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Percutaneous lymph node aspiration in patients with gynecologic tumors
Percutaneous lymph node aspiration in patients with gynecologic tumors THOMAS
L. EWING
DOLORES DAVID
A. L.
MOJIMIR
BUCHLER
HOOGERLAND G. SONEK
GEORGE
W.
Madison,
Wisconsin
WIRTANEN
Sixty-one patients with gynecologic malignancies had percutaneous transperitoneal lymph node aspiration performed by a flexible 8-inch needle guided to the nodes under monoplanar fluoroscopy. Of the patients who had malignant cetls aspirated from pelvic and periaortic lymph nodes, 84% died or are alive with disease. Only 30% who had negative cytologic testing died or are alive with disease. Of the patients who had malignant cells aspirated from periaortic nodes, 89”/0 died or are alive with disease whereas only 8% with negative cytologic testing died or are alive with disease. We believe that therapy such as extended field irradiation can be given on the basis of these results. (AM. J. OBSTET. GYNECOL. 143:824, 1982.)
STA GI N c of gynecologic malignancies is often inaccurate because nodal disease is not accounted for. It has been shown that 29% of patients with Stage II, III, and IV cervical cancer have positive periaortic nodes.’ Similarly, Creasman and co-worker? showed a high degree of periaortic node involvement for poorly differentiated adenocarcinoma of the endometrium. Despite this new knowledge, overall survival rates for cervical and endometrial cancers have not improved because positive periaortic nodes are usually associated with systemic disease. However, 10% to 20% of such patients survive when treated by operation and extended field irradiation.’ The 30% complication rate seen when transperitoneal staging laparotomy is followed by 5,500 rads or THE
From the Departments of Obstetrics and Gynecology and Human Oncology (Division of Radiation Oncology), University of Wisconsin, Center for Health Science;r. Supported in part by National Cancer Institute P30-CA-14520 and POI-CA-19278-04. Received for publication Revised
February
Accepted March
January
Grants
12, 1982.
19, 1982. 18, 1982.
Reprint requests: Dr. Thomas L. Ewing, Department of Obstetrics and Gynecology, Kaiser-Permanence Medical Center, 280 West MacArthur Blvd., Oakland, California 9461
824
I.
more to the periaortic area’ can be reduced to 2% when the retroperitoneal approach is used and 5,000 rads is given.3 However, a simpler method of determining the status of periaortic nodes must be sought when no improvement in overall survival can be shown. The fine-needle aspiration technique was initially used to diagnose pancreatic, lung, liver, and bone lesions. Gothlin” and Zornoza and associates5 adapted this technique to the aspiration of retroperitoneal lymph nodes. Our objective in this study was to evaluate this percutaneous method of detecting lymph node metastases in patients with gynecologic malignancies.
Material and methods From May, 1977, to May, 1980, 61 patients underwent percutaneous needle aspiration of periaortic and pelvic lymph nodes. Two of these patients also had aspiration of inguinal nodes. Initially, aspiration was performed only on patients with positive lymphograms. Subsequently, 21 patients with negative lymphograms were included because they were at high risk for metastatic nodal disease because of the stage of disease or grade of tumor. Gynecologic malignancies in the 61 patients were classified as follows: cervical, 32; endometrial, 19; ovarian, five: vaginal, two; vulvar, two; and Paget’s disease, one. Only six of these aspirations were performed to determine the presence of recurrent disease. 0002-9378/821150824+05$00.50/0
0
1982
The
C. V. Mosby
CO.
