Lymphatic spread of cervical cancer: an anatomical and pathological study based on 225 radical hysterectomies with systematic pelvic and aortic lymphadenectomy

Sentinel lymph node biopsy as guidance for radical trachelectomy in young patients with early stage cervical cancer

Background

The purpose of this study was to assess the feasibility and accuracy of sentinel lymph nodes (SLNs) detection using 99mTc phytate in predicting pelvic lymph nodes status for radical abdominal trachelectomy (RAT) in patients with early stage cervical cancer.

Methods

Sixty-eight women with stage IA2-IB1 cervical cancer and scheduled to undergo fertility-sparing surgery enrolled in this study. 99mTc-labeled phytate was injected before surgery. Intraoperatively, SLNs were identified, excised, and submitted to fast frozen section. Systematic bilateral pelvic lymphadenectomy and/or para-aortic lymph node dissection was performed. Then RAT was performed in patients with negative SLNs. All nodes were sent for routine pathological examination and immunostained with anti-cytokeratin antibody to detect micrometastases. Outcomes of follow up and fertility were observed.

Results

SLNs were identified in 64 of 68 patients (94.1%). Of these, SLNs of 8 patients (11.8%) were positive on frozen sections and proved to be metastasis by final pathologic examination. The sensitivity, accuracy, and false negative rates were 100%, 100%, and 0%, respectively. All 60 patients with negative SLN underwent RAT successfully. Two relapses occurred and no one died of tumor progression during follow-up. Five of the 15 patients with procreative desire conceived 8 pregnancies (3 term delivery, 2 premature birth, 1 spontaneous abortion, and 2 were still in the duration of pregnancy) after surgery.

Conclusions

The identification of SLN using 99mTc-labeled phytate is accurate and safe to assess pelvic nodes status in patients with early cervical cancer. SLNs biopsy guided RAT is feasible for patients who desire to have fertility preservation.

[Sentinel lymph node procedure and uterine cancers]

Lymph node metastases in cervical and endometrial cancer are major prognostic factors. Lymph-nodal involvement determines adjuvant therapy. As imagery is not reliable to diagnose lymph node status, pelvic +/- para-aortic lymphadenectomy remains the gold standard. These surgical procedures are, however, responsible for specific morbidity: lymphocele and lymphedema. Sentinel lymph node procedure could avoid lymphadenectomy and their complications in cervical and endometrial cancer with good negative predictive values. We present actual indications, procedure and results of sentinel lymph node procedures in cervical and endometrial cancer.

Bilateral negative sentinel nodes accurately predict absence of lymph node metastasis in early cervical cancer: results of the SENTICOL study

PURPOSE

Sentinel lymph node (SLN) biopsy may be used to target lymph node metastases in patients with early cervical cancer. Whether SLN biopsy only is acceptable in the staging and surgical management of early cervical cancer remains unknown. This prospective multicenter study (SENTICOL [Ganglion Sentinelle dans le Cancer du Col]) assessed the sensitivity and negative predictive value (NPV) of SLN biopsy.

PATIENTS AND METHODS

Adults with cervical carcinoma who met the International Federation of Gynecology and Obstetrics criteria for stage IA1 with lymphovascular space invasion to stage IB1 underwent technetium 99 lymphoscintigraphy and Patent Blue injection followed by laparoscopic lymph node mapping, SLN removal, and lymph node dissection. Only surgeons trained in SLN biopsy in cervical carcinoma participated in the study. SLNs and nonsentinel lymph nodes underwent routine staining. Negative SLNs were subjected to ultrastaging. The reference method was pelvic and/or para-aortic lymphadenectomy with histologic examination of all nodes.

RESULTS

One hundred forty-five patients were enrolled, and 139 were included in a modified intention-to-diagnose analysis. Intraoperative radioisotope-blue dye mapping detected at least one SLN in 136 patients (97.8%; 95% CI, 93.8% to 99.6%), 23 of whom had true-positive results and two who had false-negative results, yielding 92.0% sensitivity (23 of 25; 95% CI, 74.0% to 99.0%) and 98.2% NPV (111 of 113; 95% CI, 74.0% to 99.0%) for node metastasis detection. No false-negative results were observed in the 104 patients (76.5%) in whom SLN were identified bilaterally.

CONCLUSION

Combined labeling for node mapping was associated with high rates of SLN detection and with high sensitivity and NPV for metastasis detection. However, SLN biopsy was fully reliable only when SLNs were detected bilaterally.

