We identified data for this Review from searches of Medline, Current Contents, PubMed, and from references in relevant articles, from 1985 to June, 2011, with the following search terms: “locally advanced cervical cancer”, “staging surgery”, “laparoscopic paraaortic lymphadenectomy”, “paraaortic lymphadenectomy”, “PET”, “PET-CT”. Articles published in English (or with at least an abstract in English) were included. In case of repeat publications by the same team on a similar topic, the series
ReviewNodal-staging surgery for locally advanced cervical cancer in the era of PET
Introduction
Chemoradiation therapy combines external beam radiation therapy and cisplatin-based chemotherapy with intracavitary brachytherapy. It is judged by many North American and European teams the standard treatment for patients with a locally advanced cervical cancer (FIGO [International Federation of Gynecology and Obstetrics] stage IB2 or higher).1
Nodal metastasis in women with locally advanced cervical cancer, together with tumour volume and clinical stage, is the strongest prognostic factor for survival.2, 3, 4, 5 Thus, accurate pretherapeutic detection of nodal spread is key for improvement of disease control and patients' survival. Pelvic nodal involvement is noted in 30–50% of affected women but, whatever the stage of disease, pelvic nodes are included routinely in chemoradiation fields and receive a local boost when necessary.1 Para-aortic nodes are involved in 10–25% of patients; systematic extension of radiation fields to this area is associated with increased morbidity, so this strategy should be considered only if para-aortic nodal spread is either highly likely at imaging or proven by pathological examination. Therefore, accurate information about para-aortic nodal status is crucial.
Pretherapeutic staging has an important role in management of women with locally advanced cervical cancer. PET, on its own or combined with CT, raises rates of detection of extrapelvic disease compared with conventional imaging (CT or MRI).6, 7 PET might increase patients' survival by modification of treatment modalities detecting extrapelvic disease.6 Although PET is valuable for detection of extrapelvic organ metastasis, it is disappointing for recognition of small-volume metastases. Staging surgery could enable the clinician to offer individualised management. Although surgical staging is feasible, its real benefit (in terms of boosting survival) versus clinical assessment by conventional imaging continues to be discussed.8 Indeed, surgery might increase treatment morbidity and affect and delay treatment. We reviewed published studies to investigate whether para-aortic staging surgery and PET (alone or with CT) affect outcomes and survival of women with locally advanced cervical cancer.
Section snippets
Imaging of para-aortic lymph nodes
Criteria for lymph-node involvement on CT and MRI are based on size and morphology. A node is judged suspicious when shape is spherical and the smallest diameter is greater than 10 mm. MRI is the preferred method to assess local spread of a cervical tumour. However, PET seems to be more sensitive than MRI for detection of pelvic metastatic node disease.9 Findings of a meta-analysis indicate that both MRI and CT have low sensitivity (respectively, 55·5% and 57·5%) for recognition of para-aortic
Staging surgery for para-aortic nodes
30–40 years ago, para-aortic lymphadenectomy for gynaecological cancers was undertaken by laparotomy.27, 28, 29 The substantial morbidity associated with this approach led to its replacement during the 1990s by laparoscopy. Laparoscopic surgery can be undertaken by either the transperitoneal or the extraperitoneal approach.30, 31
The pattern of para-aortic dissection is important because it could affect the therapeutic strategy and morbidity of lymphadenectomy. Common iliac involvement might
Management
Many protocols for treatment of locally advanced cervical cancer have been analysed, including extended fields of radiation therapy alone (before the era of chemoradiation), nodal surgery followed by radiation therapy, nodal surgery followed by pelvic radiation therapy alone and adjuvant chemotherapy, and chemotherapy alone. As far as we know, these modalities have not been compared in a randomised trial.
Surgical techniques based on anatomical and embryologically defined compartments have been
Conclusion
PET or PET-CT is the most accurate imaging method to assess extrapelvic disease in locally advanced cervical tumours. Its high true-positive rate suggests that surgical staging is unnecessary when uptake is noted in the para-aortic area. However, the overall false-negative rate of para-aortic node involvement is around 12%, mainly attributable to non-detectable nodal disease (≤5 mm). If we only consider patients with definite nodal uptake in the pelvis, the rate of false-negative para-aortic
Search strategy and selection criteria
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