Volume Number
Percutaneous lymph node aspiration
143
7
825
Fig. 1. The tip of the thin-walled, 22-gauge needle is inserted through the short is-gauge needle and directed to a retroperitoneal lymph node under Ruoroscopic guidance. At the beginning of the study, aspirations were taken from operative specimens in order to test the accuracy of the cytopathologist. This proved to be essential for familiarizing the cytopathologist with lymph node aspiration specimens. The lymph node was located by fluoroscopy, and the skin and subcutaneous tissue were infiltrated with 1% lidocaine approximately 2 cm caudad to the node. An l&gauge, 2 3/s4-inch thin-walled needle (Potts-Cournand with obturator*) was inserted to the hub. Through the 18-gauge needle, an s-inch, 22-gauge transhepatic cholangiography needle* was introduced at a slight angle so as not to obscure visualization of the nodes. With a sponge clamp used to grasp its shaft, the needle was directed to the desired site under Auoroscopy (Figs. 1 and 2). Use of the ring forceps allowed manipulation of the needle without placing the hands in the field of irradiation, an advantage not previously reported. The stylet was withdrawn, the node was aspirated with a 20 ml syringe, and the aspirate was ejected forcibly onto a frosted slide. The material was spread with another slide, and both were placed in 95% alcohol. The residual material in the needle was collected by flushing 20 ml of normal saline through the needle. The fluid was centrifuged and collected on a Millipore filter. Both slides were stained by the Papanicolaou stain. Survival curves were drawn on the basis of KaplanMeier estimates.6
Results Of the 61 patients who had pelvic and/or periaortic lymph nodes aspirated for cytologic testing, adequate samples were obtained from 48 (79%). Aspirations *Becton-Dickinson
& Co., Rutherford,
New Jersey.
Fig. 2. X-ray view of needle tip in external iliac node.
Table I. Agreement between lymphography cytoiogic testing in 48 patients
and
LymPhography Cytologic results Positive Negative Total
Positive
21 3 29
Negative
7 12 19
Total
28 z!z? 48
were obtained from patients with positive or negative lymphograms. Twenty-nine patients had positive lymphographic findings; of this group, the cytologic specimens of the lymphographically suspicious nodes were positive for malignancy in 21 and normal in eight (Table I). At follow-up of those patients with positive cytologic results, seven had no evidence of disease when seen at 14 to 49 months, one was living with cancer, and 13 had died of the malignancy. Five of the eight patients with normal cytologic results had no evidence of disease at 11 to 28 months, whereas two patients were alive with active disease, and one had died of cancer. Of 19 patients with a normal lymphogram who had nodes aspirated for cytologic studies, seven had positive cytologic results and 12 had normal results. Follow-up of the seven patients revealed that three were without evidence of disease at 24 months and four had died of malignancy. Of the 12 patients with normal cytologic results, nine had no evidence of disease at 6 to 26 months, two were living with cancer, and one had died
826
August Am. J. Obstet.
Ewing et al.
1. 1982 Gynecol.
100
Negative cytology 80 72 72 .> 5 60 v) v) E $ 40 a 20
I 6
0, 0 0
I 18
I 12
I 24
I 30
I 36
42
Months Fig. 3. Survival
(months)
in patients
with
positive
cytologic
results
versus
those with
normal
results.
Negative lymphography
0
6
12
18
24
30
36
42
Months Fig. 4. Survival phogram.
(months) No difference
in patients is
with
positive
lymphogram
versus
those
with
negative
lym-
noted.
of disease. When the lymphogram was positive, 62% of patients with positive cytologic results died; in contrast, of patients with a negative lymphogram, 57% died of the malignancy. When lymphographic findings were disregarded and patients were reviewed according to cytologic results only, 28 patients had positive results and 20 had normal cells. Of those patients with positive cytologic results, 10 had no evidence of disease, one was living with disease, and 17 had died of malignancy. In comparison, of the 20 patients with normal cytologic results, 14 had no evidence of disease, four were living with disease, and two had died of cancer. Patients with negative cyto-
logic results lived significantly longer (p = 0.005) than patients with positive results (Fig. 3). Survival of patients with positive lymphographic results versus survival of those with negative results did not differ significantly (p = 0.703), even after cytologic results were adjusted for (p = 0.5) (Fig. 4). Many patients had both the pelvic and periaortic nodes sampled. Cells were aspirated from the periaortic nodes in 26 patients, and 13 had positive cytologic results. Of these 13, nine had died of malignancy whereas four had no evidence of disease at 14 to 24 months. Of the patients in whom the periaortic nodes were sampled, those with negative nodes lived sig-
Volume Number
143 7
Percutaneous lymph node aspiration
0 Fig. 5. Survival those with
6
12
(months) in patients with negative aspiration results.
