Inadequacy of Conventional Radiation Therapy in Stage Ii Carcinoma of Uterine Cervix Studied by Serial Section of Pelvic Lymph Nodes

Abstract

BYTHE efficacy of external radiation to the pelvic lymph nodes in patients with carcinoma of the cervix has been the subject of extensive discussion, as metastatic spread to these nodes is attended by a poor prognosis.It was felt that conventional fields of external irradiation, which are directed below the pelvic brim, will miss metastases to the common iliac and para-aortic glands. With this in mind, 50 patients with League of Nations stage I1 carcinoma of the cervix uteri, who had been fully irradiated by radium and conventional deep X-ray techniques, were explored surgically 8 weeks after completion of radiation therapy, and selected groups of lymph nodes were removed. These were examined by serial section in an attempt to discover the incidence of metastases to these nodes. Two main points are dealt with in this study: (1) whether such irradiation dosage has any effect on lymph node metastases and (2) whether such conventional radiation therapy is adequate for the treatment of stage IT cancer of cervix. Although the number of patients in this series is small, the results show that the whole problem of management in stage I1 patients needs reconsideration. MATERIAL AND METHODSOnly those patients with stage I1 cancer of the cervix are included in this study. The incidence of metastasis in pelvic lymph nodes is higher in this group than in stage I (Meigs, 1958;Navratil, 1954). The good results of radium and deep X-ray therapy in stage I make surgical interference after radiation therapy unjustifiable (Blaikley et al., 1962;Kottmeier, 1959). Fifty patients with stage I1 cancer of the cervix have had either bilateral extraperitoneal pelvic * Present address: Department of Anatomy, University of Malaya, Kuala Lumpur, Malaya.lymphadenectomy or a Wertheim hysterectomy following radiotherapy. Those with conventional radiotherapy had 10,800 mg. hours of intravaginal and intra-uterine radium in two courses of 72 hours each, using the Manchester technique. This was followed after one week by external irradiation. 3,500 r. was delivered from a conventional 250 K.V. X-ray machine, at a distance of 50 cm. at SO Ma., with 2 mm. Cu., 1 mm. Al. and 0.5 mm. Sn. as filter, over 4-5 weeks to the parametria and lateral pelvic walls. This was followed by either extraperitoneal lymphadenectomy or Wertheim type hysterectomy after 8 weeks. Patients with persistence of cancer at the primary site were not included in this study.Altogether 596 lymph nodes were available for study. Fatty tissue was removed by passing them through xylol and alcohol before section. Each node was divided and a single section taken from each half. If there was no evidence of metastatic cancer, the whole block was serially sectioned and every fifth section stained with haematoxylin and eosin. A detailed histological analysis of these glands will be dealt with in the next paper. RESULTSOf the 50 patients with stage I1 lesions on whom pelvic lymph node dissections were performed and on whom only a single section was made from each half of the node, only 4 were ...