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Genital malignancy in pregnancy
Evaluation of conventional diagnostic tests for detection of recurrent carcinoma of the cervix GUY
J.
Chupel
Hill,
PHOTOPULOS, North
ROBERT Charlottr,
RUDI Fort
E. L. North
M.D.
Carolina
SHIRLEY,
JR.,
M.D.
Carolina
ANSBACHER, Sam Houston,
M.D.,
M.S.,
COLONEL,
MC,
USA,
F.A.C.O.G.
Terns
The use of routine diagnostic tests to evaluate patients periodically after treatment for carcinoma of the cervix has been reviewed. Of 169 patients treated at Brooke Army Medical Center for carcinoma of the cervix, 73 were evaluated after their treatment by a group of six diagnostic tests referred to collectively as an oncologic survey. The survey consisted of an intravenous pyelogram (IVP), chest roentgenogram, barium enema, cystoscopy, proctoscopy, and bone scan. Although 16 patients developed recurrent tumor, the oncologic survey detected only three recurrences that had not already been suspected by physical examination. Only the IVP and chest roentgenogram were of sufficient benefit to suggest their routine use for the detection of recurrent cancer. The other tests included in the oncologic survey were not beneficial when used routinely and should be reserved to evaluate patients otherwise suspected of recurrent cancer. (AM. J. OBSTET. GYNECOL. 129: 533, 1977.)
PATIENTS SHOULD BE routinely followed after primary treatment for invasive carcinoma of the cervix in order to detect a recrudescence of cancer. The evaluation should consist of a physical examination, cytologic tests, and other diagnostic tests; however, there is no uniform agreement regarding the diagnostic tests that should be routinely used. Although most of the 193 recurrences reported by Calame’ were detected by physical examination and cytologic methods, a few were detected by the intravenous pyelograms (IVP). VanVoorhis,’ however, found no difference in survival rates between cervical carcinoma patients followed by routine examination and those patients not regularly followed.
Although methods of early detection may be inadequate, most investigators agree that the occasional detection of an early recurrence justifies periodic evaluation of the patient. Kottmeier3 reported that 10 percent of 3,063 patients who initially responded to treatment developed central pelvic recurrence. Of those patients with central pelvic recurrences, 30 per cent were successfully treated; however, only a few of the 627 patients with lateral pelvic or distant recurrences were successfully treated. Sprat and associates” inferred, from the growth rate of pulmonary metastases, that the time between the earliest diagnosis and death may be only a few months; this inference emphasizes the need for early detection. It is, therefore, important to diagnose central pelvic recurrences prior to the development of regional or distant metastases. Despite the concern for early diagnosis of recurrent carcinoma of the cervix, it is uncertain which diagnostic tests are of greatest benefit in follow-up evaluations. After reviewing the role of diagnostic radiology in the evaluation of pelvic tumors, Cunningham and associate? concluded that radiographic tests were not necessarily helpful in clinically evaluating normal patients. They cited the IVP, however, as a test of potential merit. Indeed, diagnostic tests that were the most informative in evaluating patients with carcinoma of
From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, School of Medicine, Chapel Hill, and the Department of Obstetrics and Gynecology, Department of the Army, Brooke Army Medical Center, Fort Sam Howton.
Receivedfor publication February Revised
April
14, 1977.
28, 1977.
Accepted June 9, 1977. Reprint requests: Dr. Guy Photopulos, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, 5009-B Old Clinic Bldg. 2268, Chapel Hill, North Carolina 27514.
533
534
Photopulos,
Shirley,
and Ansbacher Am.
November J. Obstet.
1, I Y 77 Gvnecol.
A. RECURRENCE NOT SUSPECTED 3 with abnormal surveys .wl -2
Treated and well Dead of Cancer
B. RECURRENCE SUSPECTED 1D PatientsY
6 with abnormal surveys
14
6 Dead of Cancer 1 Proved Recurrence ;;I:” normal survey)
with normal surveysc3
1. The status of the 73 patients receiving oncologic surveys suspected to have recurrent carcinoma at the time of the survey have recurrent carcinoma at the time of the survey (B).
Fig.
