Lymph node mapping and sentinel node detection in carcinoma of the cervix, endometrium and vulva

OBJECTIVES: Validity of the sentinel node concept in patients with cervical, endometrial and vulvar cancer. MATERIAL AND METHODS: 47 cases of FIGO stage I and II cervical cancer, 33 cases of first clinical stage of endometrial cancer and 37 patients with FIGO stage I and II of vulvar cancer. In cervical and vulvar cancer preoperative lymphoscyntygraphy and intraoperative lymphatic mapping with blue dye and handheld gamma probe were performed. In patients with endometrial cancer intraoperative lymphatic mapping with blue dye injected into the cervix and into the uterine corpus subserously were done. In the last 10 cases radiolabeled nannocolloid were administered and the patients underwent preoperative lymphoscyntygraphy and intraoperative radio detection of sentinel node. Sentinel nodes were labeled as blue, radioactive, or blue/radioactive. RESULTS: In cervical cancer sensitivity of the dye and radiocolloid methods was 94%, specificity 100% and negative predictive value 97%. Out of 33 cases of endometrial cancer sentinel node was identified in 29 (87.87%) patients. None of women with histological negative sentinel node had metastases in the rest of lymph nodes resected. Sentinel node was detected in all cases of vulvar cancer. The status of sentinel nodes were representative for all lymph node resected. CONCLUSIONS: Concept of sentinel node may be applied first of all for vulvar cancer and also for cervical and endometrial cancer.     

Value of lymphangiography in the diagnosis of paraaortic lymph node metastases from carcinoma of the cervix

A study was conducted to evaluate the accuracy of lymphangiography in the diagnosis of paraaortic lymph node metastases from carcinoma of the cervix. Thirty-nine patients with diagnoses of invasive carcinoma of the cervix underwent bipedal lymphangiography followed by exploratory laparotomy. In all, 37 required bilateral paraaortic lymphadenectomy, and 2 required paraaortic node biopsy. It was clear that lymphangiographic examination gave high predictive value when negative, but low predictive value when positive.     

Accuracy of lymphangiography in the diagnosis of paraaortic lymph node metastases from carcinoma of the cervix

A study was undertaken to evaluate the use of lymphograms as a method of diagnosing cancer of the cervix metastatic to the paraaortic lymph nodes. Twenty-one patients underwent lymphograms, surgical biopsy, and histologic examination of the paraaortic nodes. The specificity of lymphangiographic examinations is not accurate enough to be of clinical significance in the detection of paraaortic lymph node metastasis from carcinoma of the cervix. Lymphangiography can be of assistance in locating suspicious lymph nodes. These nodes should then be biopsied. The final therapeutic decisions should be based on tissue diagnosis.     

Therapy of paraaortic lymph node metastases of cervix cancer

Report about 52 patients with uterine cervical carcinoma and lymphographically positive paraaortic lymph nodes. 30 of these patients have been irradiated, 22 not. Survival times of these two groups did not differ significantly. Reasons for this result have been discussed. A more invasive diagnosis in curable cases is proposed.     

The incidence and clinical significance of paraaortic lymph node metastases in patients with uterine cervical cancer

Paraaortic lymph node dissection was performed in the treatment of patients with carcinoma of the cervix who were subjected to radical hysterectomy between June, 1982 and March, 1988 at the Department of Obstetrics and Gynecology, Hokkaido University Hospital, Sapporo, Japan. Thirteen out of 246 (5.3%) patients had metastases in the paraaortic lymph node. Of the patients with stage I carcinoma of the cervix, 1.0 per cent had positive paraaortic lymph node. Of the patients with stage II carcinoma, 4.9 per cent had metastases in the paraaortic lymph nodes, and of the stage III patients, 16.7 per cent had positive paraaortic lymph nodes. The incidence of paraaortic node involvement increased along with the advance of the disease. Of the patients with squamous cell carcinoma of the cervix, 4.6 per cent had paraaortic lymph node metastases. Of the patients with adenocarcinoma of the cervix including mixed carcinoma, 6.8 per cent had positive paraaortic node. All the patients with positive paraaortic lymph nodes had metastatic diseases in the pelvic nodes. In addition, the number of groups of positive pelvic nodes in the patients with positive paraaortic lymph nodes was significantly larger than that in those with negative paraaortic nodes. At the time of reporting, seven out of 13 patients with positive paraaortic lymph node have died of the disease. The mean survival period of those seven patients was 14.9 +/- 12.2 (mean +/- SD) months. Of the remaining six surviving patients, three have been doing well for more than three years.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous retroperitoneal lymph node biopsy in carcinoma of the cervix

