SCALENE NODE BIOPSY IN CARCINOMA OF THE CERVIX

Pelvic and Para-aortic Lymphadenectomy GREGORIO DELGADO, MD,* JULIAN P. SMITH, M D , ~ AND ALANDO J. BALLANTYNE, M D ~

Twenty-eight patients with advanced untreated carcinoma of the cervix had selective pelvic and para-aortic lymphadenectomy and a scalene fat pad biopsy to determine the extent of their disease prior to treatment. None of these patients had palpable supraclavicular lymph nodes, but 18 had metastatic cancer in Qne or more pelvic lymph nodes; in the remaining 10 patients, all lymph nodes were free of metastatic cancer. Of the 18 patients with metastatic cancer in the pelvic lymph nodes, 9 also had metastatic cancer in the para-aortic lymph nodes, and 1 had metastatic cancer in a scalene lymph node. This patient had extensive cervical cancer with positive pelvic and para-aortic lymph nodes, unilateral ureteral obstruction, and cancer growing through the posterior cul- de-sac into the pelvic peritoneum. From this study, it appears that scalene lymph node biopsies are of limited value in evaluating patients with advanced cancer of the cervix. Unless the patient has extensive metastases, scalene lymph nodes rarely contain metastatic cancer.

Cancer 35:784-786, 1975.

ETASTASES T O T H E SCALENE LYMPH NODES M have been mainly studied with car- cinoma of the lung;3 there have been few reports associated with carcinoma of the cervix.'^' Although the main pathway of the spread of car- cinoma of the cervix is the lymphatic system, there has been some discussion regarding the involvement of the lymph nodes in the supraclavicular area. Diddle' found 18 of the 746 (2.4%) women who died with invasive car- cinoma of the cervix had metastases to the supraclavicular lymph nodes. O n the other hand, Ketcham et al.' reported a 30% incidence of nonpalpable positive supraclavicular nodes in Stage IIB cancer of the cervix, and proposed scalene fat pad biopsies for patients with cancer

Presented at the 27th Annual Meeting of The James Ew- ing Society, Maui, HI, April 8-13, 1974.

* Assistant Professor and Director of Gynecologic On- cology, at Georgetown Affiliated Hospitals, Washington, DC.

I Associate Gynecologist and Associate Professor of Gynecology, The University of Texas, M. D. Anderson Hospital and Tumor Institute at Houston, TX.

t Associate Professor of Surgery, The University of Texas, M. D. Anderson Hospital and Tumor Institute at Houston, T X .

Address for reprints: Gregorio Delgado, MD, Georgetown University Hospital, Department of Obstetrics and Gynecology, 3800 Reservoir Rd., NW, Washington, D C 20007.

Received for publication August 23, 1974.

clinically confined to the pelvis, suggesting that patients with pelvic cancer would have received inadequate preoperative assessment in the one- third of the cases when supraclavicular node biopsies were not performed. If this report is cor- rect, drastic changes in diagnosis and treatment would be in order. To assess the value of scalene fat pad biopsies, a study was made of the pelvic, para-aortic, and scalene lymph nodes in patients with advanced cancer of the cervix.

METHODS

Twenty-eight patients with advanced un- treated carcinoma of the cervix had a selective pelvic and para-aortic lymphadenectomy and scalene fat pad biopsy performed by the Gynecology and Head and Neck Services at M.D. Anderson Hospital and Tumor Institute, Houston, Texas, to determine the extent of their disease prior to treatment.

The first 12 scalene fat pad biopsies were done by the Head and Neck Services with the first author assisting; the last 16 were performed by the first author. The procedure was done on the left side under general anesthesia. In the first 22 patients, the scalene fat pad biopsies were done prior to the exploratory laparotomy; all 22 had negative scalene node biopsies. The protocol was then changed so that the remaining 6

784

No. 3 SCALENE BIOPSY I N CERVICAL CANCER Delgado et al. 78 5

patients received their scalene fat pad biopsies only if their para-aortic nodes contained metatastic cancer, thus assessing only those patients with more advanced disease.

Para-aortic Lym phadenectomy','

The peritoceum at the base of the small bowel mesentery is opened from the ileocecal area to the third portion of the duodenum. After re- flecting the small bowel mesentery, the lymph nodes anterior and lateral to the aorta and vena cava, extending from the bifurcation of the aorta to the level of the third lumbar vertebrae are removed.

Pelvic Lymphadenectomy'

The peritoneum over the common, external, and internal ileac vessels, as well as the ob- turator fossa, are opened and the lymph nodes carefully dissected.

Scalene Fat Pad Biopsy'

With the patient under general anesthesia an incision is made in the skin parallel to the left clavicle. The sternomastoid muscle is tran- sected to expose the triangle anterior to the scalene muscle, bounded inferiorly by the sub- clavian vein, laterally by the omohyoid muscle, and medially by the internal jugular vein. The tissue within this triangle, which contains the scalene lymph nodes, is removed.

RESULTS

Sixteen of the 28 patients are Stage I11 and IV, the number of positive nodes correlating with the stage of disease, as shown in Table 1. Table 2 shows the number of lymph nodes removed in the 28 patients. One hundred sixty-eight non- palpable supraclavicular lymph nodes were removed; only 1 was positive (0.1%). As many as 18 lymph nodes were removed in 1 patient, with an average of 6 lymph nodes removed per pa- tient. In the 16 patients assessed by the gynecologist, the number of nodes ranged from 3 to 18. Ten patients had negative lymph nodes; 18 others had positive pelvic lymph nodes. Nine of the 18 patients had positive para-aortic lymph nodes, and 1 patient had positive pelvic, para- aortic lymph nodes and scalene lymph node.

