- Email: [email protected]
Therapy of the lateral pelvic nodes in cervical carcinoma
THERAPY
OF THE LATERAL PELVIC CERVICAL CARCINOMA
ALLAN
(From
the
Uepartmrnt
C.
BARNES,
Rf.D.,
of Obstetrics and Western Reserve
T
CLEVEL~KD, Gynecology, Uni~oersity)
NODES IN OHIO the School
of Medicine,
HE importance of adequate therapy to the lymphatics of the lateral pelvic wall in patients wit,h carcinoma of the uterine cervix has long been acknowledged. During the decades covered by Dr. Kosmak’s editorship many studies have reconfirmed this1 and many techniques have been proposed to achieve control of the spreading carcinoma in the nodes of the lateral pelvis.? Taussig” employed surgical dissection of the lateral nodes together with radiation therapy for the central lesion, a suggestion which has been made again more recently by Kimbrough.4 The addition of lateral pelvic x-ray ports to provide increased side-wall dosage of irracliation has been tried hut is associated with an increased incidence of spontaneous fracture of the neck of the femur.” Transvaginally placed interstitial needles69 7 are intended to increase the dosage to these nodes by placing the sources of radioactivity in the neighborhood of the lateral wall. Sherman and his co-workers8 have proposed reaching this area by the paracervical injection into the tissues of colloidal suspensions of radioactive gold. The present paper discusses another approach to this problem. In 1951 Morton alld his associates” proposed the use of fine Nylon tubing as a carrier for multiple weak sources of radioactive cobalt. Such a unit constitutes a plastic and pliable “needle” which possesses unique characteristics as a container for radiation sources in interstitial therapy.l”j I1 This tubing can be so attenuated that it can be threaded into a surgical needle for sewing directly into the area to be treated. More recently, these Nylon “threads” with radioactive portions have become available commercially. While their application in this particular field has not been extensive, and no five-year results are available, the technical details of their use merit discussion as a potential approach to the therapy of the lateral pelvic nodes in carcinoma of t,he cervix. The Threads.-Fine cobalt wire (0.5 mm. diameter) is cut into lengths of one-third centimeter and activated so that each such .piece has a strength of 0.2 mc. These cobalt pieces, with aluminum spacers of the same size, are placed in Nylon tubing of 1.75 mm. outside diameter. When the active sections of such “threads” are placed parallel and at an interval of 1.0 cm. from each other a fielcl is created which yields about 1,000 gamma roentgens per day to the immediate area. Since the strength of such a field results from the cross-firing of multiple sources which are individually weak, it falls off 489
190 sharply on either side of the planar zone in which the threads lie. TllC 1’5 ceedingly weak beta ray of Co”” requires no other shielding thall the walls of the Nylon tubill:;. These threads can be so loaded that, the active portion ranges between ;% and 10 cm. That portion of the tubin, 0’ which is illactive can then be warmetl and attenuated by stretching to the caliber of heavy retention suture (No. ,i Silk). !K’he total length of the threat1 should preferably be 36 inches or more, permitting the sewing which places the threads to l)e c*arried out while the active section is coluplet,rly shieltletl.
Fig. I.-Lead block container for box. Radioactive portion in individual ers” gathered around wool at base of on back and inactive portions on side.
