title: Pretreatment scalene node biopsy in gynecologic malignancy: prudent or passé?
abstract: OBJECTIVE
  Surgicopathologic evaluation of the scalene fat pad is considered a critical step in the pretreatment evaluation of patients at our institution with cervical or corpus carcinoma when the periaortic lymph nodes (PAN) are involved. However, enthusiasm for this procedure at other centers has waned, largely due to a wide discrepancy in the reported rates of occult scalene node involvement. In an attempt to clarify the benefit of pretreatment scalene node sampling in gynecologic malignancies, we present our experience over the past 18 years.
  
  
  METHODS
  We identified 57 patients who underwent scalene node sampling between 1980 and 1998. In 39 of 49 (80%), the decision to proceed with scalene node sampling was based entirely on histologically documented PAN metastases. In the remainder, scalene node sampling was prompted by the presence of suspicious clinical findings.
  
  
  RESULTS
  Of the 49 patients included in the study, 33 had carcinoma of the cervix, while 16 had corpus carcinoma. Ninety percent of scalene node sampling was performed at the time of primary diagnosis. Overall, 9 patients (18%) had scalene node metastases. Notably, not a single patient with corpus cancer was found to have scalene node metastases in the absence of clinically evident scalene node enlargement independent of PAN status. In cervix cancer cases, the presence of grossly involved PAN was predictive of a high likelihood of scalene node metastases (44%), while no patient with occult PAN metastases had involvement of the scalene node. Only 1 minor complication was encountered following scalene node sampling. The 40 scalene node-negative patients were treated with either extended field radiation or whole abdominal radiation therapy, and 20% developed a major, RTOG grade >/=3 complication such as fistula formation, bowel obstruction, or ureteral stenosis. Only 1 case of mild radiation enteritis and cellulitis occurred during palliative radiation in the group of patients with scalene node metastases.
  
  
  CONCLUSIONS
  Scalene node sampling may be of benefit in the pretreatment evaluation of patients with cervical carcinoma when PAN are grossly involved. Given that scalene node involvement satisfies the criteria for distant metastases, identification of such allows the clinician to avoid the morbidity of extended field radiotherapy in a setting without the chance for cure.
authors.affiliation: Division of Gynecologic Oncology, University of Washington, Seattle, Washington 98195, USA.
authors.forename: N S
authors.initials: NS
authors.lastname: Horowitz
authors.forename: H K
authors.initials: HK
authors.lastname: Tamimi
authors.forename: B A
authors.initials: BA
authors.lastname: Goff
authors.forename: W J
authors.initials: WJ
authors.lastname: Koh
authors.forename: R A
authors.initials: RA
authors.lastname: Schmidt
authors.forename: B E
authors.initials: BE
authors.lastname: Greer
authors.forename: P J
authors.initials: PJ
authors.lastname: Paley
mesh_terms: D001706:Biopsy; D005260:Female; D005833:Genital Neoplasms, Female / Q000473:pathology* / Q000628:therapy; D006801:Humans; D008207:Lymphatic Metastasis; D009333:Neck