A percutaneous abdominal biopsy of retroperitoneal and pelvic lymph nodes was accomplished in 17 patients with carcinoma of the cervix. The indications for the needle biopsy are: (a) to determine the extent of neoplastic disease and (b) to facilitate treatment planning. The technique is discussed in detail.     

Synchronous clear cell adenocarcinoma of the cervix and endometrioid carcinoma of the endometrium

Synchronous primary malignant neoplasms of uterus are uncommon. Patients with synchronous cervical and endometrial cancers are even rarer. We describe a case of cervical clear cell carcinoma and endometrial adenocarcinoma occurring simultaneously in a 54-year-old woman presenting with intermittent vaginal bleeding. The concept of synchronous primary malignancies of the genital tract is also reviewed in this report.     

The significance of peritoneal cytology in patients with carcinoma of the cervix

Between 1972 and 1977, 141 patients with benign gynecologic disease and 149 patients with carcinoma of the cervix were evaluated with peritoneal fluid cytology at time of celiotomy. There was no positive cytology (malignant cells) in the benign disease group. The overall incidence of positive peritoneal cytology in the cervical group was 8.1%. Positive peritoneal cytology was found four times more frequently in adenocarcinoma and adenosquamous carcinomas than squamous carcinomas. The incidence in patients undergoing surgery for recurrent or persistent carcinoma after radiation therapy was 22.6% compared to 4.5% in those treated primarily with definitive surgery. The prognoses do not seem to be influenced by peritoneal cytology status when other poor prognostic factors were considered.     

Negative sentinel lymph node accurately predicts negative status of pelvic lymph nodes in uterine cervix carcinoma

OBJECTIVE: The significance of negative sentinel lymph nodes (SLN) is important in the staging and treatment of melanoma and a few other cancers, but is controversial in uterine cervix carcinoma. Our study was aimed at correlating the SLN status in cervical carcinoma with non-sentinel lymph nodes (non-SLN), in a uniform and well controlled population. METHODS: This study includes 36 patients with stage I and IIA cervical carcinoma and bilaterally negative SLN on final pathology. SLN were identified using blue dye and radioisotopic techniques. Frozen section examination was performed for all SLN; the rest of the tissue was formalin fixed and paraffin embedded. The protocol used for SLN was also applied for non-SLN. For each block, six 4-micro m thick sections were cut at 40 micro m intervals and stained with H and E; an additional section taken between the 3rd and 4th levels was imunostained using AE1/AE3 cytokeratin. RESULTS: The mean age for the study population was 39 years (range 25-76); the number of SLN ranged from 2 to 6 (mean 2.7) and the non-SLN from 8 to 49 (mean 23) per case. No metastasis was found in any SLN and non-SLN by step sections and IHC. CONCLUSION: Our study demonstrates that bilaterally negative SLN on final pathology accurately predict the absence of metastases in non-SLN in cervical carcinoma. If confirmed by larger trials, these results may influence the clinical management of early cervical cancer.     