30
positive
nificantly longer (p = 0.014) than those with positive nodes (Fig. 5). Eight of the 13 patients who had positive periaortic nodes had carcinoma of the cervix. Four of these patients did not receive extended field irradiation because of extensive local disease and/or advanced age. Of those four who did receive irradiation, three had died of disease and one was living without disease at 2 years’ follow-up. Three patients were proved to have false positive cytologic results at operation. Because laparotomy was not done routinely, the overall percentage of false positive or false negative results is unknown. Of the 61 patients in this study, 13 (21%) had inadequate aspirate samples. The adequacy of the aspirate was not related to lymph node size, which averaged 1.5 to 2.5 cm. The only complications occurred in a patient who developed a rectus muscle hematoma and transient paresthesia along the medial aspect of the right foot lasting 24 hours.
Comment Fine-needle aspiration in the diagnosis of gynecologic malignancy has been mainly used to aspirate pelvic masses and peripheral lymph nodes. Nordqvist and co-workers’ performed 77 aspirations on 74 patients. Of these, 60% were performed transvaginally or transrectally and none was performed on retroperitoneal lymph nodes. Of the aspirations, 55% were done to diagnose recurrent malignancies. These authors demonstrated 96% accuracy in differentiating benign from malignant conditions. Belinson and associates,* performing aspirations in
cells on aspiration
of periaortic
36
lymph
827
42 45
nodes
versus
90 patients, reported that only three of 103 sites selected were from retroperitoneal lymph nodes. These authors demonstrated 95% accuracy. Dolan and McIntosh9 presented their experience with the percutaneous lymph node aspiration technique in 50 patients with gynecologic cancer. All aspirations were taken from retroperitoneal lymph nodes with the aid of a lymphangiogram and the fluoroscope. They demonstrated the inaccuracies of clinical staging and found advanced disease determined by pathologic assessment in one third of their patients. They reported overall accuracy of 86% with percutaneous lymph node aspiration versus 38% with lymphography. Operation resulted in the correct diagnosis in only 66% of the patients, including three with false negative results, two with technically unsuccessful results, and 12 in whom aspiration was not performed at the time of operation for various reasons. These authors did not report what percentage of aspirations was taken from the periaortic nodes; nor did they report their survival rates in terms of cytologic results. The reported accuracy of lymphography ranges from 65% to 92% and increases with the advanced stage of the cancer. r” To enhance the value of lymphography, and thin-needle transperitoneal technique was used to obtain cytologic material from lymphographically positive and negative nodes. Of the patients with positive lymphography, results were confirmed by cytologic testing in 72% (21/29). This percentage is comparable with that previously reported.” Malignant cells were aspirated twice as often when the lymphogram was positive. However, when malignant cells were obtained, the survival was equally poor whether the
828
Ewing et al.
August
1, 1982
Am. J. Obstet. Gynecol.
lymphogram was positive or negative. Nineteen (68%) of the patients with positive cytologic results received external irradiation to the entire pelvis as part of their treatment, which could have altered the clinical course. Enlarged nodes were easier to aspirate, although it was not difficult to locate and sample any nodes visualized by lymphography. Generally, a staging laparotomy with lymphadenectomy was not done before irradiation because of the increased morbidity.’ Because the accuracy of lymphography has been questioned, we reviewed only the cytologic results. When malignant cells were aspirated from lymph nodes, 62% (18/29) of patients had recurrence of disease or died of the malignancy. When cytologic examination showed malignant cells aspirated from the periaortic nodes, 69% (9/ 13) of the patients died of cancer within 24 months. The false positive results were thought to be the result of misinterpretation of giant cells and the difficulty of interpreting degenerated mesothelial cells and histiocytes. This error rate underlines the need for cytopathologists to become familiar with this type of cytologic testing. Many of the unsatisfactory aspirates obtained early in the study were probably the result of inexperience of the person performing the procedure.