A randomized study comparing the use of the Ligaclip with bipolar energy to prevent lymphocele during laparoscopic pelvic lymphadenectomy for gynecologic cancer

OBJECTIVE

This prospective randomized pilot study compared the use of the Ligaclip (Ethicon Endo-Surgery, Cincinnati, OH) with bipolar coagulation in preventing lymphoceles after laparoscopic pelvic lymphadenectomy for gynecologic cancer.

STUDY DESIGN

Thirty patients with gynecologic malignancy, who had laparoscopic pelvic lymphadenectomy were randomly assigned for lymphadenectomy in 1 side of the pelvis using the Ligaclip, whereas, in the other side, the bipolar coagulation to seal lymphatic vessels was used.

RESULTS

At ultrasound examination, we detected lymphocele in 10 patients (33%). Lymphocele developed in 9 (30%) patients on the side where laparoscopic pelvic lymphadenectomy was perfomed using bipolar coagulation, and in 1 (3.3%) patient on the side where laparoscopic pelvic lymphadenectomy was performed using the Ligaclip. Univariate analysis revealed that the Ligaclip's use compared with electrocoagulation in the laparoscopic pelvic lymphadenectomy is an independent predictive factor for development of lymphocele (P = .006).

CONCLUSION

This study demonstrates that the use of the Ligaclip to close lymphatic vessels may reduce the incidence of lymphoceles in patients undergoing laparoscopic pelvic lymphadenectomy.

The benefit of small bowel and pelvic bone sparing in excluding common iliac lymph node region from conventional radiation fields in patients with uterine cervical cancer: a dosimetric study

The purpose of this study was to compare dose reduction to the small bowel and sacral bone by two-field and four-field techniques when the common iliac lymph node region is excluded from the radiation field in external beam radiotherapy of uterine cervical cancer. Thirteen patients with cervical cancer were entered into the study. Conventional treatment plans based on bony landmarks were made with parallel-opposed two-field technique (C2F) and four-field box technique (C4F). Modified C2F (M2F) and C4F (M4F) plans of excluding the common iliac lymph node region from the conventional radiation fields were created in reference to the bifurcations of pelvic arteries in computed tomography images. For each patient, the dose volume histograms for the small bowel and sacral bone resulting from the C2F, C4F, M2F, and M4F plans were compared. The volumes were obtained at 10 levels of prescribed dose, at increments of 10%, from 5 Gy to 50 Gy. By sparing both small bowel and sacral bone, the M2F and M4F plans were significantly better than the C2F and C4F plans at any dose level (p < 0.05), respectively. In addition, the M4F plan was significantly better than the M2F plan in sparing both small bowel at 10-50% of the prescribed dose (p < 0.05) and sacral bone at 40-100% of the prescribed dose (p < 0.05). The present study suggests that modified treatment planning could be useful for selected patients for reducing small bowel complications and insufficiency fracture after radiotherapy.

Intratumoral lymphatic vessel density and clinicopathologic features of patients with early-stage cervical cancer after radical hysterectomy

INTRODUCTION

Lymphangiogenesis plays a key role in tumor growth, progression, and metastasis, yet few studies have investigated lymphatic vessel density (LVD) in cases of cervical cancer. The aim of this retrospective study was to evaluate intratumoral LVD, in addition to other histologic variables, in relation to lymph node metastases and survival of patients with stage IB to IIA cervical cancer after radical hysterectomy.

METHODS

Between 2000 and 2008, 144 patients had a diagnosis of cervical uterine cancer and underwent radical hysterectomy. Tumor stages for these patients were identified according to the criteria of the International Federation of Gynecology and Obstetrics and included 84 stage IB1, 44 stage IB2, and 16 stage IIA cases. With an antibody directed against human podoplanin (D2-40), immunohistochemical staining was used to measure LVD. The correlation between LVD and clinicopathologic features of the resected tumors was analyzed.

RESULTS

Lymphatic vessel density was significantly higher in tumors less than 2 cm in diameter (P = 0.001) and in tumors with 1.0-cm-or-less depth of invasion (P = 0.007), with early stage (P = 0.001), and with negative lymph nodes (P = 0.05). After multivariate analysis, the predictive factors associated with lymph node metastases were depth of infiltration (P = 0.027), lymphovascular space invasion (P < 0.001), and parametrial involvement (P = 0.01). For patient death, the predictive factors were International Federation of Gynecology and Obstetrics stage (P = 0.017), histologic type (P = 0.010), lymph node status (P = 0.031), and histologic grade (P = 0.041). Lymphatic vessel density was not a predictive variable for lymph node metastasis or death.

CONCLUSIONS

Intratumoral LVD was greater in early cervical cancer (ie, smaller tumors, early clinical stage, and negative lymph nodes), and no relationship between LVD and lymph node metastases or survival was observed.

