Distant Metastases in Squamous-Cell Carcinoma of the Uterine Cervix

Abstract

Scant attention has been paid to distant metastases from cancer of the cervix as it was considered generally not to spread above the pelvic brim. A review of the early literature reveals a wide variance in the reported incidence of metastases from cervical carcinoma, not only overall, but also in distribution (1, 3–5). Publications concerning unusual manifestations of metastases from cancer of the cervix have appeared sporadically, but a comprehensive evaluation of a large series of patients portraying the overall incidence of distant metastases as well as that of various organ involvements has not appeared. Modern radiotherapy achieves better control of cancer in the pelvis and allows more patients to survive longer, which, in turn, permits distant metastases to become clinically evident. The present study was undertaken to analyze the incidence and distribution of distant metastases in patients treated at The University of Texas M. D. Anderson Hospital and Tumor Institute, Houston, Texas, between September 1948 and December 1963 for previously untreated squamous-cell carcinoma of the cervix on intact uterus. Clinical management of the patients is discussed, with emphasis on the role of radiation in the treatment of these metastases. Clinical Material The clinical staging of invasive squamous-cell carcinoma of the cervix at this institution has subdivisions of the stages of the International Classification. Stage IA: No more than 1 cm in diameter. Stage IB: Greater than 1 cm in diameter or involving two or more positive quadrant biopsies. Stage IIA: Spread to the upper two-thirds of the vagina and/or to the medial parametria. Stage IIB: Involvement of the lateral parametria, with or without vaginal extension, or massive involvement of the corpus. Stage IIIA: Involvement of one pelvic wall or the lower third of the vagina. Stage IIIB: Spread to both pelvic walls or spread to one pelvic wall and the lower third of the vagina. Stage IV: Invasion of bladder or rectum and/or distant metastases. Of the 2,220 patients treated, distant metastases developed in 341, an incidence of 15.3 per cent. In Table I, distant metastases are correlated with staging to show that the incidence is low for the early lesions, increases as the clinical stage of disease becomes more advanced, and remains essentially fixed at approximately 20 per cent for all stages beyond Stage IIA. Of the 100 patients with Stage IV disease, 59 had rectal and/or bladder involvement and 41 had distant metastases at initial examination. Of the 59 patients classified as Stage IV because of local extension, in 14 (24 per cent) late distant metastases developed. Distant metastases were detected by routine examinations during or after radiation therapy, or at subsequent surgical procedures, and more rarely at autopsy. Most metastases were detected clinically because of symptoms related to a specific organ system. Except for chest x-ray films, screening procedures such as routine bone surveys, liver scans, etc. were employed only as indicated.