Eight patients had an abnormal intravenous pyelogram (i.v.p.) as shown in Table 3. One pa- tient had a false positive lymphangiogram, and &? others false negatives. Seven patients had local

TABLE 1. Cancer of the Cervix-Stage of Disease and Positive Lymph Nodes

Number Positive lymph nodes Stage of patients Pelvic Para-aortic Scalene

~ ~ ~

IIA 3 1 IIB 9 4 2 IIIA 9 8 4 1 IIIB 6 4 3 IV 1 1

TOTAL 28 18 9 1

invasion of the tumor into the pelvic, rectosig- moid, and bladder peritoneum. One patient also had metastases to other organs. Three of the 7 had uterine perforation by local extension of the tumor; the other 4 had perforation of the cul-de- sac necrosis with contamination of the ab- dominal cavity. Fifteen patients had persistent disease or are dead with cancer, 11 of whom had metastatic lymph nodes, as shown in Table 3.

Only one complication related to the scalene fat pad biopsy was recorded, a lymphocyst that drained and regressed spontaneously. One pa- tient had a positive scalene node biopsy. She was 53 years of age, with invasive squamous cell car- cinoma of the cervix, Stage 111, with positive lymphangiogram in the para-aortic and left scalene nodes, hydronephrosis and hydroureter, and perforation of cul-de-sac with con- tamination of the abdominal cavity. At laparotomy, 11 lymph nodes were positive: 1 scalene, 7 pelvic, and 3 para-aortic. The patient died the 3rd postoperative day with massive cerebral hemorrhage.

DISCUSSION

When patients have palpable positive supraclavicular nodes and cancer of the cervix, they have a well-advanced disease, as shown by Diddle' in his study of 746 women who died of cancer.

Ketcham et al.,' indicated that when cervical cancer is apparently still confined to the pelvis, patients with nonpalpable supraclavicular nodes

TABLE 2. Lymph Nodes Removed in 28 Patients

Type of Total No. lymph node no. removed positive Percentage

Scalene 168 1 0.1 Para-aortic 352 23 6.5 Pelvic 265 37 14.0

TOTAL 785 61 7.8

786 CANCER MARCH 1975 Vol. 35

TABLE 3. Patients with Cancer of the Cervix and Other Findings

~~~

Finding No. of patients

Abnormal i.v.p. 8 Lymphangiogram

False negative 8 False positive 1

Cul-de-sac and uterine perforation 11 Metastases to other viscera,

Persistent disease or dead with cancer 15

may have metastatic cancer, thus making scalene fat pad biopsy an important procedure in determining the extent of the disease, and in- corporating it into the routine workup of pa- tients with cancer of the cervix, even in the early stages.

In this study, 27 of 28 patients with well- advanced disease, some with abnormal i.v.p. and positive pelvic and para-aortic lymph nodes, and several with perforation and contamination of the abdominal cavity, had negative supra- clavicular nodes. After 22 consecutive scalene node biopsies in patients with positive pelvic nodes, including 3 with positive para-aortic, the protocol was changed to include only patients with more advanced disease. Only patients with

proven para-aortic nodes containing metastatic cancer underwent scalene fat pad biopsies. All patients with positive para-aortic nodes already had positive pelvic nodes.

Only 1 patient had 1 lymph node which proved to have metastatic cancer (out of a total of 168 supraclavicular nodes removed from all 28 patients). This single patient with a positive scalene node had an abnormal i.v.p., metastatic pelvic and para-aortic lymph nodes diagnosed by lymphangiogram, and contamination of the abdominal cavity.

A possible explanation of the different find- ings of this study compared to the study of Ketcham et al. is that the latter included several patients with recurrent cancer of the cervix, while this study included only patients with pri- mary cancer. Another possible explanation could be different criteria in staging cancer of the cervix.

This study indicates that the patient who has involved supraclavicular nodes, even if nonpal- pable, has far-advanced disease that can be’rec- ognized by physical examination and radiologic and laboratory information. Scalene fat pad biopsy is therefore unnecessary as part of the regular workup in patients with advanced cer- vical malignancies.

REFERENCES

1. Ashbaugh, D. G.: Scalene lymph node biopsy. Surg. Clin. North Am. 49:1385-1389, 1969.

2. Diddle, A. W.: Carcinoma of the cervix uteri with metastases to the neck. Cancer 29:453-455, 1972.

3. Lawton, R. L., and Brintnall, E. S . : Prescalene node biopsy-An analysis of 566 cases. Arch. Surg. 100:68-70, 1973.

4. Ketcham, A. S., Chretien, P. B., Hoye, R. C., Harrah, J. D., Deckers, P. J., Sugarbaker, E. V., Taylor, P. T., and Rabson, A. S.: Occult metastases to the scalene lymph

nodes in patients with clinically operable carcinoma of the cervix. Cancer 31 :180-183, 1973.

5. Piver, S. M., and Barlow, J. J.: Para-aortic lymphadenectomy. aortic node biopsy and aortic lymphangiography in staging patients with advanced cer- vical cancer. Cancer 32:367-370, 1973.

6. Rutledge, R. N., and Wharton, T. J.: Surgical procedures associated with radiation therapy for cervical cancer. In Textbook of Radiotherapy, 2nd ed. Philadelphia, Lea and Febiger, 1973; pp. 705-719.