Value of PET-CT in avoiding multimodality therapy in operable cervical cancer

BACKGROUND

Posttreatment morbidity of multimodality therapy is substantially higher than either radical surgery or chemoradiation alone. Preoperative prediction of positive nodes limits optimal selection of the primary treatment modality. Computed tomography (CT) and magnetic resonance imaging have been tried for nodal assessment with modest results. Positron emission tomography (PET) combined with CT seems to be promising in this regard. This clinicopathologic study assesses the value of PET-CT in predicting nodal metastasis and avoiding multimodality therapy.

MATERIALS AND METHODS

Eighty patients with clinically operable cervical cancer underwent PET-CT during the preoperative evaluation followed by radical hysterectomy. Adjuvant chemoradiation was administered when indicated by histopathologic findings. The histopathologic finding of the pelvic nodes was correlated with the PET-CT findings for nodal metastasis. The chi2 test was used as the test of significance in the statistical analysis.

OBSERVATIONS

Of 62 patients found PET-CT negative for nodal disease, 52 were true negative, whereas 10 were false negative on histopathologic examination. On the other hand, 14 of 18 patients found PET-CT positive for nodal disease were true positives. Specificity, sensitivity, positive predictive value, and negative predictive value of PET-CT in nodal assessment were found to be 92.8, 58.33, 77.7, and 83.8, respectively. Twenty-four patients (30%) with pelvic nodes positive for disease on histopathologic examination were administered adjuvant chemoradiation. Had we operated only on those patients who were PET-CT negative for nodal disease, 10 of 62 patients would have required adjuvant chemoradiation for positive nodes. Eighteen patients found PET-CT positive for nodal disease would be treated with primary chemoradiation. Inclusion of PET-CT in the decision-making process for primary surgery versus primary chemoradiation would allow 87.5% patients to receive a single modality of treatment (65%, only surgery; 22.5%, only chemoradiation) and the proportion of patients requiring multimodality treatment would reduce significantly from 30% to 12.5% (P < 0.01).

CONCLUSION

Positron emission tomography combined with CT in the evaluation of operable cervical cancer can help in the optimal selection of patients for surgery such that multimodality treatment with its attendant increase in morbidity is avoided.

Differential diagnostic performance of magnetic resonance imaging in the detection of lymph node metastases according to the tumor size in early-stage cervical cancer patients

OBJECTIVES

The objective of this study was to evaluate the diagnostic performance in managing early-stage cervical cancer according to the International Federation of Gynecology and Obstetrics (FIGO) stage or tumor size.

METHODS/MATERIALS

We performed a retrospective review of patients with FIGO stages IB1 to IIA cervical carcinoma who underwent magnetic resonance imaging (MRI) before lymphadenectomy. Lymphadenectomy involved all visible lymph nodes in the surgical fields. We compared the accuracy of MRI for detecting metastatic lymph nodes in the FIGO IB and IIA groups and in the nonbulky (≤ 4 cm) and bulky (>4) tumor groups. χ² analysis was used to compare the accuracy of MRI for detecting metastatic lymph nodes. P ≤ 0.05 was considered statistically significant.

RESULTS

Three hundred five patients were included. Lymph node metastases were present in 49 (16.1%) of these patients. The sensitivity, specificity, and positive and negative predictive values were 7%, 99.3%, 31.3%, and 95.8% in the nonbulky tumor group and 43.8%, 97.1%, 70%, and 91.8% in the bulky tumor group (P = 0.001, P = 0.0097, P = 0.0479, and P = 0.0142, respectively).

CONCLUSIONS

For predicting lymph node metastasis with MRI in early-stage cervical cancer patients, MRI showed a higher diagnostic performance in the bulky tumor group compared with that in the nonbulky tumor group and had a low value in the nonbulky tumor group, even when accounting for FIGO stage.

Magnetic resonance lymphography in gynaecological malignancies

Following the submission of this article to Cancer Imaging, unfortunately the European manufacturer of ferumoxtran-10 (Guerbet) has withdrawn the product pending further phase III studies. This is secondary to the view of the Committee for Medicinal Products for Human Use that the phase III data did not provide adequate statistical demonstration of the product's efficacy.

Magnetic resonance lymphography holds much promise for the non-invasive evaluation of lymph nodes. The technique utilizes ultrasmall superparamagnetic particles of iron oxide and has been shown to be highly sensitive and specific in the diagnosis of malignant lymph nodes. This article reviews the technique and the performance of magnetic resonance lymphography in studies to date; alternative newer methods of nodal assessment such as fluorodeoxyglucose-positron emission tomography/computed tomography and diffusion-weighted magnetic resonance imaging are also discussed, with emphasis on gynaecological malignancies.