Table I. The patients treated at Brooke Army Medical Center for invasive carcinoma of the cervix during the period 1958 to 1973, are shown according to the staging recommendation of FIG0 No. of patients
Unknown*
84 51 17 13 - 4
41 24 5 2 1
Total
169
73
*The ing.
records
of four
patients
were
Rccurrentr
patients surveyed
treated
IV
Table II. The results of the oncologic surveys of‘ patients not clinically suspected to have recurrent cancer and surveys of patients clinically suspected to have recurrence are shown
No. of
Stage IB II III
not adequate
for stag-
the cervix prior to treatment would likely be most informative in following patients after treatment. Shingleton and associate? reported that 14 per cent of IVP’s performed prior to treatment for carcinoma of the cervix were abnormal, whereas barium enemas, sigmoidoscopies, and cystoscopies were not routinely informative. Since this institution has offered a group of diagnostic studies, referred to as the oncologic survey, to patients after treatment for carcinoma of the cervix, we have had an opportunity to analyze this practice. We report
the
results
of these
surveys
is diagrammed, showing those not (A) and those clinically suspected to
and
our
assessment
of their merit for the detection of recurrent carcinoma of the cervix. Because the purpose of the review was specifically to evaluate the merits of the oncologic survey, we did not record data regarding other clinical changes or cytology.
Material and methods From 1958 through 1973, 169 patients were treated at Brooke Army Medical Center for invasive carcinoma of the cervix. Clinical staging was according to the rec-
Not msprcted No. of patients No. of recurrences No. of oncologic surveys Surveys with abnormal results Surveys with false normal results Abnormal IVP’s Abnormal chest roentgenogram Abnormal scan Abnormal copv Abnoimal copy Abnormal enema
Suspected
Total
63 9 208
10 7 10
73 16 218
3
6
Y
4
1
5
2 1
3 I
.5 2
bone
0
I
1
cystos-
0
1
1
proctos-
0
0
0
barium
0
0
0
ommendation of the International Federation of Obstetrics and Gynecology (FIGO) (Table I). After treatment, a physical examination and cytologic smear were done at three-month intervals for the first two years and then at progressively longer intervals. In order to enhance the detection of recurrent tumor, an oncologic survey, consisting of an IVP. chest roentgenogram, barium enema, cystoscopy, proctoscopy, and bone scan, was performed annually on all available patients. Ninety-six patients did not receive the oncologic survey because of death soon after treatment, relocation, or refusal to participate. The remaining 73 patients were evaluated by 2 18 oncologic surveys. Sixty-three patients in whom recurrent cancer
Number
5
was not clinically suspected had surveys done as a part of their routine annual evaluation. The remaining 10 patients had surveys done in order to verify the clinical suspicion of recurrent tumor and to define the extent of disease.
Results The results of the oncologic surveys are summarized in Table II and Fig. 1. Sixty-three patients not thought to have recurrent tumor underwent 208 oncologic surveys, and three patients had abnormal surveys. These included two abnormal IVP’s and one abnormal chest roentgenogram. One of these patients was found to have central recurrenE cancer and was successfully treated; the two other patients had recurrent cancer and died. Recurrent cancer was proved in four additional patients less than 12 months after a normat survey. Although the four patients may not have had tumor at the time of the survey, these surveys are considered to have given false normal results. In addition, 27 of the 63 patients had five consecutive annual surveys with normal results; two of these patients later developed recurrent cancer. Ten patients were believed to have recurrent cancer after physical examination and underwent 10 oncologic surveys. The results of six surveys were abnormal and those of four were normal. There were three abnormal IVP’s and one abnormal bone scan, chest roentgenogram, and cystoscopy. The six patients whose surveys showed abnormal results were proved to have recurrent cancer and died. Three of the four patients surveyed who had normal results did not have recurrent tumor and are well, but one of the patients whose survey results were normal was later proved to have recurrent cancer and died. That survey is considered to have given a false normal result. There were no false positive surveys reported for any patient.
