Para-aortic nodal staging in advanced cervical cancer, IRCAD 2011
Epublication WebSurg.com, Dec 2011;11(12). URL: http://websurg.com/doi/lt03enkridelka004
In this key lecture, para-aortic (PA) lymph node staging in advanced cervical cancer is discussed. The treatment of advanced cervical cancer cannot be covered by surgery alone for the primary tumor. MRI is the best option to characterize the volume of the disease and its potential extension in the parametrium. Chemoradiation is superior to radiation, as a standard of care for primary disease. In advanced cervical cancer, pelvic lymph nodes are found positive in 25% of patients; consequently they have to be irradiated. Depending on the study, 10 to 40% of para-aortic lymph nodes are invaded. The question is whether we have to extend the field of irradiation systematically with the associated morbidity and the risk of exaggerated treatment in 60 to 90% of cases or treat only the pelvis systematically, with inadequate treatment of para-aortic nodes in 10 to 40% of cases. In nodal staging, MRI gives a sensitivity of 60 to 70%; PET-scan is even better with a sensitivity of 90%. Nodal staging is important to ensure individual treatment planning. Dissection of para-aortic nodes has been proposed in order to confirm the histological status and help with decision-making for each patient: pelvic treatment only is considered if para-aortic nodes are negative; extended-field radiation should be carried out in cases when nodes are positive. In Eric Blanc’s study, patients with negative para-aortic nodes (case 1) had pelvic radiation with concomitant chemoradiation, while patients with positive para-aortic nodes (case 2) were treated by extended-field radiation with chemotherapy. Survival curves in case 1 were similar to those with microscopic para-aortic nodes that had extended-field radiation; cases with bulky nodes had deleterious results. In conclusion, staging of the primary tumor is essential to optimize radiation planning and local control success and node staging is important to ensure individual treatment planning. PET-scan in PA nodal staging is specific but lacks approximately 10% sensitivity. PA node dissection needs further evaluation: it can be performed with controlled morbidity by experienced teams and for selected patients, with a precise definition of histological and nodal status, and impact on treatment planning and potentially on patient’s outcome.