Sentinel node detection with (99m)Tc phytate alone is satisfactory for cervical cancer patients undergoing radical hysterectomy and pelvic lymphadenectomy

BACKGROUND

If the sentinel-lymph-node (SLN) concept is valid in cervical cancer, most patients could avoid pelvic lymphadenectomy when absence of metastasis is intraoperatively confirmed in the SLN. We assessed feasibility and accuracy of SLN detection using (99m)Tc phytate in patients with cervical cancer.

METHODS

Eighty-two women with stage Ia-IIb cervical cancer enrolled in this study. All underwent hysterectomy or trachelectomy with accompanying total pelvic lymphadenectomy. On the day before surgery, we injected fluid containing (99m)Tc-labeled phytate subepithelially into four cervical quadrants outside the tumor. Intraoperatively, SLNs were identified as radioactive "hot nodes" by gamma probe. Systematic bilateral pelvic lymphadenectomy was performed after the hot node sampling to evaluate the predictive ability of hot nodes.

RESULTS

A total of 157 lymph nodes were detected as SLNs in 72 of 82 patients. SLN detection rate was 88%. Detection rate was 95% for the subgroups of patients with stage Ia-Ib1 disease and smaller tumor size (<or=3 cm in maximal diameter). Lymph node metastasis was found in 15 patients. In 3 of them, no SLNs were detected. In the remaining 12 patients, each ipsilateral SLN contained metastasis when the pelvic lymph nodes contained metastases. Sensitivity was 100%, the false negative rate was 0%, and the negative predictive value of SLN was 100%.

CONCLUSION

We conclude SLN detection using (99m)Tc-labeled phytate is satisfactory to assess pelvic nodes in patients with early cervical cancer; if validated with other research, it should be incorporated into clinical practice.

Pelvic lymphadenectomy in cervical cancer--surgical anatomy and proposal for a new classification system

BACKGROUND

Pelvic lymphadenectomy is an integral component of gynecologic cancer surgery, yet there is a lack of standardization in the terminology used, the extent of the procedure, and the definition of anatomic landmarks. This lack of standardization if corrected will likely facilitate a more clear communication and analysis of outcomes from various institutions, and reduce confusion to trainees about the procedure being performed.

METHODS

We summarize the anatomic data concerning pelvic lymphatic drainage; describe the procedure based on clearly defined anatomic landmarks; and finally propose a new classification system to facilitate standardization, communication, and comparison of results. The accompanying video demonstrates the anatomic landmarks.

RESULTS

We list and define four commonly used terms related to pelvic lymph node harvesting: sentinel node mapping, excision of bulky nodes, pelvic lymph node sampling, and systematic pelvic lymphadenectomy. We list the five specific anatomic regions of the pelvic lymphatic basin: external iliac, obturator, internal iliac, common iliac, and presacral. We highlight the important neural structures located in regions of the pelvic lymphadenectomy: genitofemoral nerve, obturator nerve, cranial part of the lumbosacral plexus, hypogastric plexus, and splanchnic nerves. Finally, we propose a new, four-part classification system of types of pelvic lymph node dissection.

CONCLUSION

In this report and video, we demonstrate anatomy and offer a new classification system for pelvic lymphadenectomy.

PEGylation of polylysine dendrimers improves absorption and lymphatic targeting following SC administration in rats

Polylysine dendrimers have potential as highly flexible, biodegradable nanoparticular carriers that may also promote lymphatic transport. The current study was undertaken to determine the impact of PEGylation on the absorption and lymphatic transport of polylysine dendrimers modified by surface derivatisation with PEG (200, 570 or 2000Da) or 4-benzene sulphonate following SC or IV dosing. PEGylation led to the PEG(200) derived dendrimer being rapidly and completely absorbed into the blood after SC administration, however only 3% of the administered dose was recovered in pooled thoracic lymph over 30h. Increasing the PEG chain length led to a systematic decrease in absorption into the blood and an enhancement of the proportion recovered in the lymphatics (up to 29% over 30h). For the PEG(570) and PEG(2000) derived dendrimers, indirect access to the lymph via equilibration across the capillary beds also appeared to play a role in lymphatic targeting after both IV and SC dosing. In contrast, the anionic benzene sulphonate-capped dendrimer was not well absorbed from the SC injection site (26% bioavailability) into either the blood or the lymph. The data suggest that PEGylated poly-L-lysine dendrimers are well absorbed from SC injection sites and that the extent of lymphatic transport may be enhanced by increasing the size of the PEGylated dendrimer complex.