threads. inactive tail of thread fastened on outside of small holes bored through block. Long inactive “leadhandle. Hinged door on back closes around over holes
Techniyue.-With the section of Nylon thread which is active contained in the center of a heavy block of protective lead (Fig. l), and with the inact& ends wrapped around the outside, the entire unit can be sterilized by soaking in Zephiran l:lO,OOO prior to being transported to the operating room. This particular technique represents interstitial therapy which, when applied to pelvic lesions, requires a laparotomy. In contrast to techniques employing transvaginally placed needles, the viscera and vessels of the pelvis are under direct vision while the radioactive sources are being placed. Prior to laparotomy the patients have all received external irradiation which delivers about 3,500 gamma roentgens to the midpelvic plane over a 24 day period, as well as intravaginal therapy with colpostat and tandem which adds another 6,000 gamma roentgens to the total dosage in the paracervical
Volwue 68 h’umbe‘ I
THERAPY
OF
LATERAL
PELVlC
NODES
IN
CERVIX
CANCER
491
region (Point A). Whether the x-ray precedes or follows the intravaginal therapy with colpostat and tandem depends in great measure on the nature of the initial lesion and the clinical findings. The laparotomy is scheduled to follow this therapy, usually within 24 or 48 hours. At laparotomy, pelvic and general abdominal exploration are carried out, and any desired biopsies obtained. Threading the inactive length of the Nylon, the surgeon picks up small bites of lateral-wall peritoneum to anchor the threads over the a,rea to be treated. In general, these bites of peritoneum are taken so that the thread will be anchored approximately parallel to the iliopectineal line. The next thread is similarly anchored parallel to the first, but 1 cm. lower in the pelvis. This sewing continues, using only the inactive
Fig.
2.-Anteroposterior
view
of
pelvis
with
lateral
threads
in place.
portions of the thread until the area to be irradiated is fully coverecl. M’hen parallel rows at 1 cm. intervals have been placed satisfactorily, the radioactive portion is drawn out of the shielding lead container until it lies over the noda. region. The ends of the threads are left long and brought out of the wound at the lower pole. The incision is then closed, with emphasis on speed rather than meticulous precision of technique. Postoperative pelvic x-rays (Figs. 2, 3, and 4) can be taken to check the thread placement. The duration of such therapy depends on the total dosage desired at the lateral pelvic wall. Since, under the average course of therapy outlined above, the lateral pelvic wall (Point B) has received between 3,000 and 4,000 fewer gamma roentgens than has the paracervical region, and since parallel threads at 1 cm. intervals produce 1,000 gamma roentgens per 24 hours, the threads remain in place, in most cases, about 4 days. No anesthesia is necessary for the removal of the threads, and no form of secondary closure has as yet been required for the lower pole of the incision through which the threads emerge. Dosage CoIoulation.-Threads with 7 active cobalt pieces (0.2 me. each) and six aluminum spacers will have a 4 cm. active length. Assuming that six such threads are sewed with parallel spacing in a plane, the covered area is
Am
1. Ohct. & Gyncc.
July,
1951
4 by 5 cm., or 20 sq. cm. This field falls off rapidly at the open ends of thca threads, hut an area of 5 hy 3 cm. recei\-es an average dosage of 854 rc)entyrtls per day (24 hours). If two additional threads can then he sewrtl iI(*I*()sSth+a
Fig.
3.-Oblique
Fig.
s-ray
4.-Oblique
of pelvis
view
of
with
threads
pelvis
after
in place.
sewing
lateral
Aluminum
wall
spacers
with
do not
radioactive
show
in Alnl.
threads.
active ends of six initial threads at right angles t,o them, t,he field is, made more uniform, and the enclosed area of 5 by 4 cm. receives 1,140 roentgens per day. This form of planar implant (parall.el rows with crossing threads at right
Volume 68 Number I
THERAPY
OF
LATERAL
PELVIC
NODES
IN
CERVIX
CANCER
493
angles over the ends of the parallel group) can usually be achieved in the pelvis without too much technical difficulty. Similarly, eight threads of 4 cm. active lengths sewed parallel with the ends crossed by additional threads will produce a field 7 by 4 cm. which receives 1,120 roentgens per 24 hours.
Comment The present paper is not concerned with results; an insufficient number of cases (48) have been treated with this method to make these of any significance, The present paper simply outlines one possible approach to the therapy of the lateral pelvic lymphatics. While Co”” lends itself well to this form of regrouping and requires minimal shielding, and while the Nylon tubing constitutes an ingenious pliable “needle” for interstitial therapy, the writer is not concerned with “selling” this particular technique. Other sources of radioactivity and other methods of applying them may well be presented with undoubted advantages. The writer is interested, however, in “selling” a sense of dissatisfaction with half-doses. Adequate external x-radiation, plus central pelvic therapy from xray cone or from colpostat and tandem, delivers to the lateral pelvic nodes-one of the first major areas of bodily involvement, outside the cervix itself-a dose of irradiation which is insufficient to destroy carcinoma. Dismissing a woman in such a state of half-treatment as being “treated to tolerance” is analogous to discharging a diabetic patient on one-half the required amount of insulin as a maintenance dose. The final results with this particular technique are not as important as is a continued effort to improve the therapy of the nodes of the lateral pelvic wall.