REFERENCES 1. Calame, R. J.: Recurrent carcinoma of the cervix, AM. J. OBSTET.GYNECOL. 105:380, 1969. 2. VanVoorhis. L. W.: Carcinoma of the cervix, II. A critical evaluation of patient follow-up, AM. J. OBSTET. GYNECOL. 108: 115, 1970. 3. Kottmeier. H. L.: Evaluation of treatment of recurrences after surgery and radiotherapy for carcinoma of the cervix, in Cancer of the Uterus and Ovary, Chicago, 1969, Year Book Medical Publishers, Inc., p. 283.
utagnostlc
tests
for recurrent
cervical
carcinoma
535
Comment Our results do not support the routine annual use of all the tests used in the oncologic survey. However, use of the IVP and chest roentgenogram in addition to physical examination and cytologic evaluation was beneficial. The optimum frequency for these tests has not been determined by this study. Four recurrences were detected less than 12 months after an oncologic survey showed normal results; this fact suggests that if the IVP and chest roentgenogram are to be done routinely they should be done more frequently than at annual intervals. More recurrences were diagnosed by physical examination than were detected by the oncologic surveys. In addition, the number of oncologic surveys resulting in a false normal diagnosis (five) exceeded one half the number of all oncologic surveys demonstrating abnormal results (nine). The barium enema, proctoscopy, cystoscopy, and bone scan added significant cost and patient inconvenience without adding significantly to the detection of recurrent tumor. These tests should, therefore, be reserved to evaluate patients with clinically suspected recurrent cancer. The importance of early diagnosis of recurrent carcinoma of the cervix has been stressed. Further evaluation of diagnostic tests to determine their value and optimum frequency of use will be required. Although the IVP and chest roentgenogram were responsible for the detection of three cases of previously unrecognized recurrences, one of which was successfully treated, better techniques with greater reliability and ease of application are needed. Our experience, however, should be of assistance to clinicians planning a follow-up program after treatment for invasive carcinoma of the cervix.
4. Spratt, J. S., Butcher, H. R., and Bricker, E. M.: Exenterative Surgery of the Pelvis, Philadelphia, 1973, W. B. Saunders Company, p. 54. 5. Cunningham, J. J., Fuks, Z. Y., and Castellino, R. A.: Radiographic manifestations of carcinoma of the cervix and complications of its treatment, Radiol. Clin. North Am. 12: 93, 1974. 6. Shingleton, H. M., Fowler, W. C., Jr., and Koch, G. G.: Pretreatment evaluation in cervical cancer, AM. J. OBSTET. G~NECOL. 110: 385, 1971.
J.
Chupel
Hill,
PHOTOPULOS, North
ROBERT Charlottr,
RUDI Fort
E. L. North
M.D.
Carolina
SHIRLEY,
JR.,
M.D.
Carolina
ANSBACHER, Sam Houston,
M.D.,
M.S.,
COLONEL,
MC,
USA,
F.A.C.O.G.
Terns
The use of routine diagnostic tests to evaluate patients periodically after treatment for carcinoma of the cervix has been reviewed. Of 169 patients treated at Brooke Army Medical Center for carcinoma of the cervix, 73 were evaluated after their treatment by a group of six diagnostic tests referred to collectively as an oncologic survey. The survey consisted of an intravenous pyelogram (IVP), chest roentgenogram, barium enema, cystoscopy, proctoscopy, and bone scan. Although 16 patients developed recurrent tumor, the oncologic survey detected only three recurrences that had not already been suspected by physical examination. Only the IVP and chest roentgenogram were of sufficient benefit to suggest their routine use for the detection of recurrent cancer. The other tests included in the oncologic survey were not beneficial when used routinely and should be reserved to evaluate patients otherwise suspected of recurrent cancer. (AM. J. OBSTET. GYNECOL. 129: 533, 1977.)
PATIENTS SHOULD BE routinely followed after primary treatment for invasive carcinoma of the cervix in order to detect a recrudescence of cancer. The evaluation should consist of a physical examination, cytologic tests, and other diagnostic tests; however, there is no uniform agreement regarding the diagnostic tests that should be routinely used. Although most of the 193 recurrences reported by Calame’ were detected by physical examination and cytologic methods, a few were detected by the intravenous pyelograms (IVP). VanVoorhis,’ however, found no difference in survival rates between cervical carcinoma patients followed by routine examination and those patients not regularly followed.