This study demonstrates that a high percentage of samples obtained (79% or 48/61 in this case) can be adequate for interpretation and that transperitoneal node aspiration is a safe procedure. However, a welltrained cytopathologist must be available to interpret the cytologic test. When lymph node aspirates, especially of the periaortic nodes, show malignant cells, the prognostic significance is clear. We believe that lymphography and percutaneous lymph node aspiration of retroperitoneal common iliac and periaortic nodes should be performed in all patients with cervical cancer who are not candidates for radical hysterectomy. Patients with positive cytologic results can have extended field irradiation without the necessity of a staging laparotomy. If lymphography is positive and cytologic rest&s are negative, a sampling error may have occurred, and these cases need to be considered separately. If both the pelvic and periaortic nodes are normal by both lymphography and percutaneous lymph node aspiration, it may be possible to treat only the pelvis with irradiation. We thank R. F. Raubertas, Research Assistant, University of Wisconsin, Clinical Cancer Center Biostatistics Unit, for statistical evaluation of the data.
REFERENCES
1. Lagasse, L. D., Creasman, W. T., Shingleton, H. M., Ford, J. H., and Blessing, J. A.: Results and complications of operative gynecologic
staging in cervical oncology group,
cancer: Gynecol.
6. Kalbfleisch,
J. D.,
and
Prentice,
R. L.:
The
Statistical
Analysis of Failure Time Data (Wiley Series in Probability
experience of the Oncol. 9:90, 1980.
and Mathematical 1980, John Wiley
Statistics: Applied & Sons, Inc.
Section),
New
York,
2. Creasman. W. T.. Boronow. R. C.. Morrow. C. P.., Di Saia. P. J.. and Blessing, J.: Adenocarcinoma of the endome-
7. Nordqvist, S. R.. B., Sevin, B.-U., Nadji, M., Greening, 3. E., and NC. A. B. P.: Fine-needle a&ration cvtoloev in
trium: its metastatic lymph node potential: a preliminary report, Gynecol. Oncol. 4:239, 1976. 3. Berman, M. L., Lagasse, L. D.. Watson, G. W., Ballon, S. C., Schlasinger, R. E., Moore, J. G., and Donaldson, R. C.: The operative evaluation of patients with cervical carcinoma by an extraperitoneal approach. Obstet. Gynecol. 50:658, 1977. 4. Gothlin, J. H.: Post-lymphographic percutaneous fine needle biopsy of lymph nodes guided by fluoroscopy, Radiology 190:205, 1976. 5. Zornoza, J., Lukeman, J. M., Jing, B. S., Wharton, J. T., and Wallace, S.: Percutaneous retroperitoneal lymph node biopsy in carcinoma of the cervix, Gynecol. Oncol. 5:43, 1977.
gynecologic”oncology. I. Diagnostic’ accuracy, O&et. Gynecol. 54:719, 1979. 8. Belinson, J. L., Lynn, J. M., Papillo, J. L., Lee, K., and Korson, R.: Fine-needle aspiration cytology in the management of gynecologic cancer, AM. J. OBSTET. GYNECOL. 139:148, 1981. 9. Dolan, T. E., and McIntosh, P. K.: Percutaneous retro-
peritoneal lymph node biopsy: an appraisal for a substiIO.
tute to laparotomy in far advanced metastatic carcinoma, Gynecol. Oncol. 11:364, 1981. Koehler, P. R.: Current status of lymphography in pa-
tients with cancer, Cancer 37:503, 1976.