Conclusion Aside from the eradication of the primary growth, adequate therapy for the lymph nodes of the lateral pelvic wall is the principal challenge in the treatment of cervical carcinoma. A possible answer to this challenge is suggested and the technique is outlined for the use of the Nylon “thread” loaded with radioactive cobalt for irradiating the pelvic wall in patients with cancer of the cervix.
References 1. 2. 3. 4. 5.
6.
7. 8. 9. 10. 11.
De Alvarez, Morton, D.
R. R.: AM. J. OBST. & GYNEC. 54: 91, 1947. G.: AM. J. OBST. & GYNEC. 49: 19, 1945. Taussig, 5’. J.: AM. J. OBST. & GYNEC. 45: 733, 1943. Kimbrough, R. A.: Obst. & Gynec. 1: 238, 1953. Univ. Hosp. Bull., Ann Arbor 5: 33, 1939. Peek, W. S.: Corscaden, J. A., Gusberg, S. B., and Donlan, C. P.: Am. J. Roentgenol. 60: 522, 1948. AM. J. OBST. & GYNEC. 60: 1112, 1950. Barnes, A. C.: Sherman, A. I., Nolan, J. F., and Allen, W. M.: Am. J. Roentgenol. 64: 75, 1950. Morton, J. L., Callendine, G. W., Jr., and Myers, W. G.: Radiology 56: 553, 1951. Morton, J. L., Barnes, A. C., Hendricks, C. H., and Callendine, G. W., Jr.: Am. J. Roentgenol. 69: 813, 1953. AM. J. OBST. & GYNEC. 65: 550, 1953. Barnes, A. C.:
OF THE LATERAL PELVIC CERVICAL CARCINOMA
ALLAN
(From
the
Uepartmrnt
C.
BARNES,
Rf.D.,
of Obstetrics and Western Reserve
T
CLEVEL~KD, Gynecology, Uni~oersity)
NODES IN OHIO the School
of Medicine,
HE importance of adequate therapy to the lymphatics of the lateral pelvic wall in patients wit,h carcinoma of the uterine cervix has long been acknowledged. During the decades covered by Dr. Kosmak’s editorship many studies have reconfirmed this1 and many techniques have been proposed to achieve control of the spreading carcinoma in the nodes of the lateral pelvis.? Taussig” employed surgical dissection of the lateral nodes together with radiation therapy for the central lesion, a suggestion which has been made again more recently by Kimbrough.4 The addition of lateral pelvic x-ray ports to provide increased side-wall dosage of irracliation has been tried hut is associated with an increased incidence of spontaneous fracture of the neck of the femur.” Transvaginally placed interstitial needles69 7 are intended to increase the dosage to these nodes by placing the sources of radioactivity in the neighborhood of the lateral wall. Sherman and his co-workers8 have proposed reaching this area by the paracervical injection into the tissues of colloidal suspensions of radioactive gold. The present paper discusses another approach to this problem. In 1951 Morton alld his associates” proposed the use of fine Nylon tubing as a carrier for multiple weak sources of radioactive cobalt. Such a unit constitutes a plastic and pliable “needle” which possesses unique characteristics as a container for radiation sources in interstitial therapy.l”j I1 This tubing can be so attenuated that it can be threaded into a surgical needle for sewing directly into the area to be treated. More recently, these Nylon “threads” with radioactive portions have become available commercially. While their application in this particular field has not been extensive, and no five-year results are available, the technical details of their use merit discussion as a potential approach to the therapy of the lateral pelvic nodes in carcinoma of t,he cervix. The Threads.-Fine cobalt wire (0.5 mm. diameter) is cut into lengths of one-third centimeter and activated so that each such .piece has a strength of 0.2 mc. These cobalt pieces, with aluminum spacers of the same size, are placed in Nylon tubing of 1.75 mm. outside diameter. When the active sections of such “threads” are placed parallel and at an interval of 1.0 cm. from each other a fielcl is created which yields about 1,000 gamma roentgens per day to the immediate area. Since the strength of such a field results from the cross-firing of multiple sources which are individually weak, it falls off 489
190 sharply on either side of the planar zone in which the threads lie. TllC 1’5 ceedingly weak beta ray of Co”” requires no other shielding thall the walls of the Nylon tubill:;. These threads can be so loaded that, the active portion ranges between ;% and 10 cm. That portion of the tubin, 0’ which is illactive can then be warmetl and attenuated by stretching to the caliber of heavy retention suture (No. ,i Silk). !K’he total length of the threat1 should preferably be 36 inches or more, permitting the sewing which places the threads to l)e c*arried out while the active section is coluplet,rly shieltletl.