Management of pelvic lymph nodes by sentinel node navigation surgery in the treatment of invasive cervical cancer

OBJECTIVE

Diagnosis of lymph node metastasis is a critical issue in the treatment of cervical cancer. Many studies describing sentinel node navigation surgery (SNNS) for examination of node status have been reported in the past decade. In this study, the feasibility of node status diagnosis by SNNS, including intraoperative frozen section diagnosis, in patients with early and advanced cervical cancer was evaluated.

PATIENTS AND METHODS

Fifty-eight cervical cancer patients with early and advanced stage disease were enrolled. All patients were treated with backup pelvic lymphadenectomy after SNNS. To detect sentinel lymph nodes (SLNs), radioactive material and/or blue dye were used as tracers. Lymph nodes confirmed as SLNs were immediately sent to pathologists and diagnosed by frozen section intraoperatively.

RESULTS

A total of 118 and 16 SLNs were pathologically investigated in early and advanced stage cervical cancer, respectively. The detection rate of SLNs in the early and advanced stages was 94.7% and 66.7%, respectively, whereas the detection rate using 1 or 2 tracers was 62.5% and 90%, respectively. The false-negative rate and negative predictive value was 0% and 100% for all stages. Pathological diagnosis by frozen section was completed within 30 minutes in all cases.

CONCLUSIONS

Our data demonstrate that SNNS in cervical cancer is a promising procedure for patients with early stage (up to Ib1) disease, especially patients with small tumor diameter (<2.0 cm). However, SNNS raises several points for discussion before it can be established as a practical clinical procedure or as part of a subsequent radical hysterectomy.

Nerve-sparing radical hysterectomy: local recurrence rate, feasibility, and safety in cervical cancer patients stage IA to IIA

To clarify the debate about the possible threat of sparing the pelvic autonomic nerves in radical hysterectomy for cervical cancer to radicality, comparative studies of nerve-sparing and conventional surgery are necessary. The aim of his study was to analyze and compare local recurrence rate, feasibility, and safety of nerve-sparing and non-nerve-sparing radical hysterectomy.

METHODS

In a cohort study with 2 years of follow-up, 246 patients with cervical cancer of stages IA to IIA were analyzed: 124 in the non-nerve-sparing group (1994-1999) and 122 in the group where nerve-sparing was the intention-to-treat (2001-2005). Local recurrence rate, local recurrence-free survival, feasibility, and safety were analyzed and compared.

RESULTS

The clinical characteristics of the treatment groups were comparable. Sparing the nerves unilaterally or bilaterally was possible in 80% of cases of the nerve-sparing group. Local recurrence rates in the non-nerve-sparing (4.9%) and nerve-sparing (8.3%) group were not significantly different. Mean local recurrence-free survival within 2 years were 22.7 and 22.0 months, respectively. Univariate and multivariate regression analyses showed that nerve-sparing treatment was not a significant prognostic factor for local recurrence. With respect to perioperative and postoperative parameters, operating time and blood loss were less in the nerve-sparing group and mortality was equal (1 patient); the postoperative course of the nerve-sparing group was similar to the state-of-the-art of conventional radical hysterectomy.

CONCLUSIONS

On the basis of the results of our study, we consider the nerve-sparing technique for cervical cancer stages IA to IIA feasible and safe.

Lymph node assessment in cervical cancer: prognostic and therapeutic implications

Lymph node status is not part of the staging system for cervical cancer, but provides important information for prognosis and treatment. This article reviews the incidence and patterns of lymph node metastasis, and the issues surrounding surgical assessment of lymph nodes. The preoperative assessment of lymph nodes by imaging, as well as the intraoperative assessment by sentinel nodes will be discussed. Finally, the prognostic and therapeutic implications of lymphadenectomy in cervical cancer will be reviewed.

Pelvic and aortic lymphadenectomy in cervical cancer: the standardization of surgical procedure and its clinical impact

Cervical cancer ranks as the second most frequent cancer in women in the world, and nodal metastasis seems to be the first step of tumor spread in most cases. Since lymph node involvement is a major prognostic factor in cervical carcinoma, lymphatic spread of cervical cancer has been one of the most studied surgical topics in gynecologic oncology. Traditionally, lymph nodes stations have been accurately analyzed, improving surgical techniques of nodal dissection, which have been more and more intensive during years with the aim of improving survival. Oppositely, on the basis of recent acquisitions in cancer immunology and new anti-cancer immunotherapies and vaccines, the importance of lymph nodes has been recently reconsidered. Unfortunately, lymph node status is still difficult to be assessed pre-operatively with a high level of accuracy, and intra-operatively by sentinel node techniques, which remain inadequate for many aspects according to several gynecologic oncologists. The absence of definitive evidence of survival advantage given by extensive lymphadenectomy in all cervical cancer cases indicates that nodal dissection should be performed on the objective risk of node metastasis in each case. To date, the mainstay of detecting lymph node metastasis is still the histologic evaluation, therefore a proper resection of mostly involved lymph nodes remains a crucial surgical step when treating cervical cancer.