Although methods of early detection may be inadequate, most investigators agree that the occasional detection of an early recurrence justifies periodic evaluation of the patient. Kottmeier3 reported that 10 percent of 3,063 patients who initially responded to treatment developed central pelvic recurrence. Of those patients with central pelvic recurrences, 30 per cent were successfully treated; however, only a few of the 627 patients with lateral pelvic or distant recurrences were successfully treated. Sprat and associates” inferred, from the growth rate of pulmonary metastases, that the time between the earliest diagnosis and death may be only a few months; this inference emphasizes the need for early detection. It is, therefore, important to diagnose central pelvic recurrences prior to the development of regional or distant metastases. Despite the concern for early diagnosis of recurrent carcinoma of the cervix, it is uncertain which diagnostic tests are of greatest benefit in follow-up evaluations. After reviewing the role of diagnostic radiology in the evaluation of pelvic tumors, Cunningham and associate? concluded that radiographic tests were not necessarily helpful in clinically evaluating normal patients. They cited the IVP, however, as a test of potential merit. Indeed, diagnostic tests that were the most informative in evaluating patients with carcinoma of
From the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, School of Medicine, Chapel Hill, and the Department of Obstetrics and Gynecology, Department of the Army, Brooke Army Medical Center, Fort Sam Howton.
Receivedfor publication February Revised
April
14, 1977.
28, 1977.
Accepted June 9, 1977. Reprint requests: Dr. Guy Photopulos, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, 5009-B Old Clinic Bldg. 2268, Chapel Hill, North Carolina 27514.
533
534
Photopulos,
Shirley,
and Ansbacher Am.
November J. Obstet.
1, I Y 77 Gvnecol.
A. RECURRENCE NOT SUSPECTED 3 with abnormal surveys .wl -2
Treated and well Dead of Cancer
B. RECURRENCE SUSPECTED 1D PatientsY
6 with abnormal surveys
14
6 Dead of Cancer 1 Proved Recurrence ;;I:” normal survey)
with normal surveysc3
1. The status of the 73 patients receiving oncologic surveys suspected to have recurrent carcinoma at the time of the survey have recurrent carcinoma at the time of the survey (B).
Fig.
Table I. The patients treated at Brooke Army Medical Center for invasive carcinoma of the cervix during the period 1958 to 1973, are shown according to the staging recommendation of FIG0 No. of patients
Unknown*
84 51 17 13 - 4
41 24 5 2 1
Total
169
73
*The ing.
records
of four
patients
were
Rccurrentr
patients surveyed
treated
IV
Table II. The results of the oncologic surveys of‘ patients not clinically suspected to have recurrent cancer and surveys of patients clinically suspected to have recurrence are shown
No. of
Stage IB II III
not adequate
for stag-
the cervix prior to treatment would likely be most informative in following patients after treatment. Shingleton and associate? reported that 14 per cent of IVP’s performed prior to treatment for carcinoma of the cervix were abnormal, whereas barium enemas, sigmoidoscopies, and cystoscopies were not routinely informative. Since this institution has offered a group of diagnostic studies, referred to as the oncologic survey, to patients after treatment for carcinoma of the cervix, we have had an opportunity to analyze this practice. We report
the
results
of these
surveys
is diagrammed, showing those not (A) and those clinically suspected to
and
our
assessment
of their merit for the detection of recurrent carcinoma of the cervix. Because the purpose of the review was specifically to evaluate the merits of the oncologic survey, we did not record data regarding other clinical changes or cytology.
Material and methods From 1958 through 1973, 169 patients were treated at Brooke Army Medical Center for invasive carcinoma of the cervix. Clinical staging was according to the rec-
Not msprcted No. of patients No. of recurrences No. of oncologic surveys Surveys with abnormal results Surveys with false normal results Abnormal IVP’s Abnormal chest roentgenogram Abnormal scan Abnormal copv Abnoimal copy Abnormal enema
Suspected
Total
63 9 208
10 7 10
73 16 218
3
6
Y
4
1
5
2 1
3 I
.5 2
bone
0
I
1
cystos-
0
1
1
proctos-
0
0
0
barium
0
0
0
ommendation of the International Federation of Obstetrics and Gynecology (FIGO) (Table I). After treatment, a physical examination and cytologic smear were done at three-month intervals for the first two years and then at progressively longer intervals. In order to enhance the detection of recurrent tumor, an oncologic survey, consisting of an IVP. chest roentgenogram, barium enema, cystoscopy, proctoscopy, and bone scan, was performed annually on all available patients. Ninety-six patients did not receive the oncologic survey because of death soon after treatment, relocation, or refusal to participate. The remaining 73 patients were evaluated by 2 18 oncologic surveys. Sixty-three patients in whom recurrent cancer
Number
5
was not clinically suspected had surveys done as a part of their routine annual evaluation. The remaining 10 patients had surveys done in order to verify the clinical suspicion of recurrent tumor and to define the extent of disease.
