 129 patients with carcinoma of the uterine cervix, all clinical stages. 105 patients with negative lymphography: 2year survival rate 79 %, 5-year survival rate 69 %; 24 patients with pathologic lymphography: 2-year survival rate 48 %, 5-year survival rate 40 %. Figures indicate number of patients alive. Total number of cases (--), negative (---) and positive ( ) lymphography.
Fig. 5. Survival rates of 86 patients with carcinoma of the uterine cervix, stage I and II. 73 patients with negative lymphography: 2-year survival rate 92 %, 5-year survival rate 80 %; 13 patients with positive lymphography: 2-year survival rate 86 %. Figures indicate number of patients alive. Total number of cases (--), negative (---) and positive (......) lymphography.
%
SURVIVAL RATE 27
100 -36 9
80
\:\, \ "
70
'\
90
60 50 40 30
20
"'~"
,\
\\
"
\
\
\.
",
............(!)----.----o Fig. 6. Survival rates of 36 patients with carcinoma of the uterine cervix, stage III. 27 patients with negative lymphography: 2-year survival rate 58 %, 5-year survival rate 52 %; 9 patients with pathologic lymphography: 2-year survival rate 17 %. Figures indicate number of patients alive. Total number of cases (--), negative (---) and positive (......) lymphography.
LY.MPHOGRAPHY IN CARCINOMA OF THE UTERINE CERVIX W. A. FUCHS and G. SEILER-RoSENBERG Lymphography has become a routine procedure in patients with carcinoma of the uterine cervix. Several groups of authors have reported their results and experiences concerning the diagnostic accuracy of the method, its clinical indications and possible implications in the prognosis. In 1964 FUCHS & BOOK-HEDERSTROM presented a report on the accuracy and the clinical indications of the method based on a material of 60 patients. Comparison of these results with those of the present investigation 10 years later, covering a different case material, might yield some further information and demonstrate the advances of lymphography.
Methods and Material. A total of 158 patients with carcinoma of the uterine cervix were examined between 1963 and 1972. The ages ranged from 28 to 81 years (mean: 51 years). The patients were clinically graded into four groups according to the FIGO classification (1971), 37 being classified as stage I, 66 as stage II, 42 as stage III, 7 as stage IV, and 6 as undetermined, stage III to IV (Table I). The therapy consisted of hysterectomy and postoperative irradiation in 81 cases and radiation therapy only in 73. Two patients were treated only by operation and two cases with advanced tumor received chemotherapy alone. The main techniques for irradiation were as follows: High kilovoltage irradiation (6000 rad) in 131 cases, complemented with local radium therapy in 81 cases. Submitted for publication 6 September 1973. 23-755836 Acta Radiologica Diagnosis Vol. 16 (1975)
Downloaded from acr.sagepub.com at Karolinska Institutets Universitetsbibliotek on July 26, 2015
353
354
W. A. FUCHS AND G. SEILER-ROSENBERG
Table 1 Metastases revealed by lymphography in 158 patients with carcinoma of the uterine cervix
Stage
No. of cases
I II
III IV Undetermined (III-IV) Total
No. of lymphographies
37 66 42 7
Primary tumour Recurrence
Total
+
+
6
6 164
?
3 9 9 2
3 5 1
31 47 26 4
1 4 3
4
2
4
23
9
108
12
12
35
39 68 44 7
158
+
?
?
4 (10%) 13 (19 %) 12 (27 %) 2
4 5 1
3 5 1
35 52 27 4
9
120
2
+ = metastases present ? = uncertain - = no metastases
The actuarial method of BERKSON & GAGE (1950) was used to evaluate the survival rate. Altogether 164 lymphographies were carried out on 158 patients: in 134 cases a combination of lymphography, cavography and urography and in 30 cases lymphography and urography. In 18 cases the lymphography was conducted only unilaterally because of technical difficulties; in 6 patients it was repeated during the course of the disease. In 78 cases lymphography was performed initially, in 62 cases during Table 2 Accuracy of lymphographic diagnosis in 135 cases with carcinoma of the uterine cervix
Stage
I II
III IV Undetermined (III-IV) Total
No. of lyrnphographies
36 55 32
Correct
False positive
False negative
Operative Clinical and course histologic findings
Histology Clinical course
Histology Clinical course
28 27 2
5 21 24
6
4
6 135
4 59 58 117(86.7%)
2
2 2 (1.5 %)
1 2
2 3 6 (2 uncertain) 1
1 13 3 16 (11.8 %)
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LYMPHOGRAPHY IN CARCINOMA OF THE UTERINE CERVIX
355
Fig. I. Solitary filling defect of 10 mm diameter due to metastasis within a medial external iliac lymph node of normal size in a 42-year-old patient. Obliteration of the intermediary sinuses confirmed by histology.