The lateral infraureteral parametrium: myth or reality?

OBJECTIVE

The objective of the study was to describe the surgical anatomy of infraureteral parametrium.

STUDY DESIGN

Findings of laparoscopic dissections during 12 type III radical hysterectomies were compared with findings obtained by bilateral pelvic dissections of 5 fresh and 5 embalmed female cadavers and to magnetic resonance imaging of 10 healthy controls.

RESULTS

Two anatomical entities of the parametrium were distinguished: (1) the lateral mesometrium corresponding to the blade containing vessels and lymph nodes of the uterus; and (2) the infraureteral parametrium extending dorsally from cervix and vagina. The lateral paracervix classically described under the ureter was never identified. Infraureteral parametrium appeared as a fibrous tissue extending in a lateral, dorsal, and caudal direction on both sides of the rectum and very close to the pelvic plexus.

CONCLUSION

Our results attest to the absence of infraureteral parametrium, raising the issue of the surgical relevance of radical hysterectomy classification and the redefinition of the concept of radical hysterectomy.

Conformal and intensity-modulated radiotherapy for cervical cancer

Three-dimensional radiotherapy planning techniques, including conformal radiotherapy and intensity-modulated radiotherapy, have potential for improving outcomes in cervical cancer. Accurate target volume definition is essential in order to maximise normal tissue sparing while minimising the risk of a geographical miss. This reduction in toxicity provides the option of dose escalation, particularly with simultaneous integrated boost intensity-modulated radiotherapy. The evidence for the current use and potential applications of these techniques in the treatment of cervical cancer are discussed.

Sentinel lymph node biopsy in gynaecological cancers: the importance of micrometastases in cervical cancer

Lymph node metastases is a recognized prognostic factor in women with cervical cancer. However, there is a need for consensual histological definition of micrometastases in this indication which could give rise to a classification system similar to that used in breast cancer. We thus conducted a MEDLINE and EMBASE database analysis to evaluate the concept of micrometastases in cervical cancer. Retrospective studies place the incidence of micrometastasis between 1.5 and 15% depending on the technique used to evaluate lymph node status. Sentinel lymph node biopsy with serial sectioning and immunohistochemical analysis appears to be the most accurate micrometastases detection technique. The value of RT-PCR in micrometastases detection remains to be clarified by further studies. From a clinical view point, few data are available to support the prognostic relevance of micrometastases. However, case control and longitudinal studies have underlined the risk of recurrence in women with micrometastases, raising the issue of a revision of adjuvant therapy indications in this specific population.

Advances in Surgical Treatment of Cervical Cancer

Radical hysterectomy has been the standard surgical treatment for cervical cancer, achieving a good survival outcome. However, it is a major operation that has considerable potential long-term morbidity. With good prognosis achieved in most early cervical cancers, there is a trend towards more emphasis on maintaining good quality of life post-treatment. Many women diagnosed with cervical cancer are young, and fertility-sparing surgery such as trachelectomy would preserve their reproductive potential. Minimally invasive surgery, such as laparoscopic radical hysterectomy, can potentially improve post-operative recovery and cosmetic results while maintaining oncological safety. Sentinel lymph nodes assessment can minimize unnecessary systematic pelvic lymphadenectomy. Radicality of the hysterectomy may also be reduced in selected individuals with good prognostic factors, thus minimizing long-term pelvic floor dysfunction. This review aims to give a broad overview of the current status of these new trends in surgical management for cervical cancer.

Clear cell carcinoma of the cervix: a multi-institutional review in the post-DES era

OBJECTIVE

To conduct an outcome analysis of patients with cervical clear cell carcinoma (CCCC) in the post-DES era.

METHODS

A retrospective review was conducted at 3 major gynecologic cancer centers of all primary CCCC between 1982 and 2004.

RESULTS

CCCC was confirmed in 34 patients. Median age was 53 years. DES exposure was confirmed in 2 (6%) patients. A history of smoking was elicited in 22%, and of abnormal Pap smear 18% patients. Primary surgical resection was performed in all stage I or IIA patients (n=26); they displayed superior 3-year overall survival (OS) compared to advanced stage (n=8) patients (91% vs. 22%, p<0.001). Pelvic lymph node involvement was noted in 25%; all patients with positive para-aortic nodes (20% of patients sampled) had positive pelvic nodes. All node positive patients were treated with adjuvant radiation, but nevertheless displayed reduced progression free (31% vs 92%, p<0.001) and overall survival (80% vs. 100%, p=0.02). Adjuvant radiotherapy did not appear to impact OS in patients with negative lymph nodes.