Results The results of the oncologic surveys are summarized in Table II and Fig. 1. Sixty-three patients not thought to have recurrent tumor underwent 208 oncologic surveys, and three patients had abnormal surveys. These included two abnormal IVP’s and one abnormal chest roentgenogram. One of these patients was found to have central recurrenE cancer and was successfully treated; the two other patients had recurrent cancer and died. Recurrent cancer was proved in four additional patients less than 12 months after a normat survey. Although the four patients may not have had tumor at the time of the survey, these surveys are considered to have given false normal results. In addition, 27 of the 63 patients had five consecutive annual surveys with normal results; two of these patients later developed recurrent cancer. Ten patients were believed to have recurrent cancer after physical examination and underwent 10 oncologic surveys. The results of six surveys were abnormal and those of four were normal. There were three abnormal IVP’s and one abnormal bone scan, chest roentgenogram, and cystoscopy. The six patients whose surveys showed abnormal results were proved to have recurrent cancer and died. Three of the four patients surveyed who had normal results did not have recurrent tumor and are well, but one of the patients whose survey results were normal was later proved to have recurrent cancer and died. That survey is considered to have given a false normal result. There were no false positive surveys reported for any patient.
REFERENCES 1. Calame, R. J.: Recurrent carcinoma of the cervix, AM. J. OBSTET.GYNECOL. 105:380, 1969. 2. VanVoorhis. L. W.: Carcinoma of the cervix, II. A critical evaluation of patient follow-up, AM. J. OBSTET. GYNECOL. 108: 115, 1970. 3. Kottmeier. H. L.: Evaluation of treatment of recurrences after surgery and radiotherapy for carcinoma of the cervix, in Cancer of the Uterus and Ovary, Chicago, 1969, Year Book Medical Publishers, Inc., p. 283.
utagnostlc
tests
for recurrent
cervical
carcinoma
535
Comment Our results do not support the routine annual use of all the tests used in the oncologic survey. However, use of the IVP and chest roentgenogram in addition to physical examination and cytologic evaluation was beneficial. The optimum frequency for these tests has not been determined by this study. Four recurrences were detected less than 12 months after an oncologic survey showed normal results; this fact suggests that if the IVP and chest roentgenogram are to be done routinely they should be done more frequently than at annual intervals. More recurrences were diagnosed by physical examination than were detected by the oncologic surveys. In addition, the number of oncologic surveys resulting in a false normal diagnosis (five) exceeded one half the number of all oncologic surveys demonstrating abnormal results (nine). The barium enema, proctoscopy, cystoscopy, and bone scan added significant cost and patient inconvenience without adding significantly to the detection of recurrent tumor. These tests should, therefore, be reserved to evaluate patients with clinically suspected recurrent cancer. The importance of early diagnosis of recurrent carcinoma of the cervix has been stressed. Further evaluation of diagnostic tests to determine their value and optimum frequency of use will be required. Although the IVP and chest roentgenogram were responsible for the detection of three cases of previously unrecognized recurrences, one of which was successfully treated, better techniques with greater reliability and ease of application are needed. Our experience, however, should be of assistance to clinicians planning a follow-up program after treatment for invasive carcinoma of the cervix.
4. Spratt, J. S., Butcher, H. R., and Bricker, E. M.: Exenterative Surgery of the Pelvis, Philadelphia, 1973, W. B. Saunders Company, p. 54. 5. Cunningham, J. J., Fuks, Z. Y., and Castellino, R. A.: Radiographic manifestations of carcinoma of the cervix and complications of its treatment, Radiol. Clin. North Am. 12: 93, 1974. 6. Shingleton, H. M., Fowler, W. C., Jr., and Koch, G. G.: Pretreatment evaluation in cervical cancer, AM. J. OBSTET. G~NECOL. 110: 385, 1971.