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Diagnostic performance of ultrasonography in pre-operative assessment of lymph nodes in patients with cervical cancer
  1. Filip Fruhauf1,
  2. David Cibula1,
  3. Roman Kocian1,
  4. Michal Zikan2,
  5. Pavel Dundr3,
  6. Jiri Jarkovsky4 and
  7. Daniela Fischerova1
    1. 1 Department of Gynaecology, Obstetrics, and Neonatology, Gynaecologic Oncology Center, General University Hospital and 1st Faculty of Charles University, Prague, Czech Republic
    2. 2 Department of Gynaecology and Obstetrics, Bulovka University Hospital and 1st Faculty of Charles University, Prague, Czech Republic
    3. 3 Institute of Pathology, General University Hospital and 1st Faculty of Charles University, Prague, Czech Republic
    4. 4 Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
    1. Correspondence to Dr Filip Fruhauf, Department of Gynaecology, Obstetrics, and Neonatology, Gynaecologic Oncology Centre, Charles University, Praha 12000, Czech Republic; filip.fruhauf{at}vfn.cz

    Abstract

    Objectives To assess the diagnostic performance of ultrasonography in pre-operative assessment of lymph nodes in patients with cervical cancer, to compare the outcomes for pelvic and para-aortic regions, and to detect macrometastases and micrometastases separately.

    Methods Patients were retrospectively included if they met the following inclusion criteria: pathologically verified cervical cancer; ultrasonography performed by one of four experienced sonographers; surgical lymph node staging, at least in the pelvic region—sentinel lymph node biopsy or systematic pelvic lymphadenectomy or debulking. The final pathological examination was the reference standard.

    Results 390 patients met the inclusion criteria between 2009 and 2019. Pelvic node macrometastases (≥2 mm) were confirmed in 54 patients (13.8%), and micrometastases (≥0.2 mm and <2 mm) in another 21 patients (5.4%). Ultrasonography had sensitivity 72.2%, specificity 94.0%, and area under the curve (AUC) 0.831 to detect pelvic macrometastases, while sensitivity 53.3%, specificity 94.0%, and AUC 0.737 to detect both pelvic macrometastases and micrometastases (pN1). Ultrasonography failed to detect pelvic micrometastases, with sensitivity 19.2%, specificity 85.2%, and AUC 0.522. There was no significant impact of body mass index on diagnostic accuracy. Metastases in para-aortic nodes (macrometastases only) were confirmed in 16 of 71 patients who underwent para-aortic lymphadenectomy. Ultrasonography yielded sensitivity 56.3%, specificity 98.2%, and AUC 0.772 to identify para-aortic node macrometastases.

    Conclusion Ultrasonography performed by an experienced sonographer can be considered a sufficient diagnostic tool for pre-operative assessment of lymph nodes in patients with cervical cancer, showing similar diagnostic accuracy in detection of pelvic macrometastases as reported for other imaging methods (18F-fluorodeoxyglucose positron emission tomography/CT or diffusion-weighted imaging/MRI). It had low sensitivity for detection of small-volume macrometastases (largest diameter <5 mm) and micrometastases. The accuracy of para-aortic assessment was comparable to that for pelvic lymph nodes, and assessment of the para-aortic region should be an inseparable part of the examination protocol.

    • Cervical Cancer
    • Lymph Nodes
    • Lymphatic Metastasis
    • Area Under Curve

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • Contributors FF, RK, MZ, and DF performed the examinations; FF, DC, and DF were involved in planning and supervised the work; JJ performed the statistical analysis; FF and DF processed the experimental data; FF (guarantor responsible for overall content) drafted the manuscript and designed the figures. All authors discussed the results and commented on the manuscript.

    • Funding This work was supported by a grant from the Czech Health Research Council, Ministry of Health (AZV ČR NU21-03-00461).

    • Competing interests None declared.

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

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.