DISCUSSION

This series provides insight into the management of early stage CCCC in the post-DES era. Although these patients may be at slightly higher risk of nodal spread, clear cell histology by itself does not appear to portend a worse prognosis than squamous cell carcinoma of the cervix in the absence of traditional risk factors. Our data suggest that patients with low risk early stage CCCC may be managed with radical surgery alone, without the need for adjuvant chemotherapy or radiation.

Where to look for the sentinel lymph node in cervical cancer

OBJECTIVE

The aim of this study was to analyze lymphatic spread to pelvic, parametrial, and paraaortic lymph nodes in patients with cervical cancer.

STUDY DESIGN

We reviewed 619 patients with invasive cervical cancer treated by radical abdominal hysterectomy and systematic pelvic or pelvic and paraaortic lymphadenectomy between 1971 and 2005. The present study included 61 patients with one positive lymph node (10%) and 59 patients with two positive lymph nodes (10%) at any location.

RESULTS

The external iliac (43%) and obturator (26%) regions and the parametrium (21%) were the most commonly involved pelvic lymph node sites with solitary metastases. Isolated metastases to common iliac, presacral (internal iliac), and paraaortic nodes were found in 7%, 1%, and 1% of patients, respectively. Patients with 2 positive nodes had 1 parametrial and 1 pelvic node involved (32%), 2 ipsilateral positive nodes (31%), 1 positive lymph node on both sides of the pelvis (27%), and 2 positive nodes within the parametrium (10%).

CONCLUSIONS

In cervical cancer patients with only 1 positive lymph node, this node is most frequently located within the external iliac and obturator regions and the parametrium. Sentinel node identification should primarily address these lymph node sites. If 1 positive lymph node is found, further metastases are unpredictable within pelvic and parametrial lymph node sites. Paraaortic spread without pelvic node involvement is rare.

Aortic lymphadenectomy in cervical cancer: Anatomy, classification and technique

Lymphatics are the main pathway of dissemination for gynaecologic malignancies and in particular those with preferential regional spread, so the evaluation of lymph node status has an important role in diagnosis, prognosis and treatment of patients with gynaecologic cancer. Hence, gynecologic oncologist must be familiar with lymphatic anatomy and the ability to perform a systematic retroperitoneal pelvic and aortic lymph node dissection is an important skill in their surgical armamentarium. This review will focus on the performance of systematic aortic lymphadenectomy in cervical cancer.

Conservative approaches in early stages of cervical cancer

Several authors have proposed the use of a less aggressive surgery (i.e. conization, trachelectomy plus laparoscopic lymphadenectomy, modified or type 2 radical hysterectomy) for patients affected by early stages invasive cervical carcinoma. Tumor size and pelvic nodal status are parameters that must be evaluated to better select a patient's population suitable of a less aggressive surgery, with the aim of sparing morbidity without jeopardizing cancer cure.

Sentinel lymph node detection in early stage uterine cervix carcinoma: A systematic review

OBJECTIVE

The aim of this study was to systematically review the diagnostic performance of Sentinel Node (SN) detection for assessing the nodal status in early stage cervical carcinoma, and to determine which technique (using blue dye, Technetium-99m colloid (99mTc), or the combined method) had the highest success rate in terms of detection rate and sensitivity.

METHODS

A comprehensive computer literature search of English language studies in human subjects on Sentinel Node procedures was performed in MEDLINE and EMBASE databases up to July 2006. For each article two reviewers independently performed a methodological qualitative analysis and data extraction using a standard form. Pooled values of the SN detection rate and pooled sensitivity values of the SN procedure are presented with a 95% confidence interval (95% CI) for the three different SN detection techniques.

RESULTS

We identified 98 articles, and 23 met the inclusion criteria, comprising a total of 842 patients. Ultimately, 12 studies used the combined technique with a sensitivity of 92% (95% CI: 84-98%). Five studies used 99mTc-colloid, with a pooled sensitivity of 92% (95% CI: 79-98%; p=0.71 vs. combined technique), and four used blue dye with a pooled sensitivity of 81% (67-92%, p=0.17 vs. combined technique). The SN detection rate was highest for the combined technique: 97% (95% CI: 95-98%), vs. 84% for blue dye (95% CI: 79-89%; p<0.0001), and 88% (95% CI: 82-92%, p=0.0018) for 99mTc colloid.

