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Pretreatment Retroperitoneal Para-aortic Lymph Node Staging in Advanced Cervical Cancer: A Review

Smits, Roos Marthe MD; Zusterzeel, Petra L.M. MD, PhD; Bekkers, Ruud L.M. MD, PhD

International Journal of Gynecological Cancer: July 2014 - Volume 24 - Issue 6 - p 973–983
doi: 10.1097/IGC.0000000000000177
Review Articles

Objective: The aims of this study were to evaluate the safety and impact of pretreatment surgical para-aortic lymph node staging (PALNS) in advanced cervical cancer (International Federation of Gynecology and Obstetrics stage IB2-IVA) and to evaluate the preoperative imaging of PALNs.

Methods: We searched in PubMed and the Cochrane Library to identify data investigating the role of surgical PALNS. Selection criteria included English-language and advanced-stage cervical cancer (International Federation of Gynecology and Obstetrics stage IB2-IVA) articles.

Results: Twenty-two articles were included. Para-aortic lymph node metastases were present in 18% (range, 8%–42%) of all patients with cervical cancer stage IB to IVA. The proportions of positive para-aortic nodes on histological analysis with suspicious para-aortic nodes on imaging (positive predictive value) were 20% to 66%, 0% to 27%, 86% to 100%, and 50% to 75% for computed tomographic (CT) scan, magnetic resonance imaging (MRI) scan, positron emission tomography (PET), and PET-CT, respectively. The negative predictive values of the imaging techniques were 53% to 92% for CT scan, 75% to 91% for MRI, 87% to 94% for PET, and 83% to 92% for PET-CT. The proportions of histologically proven PALN metastasis with normal findings on imaging were 9% to 35% for CT scan and MRI, 4% to 11% for PET, and 6% to 15% for PET-CT. The mean complication rate of PALNS is 9%, with a range of 4% to 24%, with lymphocysts being the most common complication.

Conclusions: Pretreatment surgical PALN dissection or sampling is feasible, with low complication rates and short delay in starting treatment. Pretreatment PET or PET-CT is the most accurate imaging method in detecting PALN metastases but has limitations detecting microscopic tumor volumes. Even with normal findings on PET-CT, PALN metastases are present in 4% to 15% of patients. Positive PALNs in stage IB2 to IVA cervical cancer will lead to modification of treatment and may lead to better overall and disease-free survival.

Department of Gynecology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.

Address correspondence and reprint requests to Ruud L.M. Bekkers, MD, PhD, Department of Gynecology, Radboud University Nijmegen Medical Centre, 791, PO Box 9101, 6500 HB Nijmegen, the Netherlands. E-mail: Ruud.Bekkers@radboudumc.nl.

The authors declare no conflicts of interest.

Received March 11, 2014

Accepted April 29, 2014

© 2014 by the International Gynecologic Cancer Society and the European Society of Gynaecological Oncology.