the first days of treatment and in 24 cases when a recurrence was suggested. At lymphography a positive diagnosis of malignant metastatic involvement was made only when solitary or multiple well-demarcated filling defects of at least 10 mm diameter in regional lymph nodes were present (Figs 1, 2). Obstruction of the lymphatic circulation was an additional finding indicating malignant involvement of the lymphatic system (Fig. 3). Results
Thirtyfive (21 per cent) of the 164 lymphographic examinations in the 158 cases were considered pathologic, 9 (5.5 per cent) possibly pathologic, and 120 (73 per cent) normal. Four positive findings (10 per cent) were encountered in stage I (n = 39); 13 (19 per cent) in stage II (n =68); and 18 (31.5 per cent) in the advanced stages III (n = 44) and IV (n = 7) (undetermined stage III to IV: n = 6) (Table I). In 23 lymphographies (66 per cent) the external iliac lymph nodes alone were invaded by metastases, in 5 (14 per cent) the aortic lymph nodes alone, and in 4 (11 per cent) both the iliac and aortic lymph nodes. In I case with infiltration of the vulva the inguinal lymph nodes were involved, 2 cases had iliac and inguinal metastases, and 2 cases had microscopically confirmed metastases in obturator lymph nodes. Malignant tissue was found in the supraclavicular lymph nodes in a patient with aortic lymph node involvement. The accuracy of the lymphographic diagnosis was evaluated in 135 cases; operative
Downloaded from acr.sagepub.com at Karolinska Institutets Universitetsbibliotek on July 26, 2015
356
W. A. FUCHS AND G. SEILER-ROSENBERG
Fig. 2. Multiple confluent filling defects within enlarged left aortic lymph nodes due to metastases in a 42-yearold patient. Slight displacement of the left ureter. Fig. 3. Large confluent filling defects in lymph nodes and obstruction of the lymphatic circulation in the right aortic area in a 61-year-old patient. No displacement of the right ureter. Fig. 2
Fig. 3
and histologic findings were available in 62 of these, and in 73 the clinical course of the disease was considered to confirm the evaluation. Twenty-three patients had died within two years following the initial treatment and were therefore not included. A correct lymphographic diagnosis was made in' 87 per cent, a false positive diagnosis in 1.5 per cent, and a false negative in 12 per cent (Table 2). The overall failure rate was therefore approximately 14 per cent. In 9 cases the lymphographic diagnosis was not conclusive, and only suggestive of malignancy; in 2 cases microscopy revealed a negative result. The clinical course of the disease was uneventful in 2 cases, but malignant spread was suggested in 2 cases. In 3 patients the observation time was too short for evaluation. Cavography did not reveal abnormality in all the 103 cases of stages I and II. In advanced stages III and IV pathology was present in about 25 per cent of the cases. In one patient metastatic spread to the right aortic lymph nodes was diagnosed only by cavography. The survival rate of carcinoma of the uterine cervix was estimated in 129 patients of all clinical stages with malignant disease at first presentation (86 cases stages I and II, 36 cases stage III, 7 cases stage IV). The 2-year survival rate was 79 per cent, the 5-year survival rate 69 per cent, for the 105 cases with negative lymphography. For the 24 patients with abnormal lymphography the 2-year and 5-year survival rates were 48 and 40 per cent, respectively (Fig. 4). In clinical stage I and II carcinoma (n = 86) the survival rate of patients with negative lymphography (n = 73) was for two years 92 per cent and for five years 80 per cent. Patients with positive lympho-
Downloaded from acr.sagepub.com at Karolinska Institutets Universitetsbibliotek on July 26, 2015
357
LYMPHOGRAPHY IN CARCINOMA OF THE UTERINE CERVIX
%
SURVIVAL RATE
SURVIVAL RATE
100
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
%
··············0
0
I
234
567
89m
2
3
4
5
SURVIVAL TIME IN YEARS
Fig. 4. Survival rates of 129 patients with carcinoma of the uterine cervix, all clinical stages. 105 patients with negative lymphography: 2year survival rate 79 %, 5-year survival rate 69 %; 24 patients with pathologic lymphography: 2-year survival rate 48 %, 5-year survival rate 40 %. Figures indicate number of patients alive. Total number of cases (--), negative (---) and positive ( ) lymphography.
Fig. 5. Survival rates of 86 patients with carcinoma of the uterine cervix, stage I and II. 73 patients with negative lymphography: 2-year survival rate 92 %, 5-year survival rate 80 %; 13 patients with positive lymphography: 2-year survival rate 86 %. Figures indicate number of patients alive. Total number of cases (--), negative (---) and positive (......) lymphography.
%
SURVIVAL RATE 27
100 -36 9
80
\:\, \ "
70
'\
90
60 50 40 30
20
"'~"
,\
\\
"
\
\
\.
",
............(!)----.----o Fig. 6. Survival rates of 36 patients with carcinoma of the uterine cervix, stage III. 27 patients with negative lymphography: 2-year survival rate 58 %, 5-year survival rate 52 %; 9 patients with pathologic lymphography: 2-year survival rate 17 %. Figures indicate number of patients alive. Total number of cases (--), negative (---) and positive (......) lymphography.
