The value of pelvic arteriography for the staging of carcinoma of the cervix.

Abstract

Recent advances in the treatment of carcinoma of the cervix are largely attributable to individualization and careful selection of the therapeutic modality based on accurate assessment and staging of the lesion. A critical analysis of the data reported by various authors in the light of this concept suggests that the marked improvement in five-year cure rates in the last two decades can be ascribed to two factors sequential in development. Kottmeier first emphasized the value of accurate staging of carcinoma of the cervix, and one might speculate that his reported 20 per cent improvement in five-year cure rates of Stage I lesions of carcinoma of the cervix reflects the impact of more accurate staging by removing patients with a higher and, hence, less curable form of the disease rather than a truly increased salvage rate attributable to treatment (9). The lack of concomitant change in the cure rates of lesions of carcinoma of the cervix Stages IIa, IIb, and III would particularly mitigate against the conclusion that his therapeutic approach significantly influenced curability of the disease. The introduction of megavoltage therapy as advocated by Fletcher, capable of sterilizing tumor in the parametrium and lymph nodes, marks the second phase of this development but still depends on meticulous triage of the patient material by careful staging (7). Fletcher's communication reporting an improvement of five-year survival rates in Stage Ha, carcinoma of the cervix, of almost 20 per cent over previous series supports this supposition. The interrelationship of staging and individualized therapy in still more advanced lesions was studied by Rutledge et al. in 100 consecutive patients with Stage III squamous carcinoma of the cervix who underwent lymphadenectomy after radiation to the whole pelvis (19). An improvement in five-year survival rates in the group of IIIa lesions of carcinoma of the cervix was noted; however, no cures were obtained in those patients in whom positive nodes were found after radiation therapy. The results were particularly poor if positive nodes were present in the para-aortic chain, an area clearly outside the radiation treatment fields. The existing disparity of the apparent capability to sterilize tumor metastases to lymph nodes and our lack of ability to recognize lymph node metastases has received much emphasis in recent literature (2, 4, 6, 16, 22, 24). Morton reviewed the literature and found an average incidence of lymph node metastases established on the basis of histopathologic studies of 16.3 per cent in Stage I, 32.5 per cent in Stage II, and 45.6 per cent in Stage III carcinoma of the cervix (16). Carlson reported distant metastases in his series of some 2,220 patients in 5 per cent of the patients with a Ib carcinoma of the cervix lesion, 16 per cent in the lib stage, and 20 per cent in the IIIa and IIIb stages (2).