Fig. I.-Lead block container for box. Radioactive portion in individual ers” gathered around wool at base of on back and inactive portions on side.
threads. inactive tail of thread fastened on outside of small holes bored through block. Long inactive “leadhandle. Hinged door on back closes around over holes
Techniyue.-With the section of Nylon thread which is active contained in the center of a heavy block of protective lead (Fig. l), and with the inact& ends wrapped around the outside, the entire unit can be sterilized by soaking in Zephiran l:lO,OOO prior to being transported to the operating room. This particular technique represents interstitial therapy which, when applied to pelvic lesions, requires a laparotomy. In contrast to techniques employing transvaginally placed needles, the viscera and vessels of the pelvis are under direct vision while the radioactive sources are being placed. Prior to laparotomy the patients have all received external irradiation which delivers about 3,500 gamma roentgens to the midpelvic plane over a 24 day period, as well as intravaginal therapy with colpostat and tandem which adds another 6,000 gamma roentgens to the total dosage in the paracervical
Volwue 68 h’umbe‘ I
THERAPY
OF
LATERAL
PELVlC
NODES
IN
CERVIX
CANCER
491
region (Point A). Whether the x-ray precedes or follows the intravaginal therapy with colpostat and tandem depends in great measure on the nature of the initial lesion and the clinical findings. The laparotomy is scheduled to follow this therapy, usually within 24 or 48 hours. At laparotomy, pelvic and general abdominal exploration are carried out, and any desired biopsies obtained. Threading the inactive length of the Nylon, the surgeon picks up small bites of lateral-wall peritoneum to anchor the threads over the a,rea to be treated. In general, these bites of peritoneum are taken so that the thread will be anchored approximately parallel to the iliopectineal line. The next thread is similarly anchored parallel to the first, but 1 cm. lower in the pelvis. This sewing continues, using only the inactive
Fig.
2.-Anteroposterior
view
of
pelvis
with
lateral
threads
in place.
portions of the thread until the area to be irradiated is fully coverecl. M’hen parallel rows at 1 cm. intervals have been placed satisfactorily, the radioactive portion is drawn out of the shielding lead container until it lies over the noda. region. The ends of the threads are left long and brought out of the wound at the lower pole. The incision is then closed, with emphasis on speed rather than meticulous precision of technique. Postoperative pelvic x-rays (Figs. 2, 3, and 4) can be taken to check the thread placement. The duration of such therapy depends on the total dosage desired at the lateral pelvic wall. Since, under the average course of therapy outlined above, the lateral pelvic wall (Point B) has received between 3,000 and 4,000 fewer gamma roentgens than has the paracervical region, and since parallel threads at 1 cm. intervals produce 1,000 gamma roentgens per 24 hours, the threads remain in place, in most cases, about 4 days. No anesthesia is necessary for the removal of the threads, and no form of secondary closure has as yet been required for the lower pole of the incision through which the threads emerge. Dosage CoIoulation.-Threads with 7 active cobalt pieces (0.2 me. each) and six aluminum spacers will have a 4 cm. active length. Assuming that six such threads are sewed with parallel spacing in a plane, the covered area is
Am
1. Ohct. & Gyncc.
July,
1951
4 by 5 cm., or 20 sq. cm. This field falls off rapidly at the open ends of thca threads, hut an area of 5 hy 3 cm. recei\-es an average dosage of 854 rc)entyrtls per day (24 hours). If two additional threads can then he sewrtl iI(*I*()sSth+a
Fig.
