The mode of treatment of carcinoma of the cervix is guided largely by clinical staging based on physical examination. In 1955, Graham (9) reported that 15 per cent of patients with carcinoma of the cervix, International Classification I, were found on examination of the surgical specimen to have lymph node metastases. This clearly demonstrates the need for additional methods of clinical diagnosis which will permit detection of lymph node involvement overlooked by conventional examination. Two logical approaches may be brought to bear on this problem: (a) direct visualization of the lymphatic system on roentgenograms by injection of a contrast medium and (b) indirect visualization of the lymph nodes on scintiscanograms. Much of the pertinent data enabling us to select certain contrast media which will be transported via the lymphatic system have been previously compiled. The experiments of Sherman, Nolan, and Allen (11) demonstrated that radioactive colloidal gold injected into parametrial tissues reaches the regional lymph nodes, the migration taking place quite promptly. Ter-Pogossian (12) showed that the concentration of colloidal gold in the regional lymph nodes of rabbits reached a maximum six to ten hours after the parametrial injection. Flocks et al. (6, 7), as well as Seaman and Powers (10), reported that lymph nodes completely replaced by tumor failed to pick up any radioactive colloidal gold. These data suggest the suitability of radioactive gold for the demonstration of normal lymph nodes on scintiscanograms. Seaman and Powers, however, noted that some of the normal nodes failed to take up the gold, for reasons which were not readily apparent. Direct visualization of the lymphatic system by lymphangiography may be used for the demonstration of tumor infiltration and even partial replacement of pelvic lymph nodes. This method, as outlined by Fuchs and his group (8), may ultimately be a useful technic, but major technical difficulties must first be overcome. In an attempt to study the problems of lymph node visualization, patients with clinically demonstrable involvement of the nodes of the pelvis were subjected to both lymphangiography and scintiscanning after the injection of colloidal gold into the paracervical tissues. The technic employed for lymphangiography utilized the in vivo staining capacity of the lymphatic system for 4 per cent colloidal sky blue. The dye was usually injected into the dorsum of the foot because of its easy accessibility, and a cut-down was then performed on the dye stained lymphatic trunks. A small cannula was inserted into the lymphatic vessels and approximately 12 c.c. of 50 per cent Hypaque was injected. Roentgenograms were obtained during and immediately after the completion of the injection. This method shows filling of the medial lymphatic trunk of the leg with the contrast substance and flow of the medium into the region of the obturator nodes as well as the iliac and para-aortic nodes. Scintiscanograms were obtained on all patients: 20 to 40 microcuries of radioactive colloidal gold, diluted in 1 c.c. of Wydase, was injected into the paracervical area. Scintiscanograms were obtained six, twenty-four, and forty-eight hours after injection. In some cases, a delayed scintiscanogram was obtained after seven days. A 3-inch sodium iodide (thallium-activated) crystal with a 69-hole focusing collimator was used in these studies. An examination of the experimental data reveals gratifying agreement between the clinical findings, the lymphangiograms, and the scintiscanograms in carcinoma of the cervix of stages IC3 and IC4. The pelvic lymph nodes failed to fill with the contrast medium on lymphangiography. The routine six, twenty-four, and forty-eight hour scintiscanograms, as well as studies obtained as long as one week after the injection, showed concentration of the radioactive material at the injection site and failure of its normal distribution into the regional and para-aortic nodes.
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Erich K. Lang (1960) studied this question.