L. EWING
DOLORES DAVID
A. L.
MOJIMIR
BUCHLER
HOOGERLAND G. SONEK
GEORGE
W.
Madison,
Wisconsin
WIRTANEN
Sixty-one patients with gynecologic malignancies had percutaneous transperitoneal lymph node aspiration performed by a flexible 8-inch needle guided to the nodes under monoplanar fluoroscopy. Of the patients who had malignant cetls aspirated from pelvic and periaortic lymph nodes, 84% died or are alive with disease. Only 30% who had negative cytologic testing died or are alive with disease. Of the patients who had malignant cells aspirated from periaortic nodes, 89”/0 died or are alive with disease whereas only 8% with negative cytologic testing died or are alive with disease. We believe that therapy such as extended field irradiation can be given on the basis of these results. (AM. J. OBSTET. GYNECOL. 143:824, 1982.)
STA GI N c of gynecologic malignancies is often inaccurate because nodal disease is not accounted for. It has been shown that 29% of patients with Stage II, III, and IV cervical cancer have positive periaortic nodes.’ Similarly, Creasman and co-worker? showed a high degree of periaortic node involvement for poorly differentiated adenocarcinoma of the endometrium. Despite this new knowledge, overall survival rates for cervical and endometrial cancers have not improved because positive periaortic nodes are usually associated with systemic disease. However, 10% to 20% of such patients survive when treated by operation and extended field irradiation.’ The 30% complication rate seen when transperitoneal staging laparotomy is followed by 5,500 rads or THE
From the Departments of Obstetrics and Gynecology and Human Oncology (Division of Radiation Oncology), University of Wisconsin, Center for Health Science;r. Supported in part by National Cancer Institute P30-CA-14520 and POI-CA-19278-04. Received for publication Revised
February
Accepted March
January
Grants
12, 1982.
19, 1982. 18, 1982.
Reprint requests: Dr. Thomas L. Ewing, Department of Obstetrics and Gynecology, Kaiser-Permanence Medical Center, 280 West MacArthur Blvd., Oakland, California 9461
824
I.
more to the periaortic area’ can be reduced to 2% when the retroperitoneal approach is used and 5,000 rads is given.3 However, a simpler method of determining the status of periaortic nodes must be sought when no improvement in overall survival can be shown. The fine-needle aspiration technique was initially used to diagnose pancreatic, lung, liver, and bone lesions. Gothlin” and Zornoza and associates5 adapted this technique to the aspiration of retroperitoneal lymph nodes. Our objective in this study was to evaluate this percutaneous method of detecting lymph node metastases in patients with gynecologic malignancies.
Material and methods From May, 1977, to May, 1980, 61 patients underwent percutaneous needle aspiration of periaortic and pelvic lymph nodes. Two of these patients also had aspiration of inguinal nodes. Initially, aspiration was performed only on patients with positive lymphograms. Subsequently, 21 patients with negative lymphograms were included because they were at high risk for metastatic nodal disease because of the stage of disease or grade of tumor. Gynecologic malignancies in the 61 patients were classified as follows: cervical, 32; endometrial, 19; ovarian, five: vaginal, two; vulvar, two; and Paget’s disease, one. Only six of these aspirations were performed to determine the presence of recurrent disease. 0002-9378/821150824+05$00.50/0
0
1982
The
C. V. Mosby
CO.