3.-Oblique
Fig.
s-ray
4.-Oblique
of pelvis
view
of
with
threads
pelvis
after
in place.
sewing
lateral
Aluminum
wall
spacers
with
do not
radioactive
show
in Alnl.
threads.
active ends of six initial threads at right angles t,o them, t,he field is, made more uniform, and the enclosed area of 5 by 4 cm. receives 1,140 roentgens per day. This form of planar implant (parall.el rows with crossing threads at right
Volume 68 Number I
THERAPY
OF
LATERAL
PELVIC
NODES
IN
CERVIX
CANCER
493
angles over the ends of the parallel group) can usually be achieved in the pelvis without too much technical difficulty. Similarly, eight threads of 4 cm. active lengths sewed parallel with the ends crossed by additional threads will produce a field 7 by 4 cm. which receives 1,120 roentgens per 24 hours.
Comment The present paper is not concerned with results; an insufficient number of cases (48) have been treated with this method to make these of any significance, The present paper simply outlines one possible approach to the therapy of the lateral pelvic lymphatics. While Co”” lends itself well to this form of regrouping and requires minimal shielding, and while the Nylon tubing constitutes an ingenious pliable “needle” for interstitial therapy, the writer is not concerned with “selling” this particular technique. Other sources of radioactivity and other methods of applying them may well be presented with undoubted advantages. The writer is interested, however, in “selling” a sense of dissatisfaction with half-doses. Adequate external x-radiation, plus central pelvic therapy from xray cone or from colpostat and tandem, delivers to the lateral pelvic nodes-one of the first major areas of bodily involvement, outside the cervix itself-a dose of irradiation which is insufficient to destroy carcinoma. Dismissing a woman in such a state of half-treatment as being “treated to tolerance” is analogous to discharging a diabetic patient on one-half the required amount of insulin as a maintenance dose. The final results with this particular technique are not as important as is a continued effort to improve the therapy of the nodes of the lateral pelvic wall.
Conclusion Aside from the eradication of the primary growth, adequate therapy for the lymph nodes of the lateral pelvic wall is the principal challenge in the treatment of cervical carcinoma. A possible answer to this challenge is suggested and the technique is outlined for the use of the Nylon “thread” loaded with radioactive cobalt for irradiating the pelvic wall in patients with cancer of the cervix.
References 1. 2. 3. 4. 5.
6.
7. 8. 9. 10. 11.
De Alvarez, Morton, D.
R. R.: AM. J. OBST. & GYNEC. 54: 91, 1947. G.: AM. J. OBST. & GYNEC. 49: 19, 1945. Taussig, 5’. J.: AM. J. OBST. & GYNEC. 45: 733, 1943. Kimbrough, R. A.: Obst. & Gynec. 1: 238, 1953. Univ. Hosp. Bull., Ann Arbor 5: 33, 1939. Peek, W. S.: Corscaden, J. A., Gusberg, S. B., and Donlan, C. P.: Am. J. Roentgenol. 60: 522, 1948. AM. J. OBST. & GYNEC. 60: 1112, 1950. Barnes, A. C.: Sherman, A. I., Nolan, J. F., and Allen, W. M.: Am. J. Roentgenol. 64: 75, 1950. Morton, J. L., Callendine, G. W., Jr., and Myers, W. G.: Radiology 56: 553, 1951. Morton, J. L., Barnes, A. C., Hendricks, C. H., and Callendine, G. W., Jr.: Am. J. Roentgenol. 69: 813, 1953. AM. J. OBST. & GYNEC. 65: 550, 1953. Barnes, A. C.: