Early cervical carcinoma - The natural history of lymph node involvement redefined on the basis of thorough parametrectomy and giant section study

BACKGROUND. Although parametrectomy is the most difficult step in the surgi cal treatment of cervical carcinoma and is the main cause of postoperative complications, little attention has been given to the patterns of parametri al spread. METHODS. Sixty-nine patients with previously untreated cervical carcinoma ( Federation Internationale de Gynecologie et d'Obstetrique [FIGO] Stage IB1, 49 patients [71%]; Stage IB2, 8 patients [12%]; and Stage IIA, 12 patients [17%]; squamous, 59 patients [86%]; and adenocarcinoma, 10 patients [14%]) underwent radical hysterectomy and pelvic +/- aortic lymphadenectomy. Hyst erectomy specimens were processed with the giant section technique. To obta in a thorough three-dimensional assessment of the paracervical tissue, both the superficial and deep layers of the cervicovesical ligament (anterior p arametrium) and the uterosacral ligament (posterior parametrium) were separ ated from the uterus and submitted for pathologic evaluation. After resecti on of the lateral parametrium with hemoclips, the lympho-fatty tissue remai ning around the pudendal vessels was removed carefully and referred to as " the distal part of the lateral parametrium." RESULTS. When analyzing all the parametria, lymph nodes were present in 64 patients (93%). Clinically undetected parametrial involvement was found by pathologic examination in 15 Stage IB1 patients (31%), 5 Stage IB2 patients (63%), and 7 Stage IIA patients (58%). Metastases were found in the cardin al, cervicovesical, and sacrouterine ligaments and principally were compris ed of lymph node and vascular space invasion. Twenty-five patients (36%) ha d pelvic lymph node metastases whereas concomitant parametrial involvement was observed in all patients. The overall 5-year survival was 91%, being hi gher for parametria and lymph node negative patients (100%) than for those with lymph node and/or parametrial metastases (78%). CONCLUSIONS. A three-dimensional pathologic assessment showed that subclini cal parametrial spreading of the so-called "early" rumors (Stage IB-IIA) oc curred in approximately 30-60% of these patients, and metastasis to the pel vic lymph nodes always was associated with parametrial disease. A better un derstanding of the patterns of parametrial diffusion will improve knowledge of the natural history of cervical carcinoma and in the future may influen ce the treatment of these patients. Furthermore, pathologic assessment of c ervical carcinoma should be modified to evaluate correctly the parametrial status of each patient. The current routine pathologic evaluation of the pa rametria makes it very difficult to detect lymph node metastases and tumor emboli. Cancer 2000;88:2267-74. (C) 2000 American Cancer Society.