Volume Number
Percutaneous lymph node aspiration
143
7
825
Fig. 1. The tip of the thin-walled, 22-gauge needle is inserted through the short is-gauge needle and directed to a retroperitoneal lymph node under Ruoroscopic guidance. At the beginning of the study, aspirations were taken from operative specimens in order to test the accuracy of the cytopathologist. This proved to be essential for familiarizing the cytopathologist with lymph node aspiration specimens. The lymph node was located by fluoroscopy, and the skin and subcutaneous tissue were infiltrated with 1% lidocaine approximately 2 cm caudad to the node. An l&gauge, 2 3/s4-inch thin-walled needle (Potts-Cournand with obturator*) was inserted to the hub. Through the 18-gauge needle, an s-inch, 22-gauge transhepatic cholangiography needle* was introduced at a slight angle so as not to obscure visualization of the nodes. With a sponge clamp used to grasp its shaft, the needle was directed to the desired site under Auoroscopy (Figs. 1 and 2). Use of the ring forceps allowed manipulation of the needle without placing the hands in the field of irradiation, an advantage not previously reported. The stylet was withdrawn, the node was aspirated with a 20 ml syringe, and the aspirate was ejected forcibly onto a frosted slide. The material was spread with another slide, and both were placed in 95% alcohol. The residual material in the needle was collected by flushing 20 ml of normal saline through the needle. The fluid was centrifuged and collected on a Millipore filter. Both slides were stained by the Papanicolaou stain. Survival curves were drawn on the basis of KaplanMeier estimates.6
Results Of the 61 patients who had pelvic and/or periaortic lymph nodes aspirated for cytologic testing, adequate samples were obtained from 48 (79%). Aspirations *Becton-Dickinson
& Co., Rutherford,
New Jersey.
Fig. 2. X-ray view of needle tip in external iliac node.
Table I. Agreement between lymphography cytoiogic testing in 48 patients
and
LymPhography Cytologic results Positive Negative Total
Positive
21 3 29
Negative
7 12 19
Total
28 z!z? 48
were obtained from patients with positive or negative lymphograms. Twenty-nine patients had positive lymphographic findings; of this group, the cytologic specimens of the lymphographically suspicious nodes were positive for malignancy in 21 and normal in eight (Table I). At follow-up of those patients with positive cytologic results, seven had no evidence of disease when seen at 14 to 49 months, one was living with cancer, and 13 had died of the malignancy. Five of the eight patients with normal cytologic results had no evidence of disease at 11 to 28 months, whereas two patients were alive with active disease, and one had died of cancer. Of 19 patients with a normal lymphogram who had nodes aspirated for cytologic studies, seven had positive cytologic results and 12 had normal results. Follow-up of the seven patients revealed that three were without evidence of disease at 24 months and four had died of malignancy. Of the 12 patients with normal cytologic results, nine had no evidence of disease at 6 to 26 months, two were living with cancer, and one had died
826
August Am. J. Obstet.
Ewing et al.
1. 1982 Gynecol.
100
Negative cytology 80 72 72 .> 5 60 v) v) E $ 40 a 20
I 6
0, 0 0
I 18
I 12
I 24
I 30
I 36
42
Months Fig. 3. Survival
(months)
in patients
with
positive
cytologic
results
versus
those with
normal
results.
Negative lymphography
0
6
12
18
24
30
36
42
Months Fig. 4. Survival phogram.
(months) No difference
in patients is
with
positive
lymphogram
versus
those
with
negative
lym-
noted.
of disease. When the lymphogram was positive, 62% of patients with positive cytologic results died; in contrast, of patients with a negative lymphogram, 57% died of the malignancy. When lymphographic findings were disregarded and patients were reviewed according to cytologic results only, 28 patients had positive results and 20 had normal cells. Of those patients with positive cytologic results, 10 had no evidence of disease, one was living with disease, and 17 had died of malignancy. In comparison, of the 20 patients with normal cytologic results, 14 had no evidence of disease, four were living with disease, and two had died of cancer. Patients with negative cyto-
logic results lived significantly longer (p = 0.005) than patients with positive results (Fig. 3). Survival of patients with positive lymphographic results versus survival of those with negative results did not differ significantly (p = 0.703), even after cytologic results were adjusted for (p = 0.5) (Fig. 4). Many patients had both the pelvic and periaortic nodes sampled. Cells were aspirated from the periaortic nodes in 26 patients, and 13 had positive cytologic results. Of these 13, nine had died of malignancy whereas four had no evidence of disease at 14 to 24 months. Of the patients in whom the periaortic nodes were sampled, those with negative nodes lived sig-
Volume Number
143 7
Percutaneous lymph node aspiration
0 Fig. 5. Survival those with
6
12
(months) in patients with negative aspiration results.
30
positive
nificantly longer (p = 0.014) than those with positive nodes (Fig. 5). Eight of the 13 patients who had positive periaortic nodes had carcinoma of the cervix. Four of these patients did not receive extended field irradiation because of extensive local disease and/or advanced age. Of those four who did receive irradiation, three had died of disease and one was living without disease at 2 years’ follow-up. Three patients were proved to have false positive cytologic results at operation. Because laparotomy was not done routinely, the overall percentage of false positive or false negative results is unknown. Of the 61 patients in this study, 13 (21%) had inadequate aspirate samples. The adequacy of the aspirate was not related to lymph node size, which averaged 1.5 to 2.5 cm. The only complications occurred in a patient who developed a rectus muscle hematoma and transient paresthesia along the medial aspect of the right foot lasting 24 hours.
Comment Fine-needle aspiration in the diagnosis of gynecologic malignancy has been mainly used to aspirate pelvic masses and peripheral lymph nodes. Nordqvist and co-workers’ performed 77 aspirations on 74 patients. Of these, 60% were performed transvaginally or transrectally and none was performed on retroperitoneal lymph nodes. Of the aspirations, 55% were done to diagnose recurrent malignancies. These authors demonstrated 96% accuracy in differentiating benign from malignant conditions. Belinson and associates,* performing aspirations in
cells on aspiration
of periaortic
36
lymph
827
42 45
nodes
versus
90 patients, reported that only three of 103 sites selected were from retroperitoneal lymph nodes. These authors demonstrated 95% accuracy. Dolan and McIntosh9 presented their experience with the percutaneous lymph node aspiration technique in 50 patients with gynecologic cancer. All aspirations were taken from retroperitoneal lymph nodes with the aid of a lymphangiogram and the fluoroscope. They demonstrated the inaccuracies of clinical staging and found advanced disease determined by pathologic assessment in one third of their patients. They reported overall accuracy of 86% with percutaneous lymph node aspiration versus 38% with lymphography. Operation resulted in the correct diagnosis in only 66% of the patients, including three with false negative results, two with technically unsuccessful results, and 12 in whom aspiration was not performed at the time of operation for various reasons. These authors did not report what percentage of aspirations was taken from the periaortic nodes; nor did they report their survival rates in terms of cytologic results. The reported accuracy of lymphography ranges from 65% to 92% and increases with the advanced stage of the cancer. r” To enhance the value of lymphography, and thin-needle transperitoneal technique was used to obtain cytologic material from lymphographically positive and negative nodes. Of the patients with positive lymphography, results were confirmed by cytologic testing in 72% (21/29). This percentage is comparable with that previously reported.” Malignant cells were aspirated twice as often when the lymphogram was positive. However, when malignant cells were obtained, the survival was equally poor whether the
828
Ewing et al.
August
1, 1982
Am. J. Obstet. Gynecol.
lymphogram was positive or negative. Nineteen (68%) of the patients with positive cytologic results received external irradiation to the entire pelvis as part of their treatment, which could have altered the clinical course. Enlarged nodes were easier to aspirate, although it was not difficult to locate and sample any nodes visualized by lymphography. Generally, a staging laparotomy with lymphadenectomy was not done before irradiation because of the increased morbidity.’ Because the accuracy of lymphography has been questioned, we reviewed only the cytologic results. When malignant cells were aspirated from lymph nodes, 62% (18/29) of patients had recurrence of disease or died of the malignancy. When cytologic examination showed malignant cells aspirated from the periaortic nodes, 69% (9/ 13) of the patients died of cancer within 24 months. The false positive results were thought to be the result of misinterpretation of giant cells and the difficulty of interpreting degenerated mesothelial cells and histiocytes. This error rate underlines the need for cytopathologists to become familiar with this type of cytologic testing. Many of the unsatisfactory aspirates obtained early in the study were probably the result of inexperience of the person performing the procedure.
This study demonstrates that a high percentage of samples obtained (79% or 48/61 in this case) can be adequate for interpretation and that transperitoneal node aspiration is a safe procedure. However, a welltrained cytopathologist must be available to interpret the cytologic test. When lymph node aspirates, especially of the periaortic nodes, show malignant cells, the prognostic significance is clear. We believe that lymphography and percutaneous lymph node aspiration of retroperitoneal common iliac and periaortic nodes should be performed in all patients with cervical cancer who are not candidates for radical hysterectomy. Patients with positive cytologic results can have extended field irradiation without the necessity of a staging laparotomy. If lymphography is positive and cytologic rest&s are negative, a sampling error may have occurred, and these cases need to be considered separately. If both the pelvic and periaortic nodes are normal by both lymphography and percutaneous lymph node aspiration, it may be possible to treat only the pelvis with irradiation. We thank R. F. Raubertas, Research Assistant, University of Wisconsin, Clinical Cancer Center Biostatistics Unit, for statistical evaluation of the data.
REFERENCES
1. Lagasse, L. D., Creasman, W. T., Shingleton, H. M., Ford, J. H., and Blessing, J. A.: Results and complications of operative gynecologic
staging in cervical oncology group,
cancer: Gynecol.
6. Kalbfleisch,
J. D.,
and
Prentice,
R. L.:
The
Statistical
Analysis of Failure Time Data (Wiley Series in Probability
experience of the Oncol. 9:90, 1980.
and Mathematical 1980, John Wiley
Statistics: Applied & Sons, Inc.
Section),
New
York,
2. Creasman. W. T.. Boronow. R. C.. Morrow. C. P.., Di Saia. P. J.. and Blessing, J.: Adenocarcinoma of the endome-
7. Nordqvist, S. R.. B., Sevin, B.-U., Nadji, M., Greening, 3. E., and NC. A. B. P.: Fine-needle a&ration cvtoloev in
trium: its metastatic lymph node potential: a preliminary report, Gynecol. Oncol. 4:239, 1976. 3. Berman, M. L., Lagasse, L. D.. Watson, G. W., Ballon, S. C., Schlasinger, R. E., Moore, J. G., and Donaldson, R. C.: The operative evaluation of patients with cervical carcinoma by an extraperitoneal approach. Obstet. Gynecol. 50:658, 1977. 4. Gothlin, J. H.: Post-lymphographic percutaneous fine needle biopsy of lymph nodes guided by fluoroscopy, Radiology 190:205, 1976. 5. Zornoza, J., Lukeman, J. M., Jing, B. S., Wharton, J. T., and Wallace, S.: Percutaneous retroperitoneal lymph node biopsy in carcinoma of the cervix, Gynecol. Oncol. 5:43, 1977.
gynecologic”oncology. I. Diagnostic’ accuracy, O&et. Gynecol. 54:719, 1979. 8. Belinson, J. L., Lynn, J. M., Papillo, J. L., Lee, K., and Korson, R.: Fine-needle aspiration cytology in the management of gynecologic cancer, AM. J. OBSTET. GYNECOL. 139:148, 1981. 9. Dolan, T. E., and McIntosh, P. K.: Percutaneous retro-
peritoneal lymph node biopsy: an appraisal for a substiIO.
tute to laparotomy in far advanced metastatic carcinoma, Gynecol. Oncol. 11:364, 1981. Koehler, P. R.: Current status of lymphography in pa-
tients with cancer, Cancer 37:503, 1976.