Clinical-pathologic study of stage IIB, III, and IVA carcinoma of the cervix: extended diagnostic evaluation for paraaortic node metastasis--a Gynecologic Oncology Group study

Three hundred twenty patients were entered into GOG Protocol 63, a clinical-pathologic study of stage IIB, III, and IVA cervical carcinoma. Following the completion of FIGO staging prerequisites, patients had computerized tomography (CT), a lymph-angiogram (LAG), and an ultrasound (US) of the aortic area. If any study was positive, a cytologic or histologic evaluation by fine-needle aspiration or selective paraaortic lymphadenectomy was performed. Paraaortic node dissection was mandated for patients with negative extended staging studies. Results of extended staging evaluations were compared with histologic or cytologic results. Two hundred sixty-four patients were eligible and evaluable. One hundred sixty-seven patients (63%) were stage IIB, 89 (34%) were stage III, and 8 (3%) were stage IVA. Positive paraaortic nodes occurred in 21% of stage IIB, 31% of stage III, and 13% of stage IVA. LAG sensitivity was 79% with a specificity of 73%. Sensitivity of CT and US was 34 and 19%, respectively, with specificities of 96 and 99%, respectively. The frequency of false-negative results with LAG for patients with stage IIB disease was 6%. This decrease is consistent with a stable sensitivity and specificity. These findings suggest that a negative LAG may be adequate to eliminate surgical staging in subgroups with low risk of metastasis to the aortic nodes. Until new noninvasive testing methods are developed, LAG appears to be the most reliable noninvasive examination to evaluate spread of cervical cancer to aortic nodes.     

The prognostic significance of surgical staging for carcinoma of the endometrium.

This study is based on a retrospective review of 156 patients with endometrial carcinoma from 1978 through 1984 who underwent primary surgical evaluation. All cases were retrospectively restaged using the newly adopted FIGO surgical staging. The preoperative FIGO clinical stage distribution for this study was as follows: 121 (77.6%) Stage I, 22 (14.1%) Stage II, 5 (3.2%) Stage III, 2 (1.3%) Stage IV, and 6 (3.8%) unstaged patients. Most patients had TAH-BSO with a collection of peritoneal washings and retroperitoneal lymph node sampling. Surgical staging revealed 122 (78.2%) Stage I, 9 (5.8%) Stage II, 12 (7.7%) Stage III, and 13 (8.3%) Stage IV patients. Surgery upstaged 12.4% of clinical Stage I. In clinical stage II, 59.0% were downstaged while 27.3% were upstaged. For clinical Stage III, 60.6% were upstaged, but no downstaging occurred. No change in stage occurred for clinical Stage IV patients. Ninety-seven surgically staged patients received no adjuvant therapy. The remaining 59 patients had adjunctive treatment which consisted of radiotherapy (59.3%), hormonal therapy (25.4%), chemotherapy (5.1%), or combined modality treatment (10.2%). All patients were followed until death or a minimum of 5 years (60-139 months; median, 82 months) with the exception of 13 patients who were lost to follow-up (2-58 months; median, 34 months). Five-year survival by clinical staging was as follows: 86.2% for Stage I, 85.9% for Stage II, and 0% for Stage III and IV. Five-year survival by surgical staging was 90.6% for Stage I, 85.7% for Stage II, 58.3% for Stage III, and 0% for Stage IV. The 13 patients who were lost to follow-up were censored in all survival analyses at the time of last contact. Stepwise regression analysis using a parametric proportional hazards model identified surgical stage as the most significant prognostic factor (P = 0.02). Univariate analysis showed that patients with surgical Stage IC had significantly worse prognosis (75.0%, 5 years) than those in surgical Stage IA (93.8% 5 YS) or IB (95.4% 5 years). In summary, this study demonstrates that surgical staging as recommended by FIGO is indicated to accurately determine the initial extent of disease in endometrial carcinoma. In addition, surgical staging is the strongest predictor of survival. Deep myometrial invasion appears to be a significant independent prognostic factor within surgical Stage I. The role of adjunctive radiotherapy in Stage I disease awaits the results from an ongoing multi-institutional, prospectively randomized trial.     

Intraepithelial epidermoid carcinoma of the cervix, endometrium, and a fallopian tube

A patient with intraepithelial epidermoid carcinoma of the uterine cervix, endometrium, and a fallopian tube is presented. This abnormality is discussed with particular attention to the association with chronic inflammation. This rare lesion might represent a superficial spread of atypical cervical epithelium to include the endometrium and fallopian tube or could reflect a field change. The effect of this finding upon the prognosis of intraepithelial carcinoma of the cervix is unknown.