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How should we stage and tailor treatment strategy in locally advanced cervical cancer? Imaging versus para-aortic surgical staging
  1. Alejandra Martinez1,2,
  2. Martina Aida Angeles2,
  3. Denis Querleu3,
  4. Gwenael Ferron2,4 and
  5. Christophe Pomel5
  1. 1 INSERM CRCT Team 1, Tumor Immunology and Immunotherapy, Toulouse, France
  2. 2 Department of Surgical Oncology, Institut Universitaire du Cancer Toulouse Oncopole - Institut Claudius Regaud, Toulouse, France
  3. 3 Department of Surgical Oncology, Institut Bergonié, Bordeaux, France
  4. 4 INSERM CRCT Team 19, ONCOSARC – Oncogenesis of sarcomas, Toulouse, France
  5. 5 Department of Surgical Oncology, Institut Jean Perrin, Clermont-Ferrand, France
  1. Correspondence to Dr Alejandra Martinez, Department of Surgical Oncology, Institut Universitaire du Cancer Toulouse Oncopole - Institut Claudius Regaud, 1 Avenue Irène Joliot-Curie, 31059, Toulouse, France; martinez.alejandra{at}iuct-oncopole.fr

Abstract

Para-aortic lymph node status at initial assessment is the most important prognostic factor and a key point for the therapeutic strategy in patients with locally advanced cervical cancer. Undiagnosed lymph node metastasis is a major clinical problem as the finding of positive para-aortic lymph nodes leads to treatment modification, with a possible impact on disease free survival. When aortic lymph node disease is discovered, radiotherapy is extended to the para-aortic area, and other treatment modalities may be considered. Fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) is the most accurate imaging examination to assess para-aortic extension in patients with locally advanced cervical cancer. The gold standard to identify para-aortic extension remains histologic evaluation of the lymph nodes. Indeed, PET/CT fails to detect approximately 10–15% of patients with negative PET/CT aortic nodes who have lymph node metastasis on pathologic staging. Patients with positive pelvic lymph nodes have para-aortic extension in 25–30% of cases, and surgical staging will lead to treatment modification and probably to improved para-aortic and distant control. Surgical staging also avoids unnecessary toxicity associated with extended field radiation in approximately 75% of patients with pelvic lymph node metastasis. The best modality to identify para-aortic extension is histological evaluation of the lymph nodes, but the survival benefit of surgical staging remains controversial. On the other hand, current studies include a majority of patients without pelvic lymph node spread, who are likely to be those who will benefit the least from surgical staging.

  • cervical cancer
  • surgical procedures, operative
  • lymph nodes
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Footnotes

  • Twitter @Alejandra, @AngelesFite

  • Contributors AM: conceptualization, project administration, methodology, and writing–original draft. MAA, DQ, GF, and CP: conceptualization, data curation, methodology, and writing–review.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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