CONCLUSION

SN biopsy has the highest SN detection rate when 99mTc is used in combination with blue dye (97%), and a sensitivity of 92%. Hence, according to the present evidence in literature the combination of 99mTc and a blue dye for SN biopsy in patients with early stage cervical cancer is a reliable method to detect lymph node metastases in early stage cervical cancer.

An Atlas of the Pelvic Lymph Node Regions to Aid Radiotherapy Target Volume Definition

AIMS

The implementation of advanced three-dimensional radiotherapy planning techniques requires accurate target volume localisation. We have previously developed guidelines to aid definition of the pelvic lymph node regions, and the aim of this study was to produce a CT atlas.

MATERIALS AND METHODS

The guidelines were applied to a CT scan of a patient to receive adjuvant radiotherapy.

RESULTS

Reference CT images of the pelvis were generated, illustrating the nodal regions and a typical target volume for adjuvant pelvic radiotherapy for gynaecological cancer.

CONCLUSION

These images can be used as an aid for target volume definition of the pelvic nodal regions.

Up-to-date management of lymph node metastasis and the role of tailored lymphadenectomy in cervical cancer

Lymph node metastasis (LNM), together with parametrial infiltration and positive surgical margins, is an important prognostic factor in cervical cancer. The incidence of LNM increases with International Federation of Gynecology and Obstetrics (FIGO) stage, with rates being 12%-22% in stage Ib, 10%-27% in stage IIa, and 34%-43% in stage IIb. Radical hysterectomy and pelvic lymphadenectomy are widely used treatments for early-stage (Ib to IIa) cervical cancer, as well as for stage IIb disease, in some European and Asian countries. In several types of cancer, the therapeutic significance of systematic lymphadenectomy has been demonstrated by recent reports showing that a larger number of lymph nodes removed relates to better survival. In cervical cancer, a significant relationship between the number of lymph nodes removed and disease-free survival has been reported in node-positive patients. Preoperative evaluation of nodal status with computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) imaging techniques is not sensitive enough to replace the histological examination of dissected nodes. The sentinel node procedure may be an alternative to systematic lymphadenectomy to reduce treatment-related morbidity, but more work on this is needed. Although the presence of LNM does not change FIGO staging, it will modulate postoperative therapy. Progression-free and overall survivals were significantly improved by the addition of chemotherapy to adjuvant radiotherapy after radical hysterectomy and lymphadenectomy. Adjuvant chemotherapy combined solely with radical hysterectomy and systematic lymphadenectomy may also provide a survival benefit. In conclusion, efforts to establish more tailored surgical strategies, by introducing advanced imaging technologies and molecular diagnostic procedures, are needed for cervical cancer.

Pattern of lymph node metastasis and the optimal extent of pelvic lymphadenectomy in FIGO stage IB cervical cancer

AIM

To evaluate the distribution pattern of lymph node metastasis and to determine the optimal extent of pelvic lymphadenectomy (LA) in FIGO stage IB cervical cancer.

METHODS

The medical records of 187 patients with FIGO stage IB cervical cancer from March 1996 to December 2002 were reviewed retrospectively. The distribution pattern and risk factors of lymph node metastases were analyzed in 31 patients with lymph node metastases confirmed surgically. One hundred patients, who underwent type III hysterectomy with pelvic LA but did not receive any adjuvant treatment, were analyzed to evaluate whether the extent of LA affected the prognosis of FIGO stage IB cervical cancer. Type I LA included the external iliac nodes, hypogastric nodes, obturator nodes, and parametrial nodes. Type II LA included the pelvic nodes described in type I LA, the common iliac nodes, gluteal nodes, deep inguinal nodes and sometimes the presacral nodes.

RESULTS

Solitary lymph node metastasis confined to one node group was seen in the obturator, external iliac or hypogastric lymph nodes. All patients with lymph node metastases at multiple sites had metastasis in at least one of these lymph-node groups. There was no significant difference in disease-free survival and overall survival in patients without pathologic high-risk factors according to the type of pelvic LA.

CONCLUSION

The extent of LA should be adjusted to reduce complications and not to affect adversely the prognosis of FIGO stage IB cervical cancer patients without pathologic high-risk factors.

The incidence of parametrial tumor involvement in select patients with early cervix cancer is too low to justify parametrectomy

OBJECTIVE

To determine the incidence of parametrial involvement in a select group of patients with early cervical cancer.

METHODS

We retrospectively reviewed the records of patients with cervical cancer and a maximum tumor diameter of 2 cm, infiltration depth<10 mm and negative pelvic lymph nodes who underwent a radical hysterectomy in two university hospitals. In addition, the literature was reviewed.

RESULTS

103 patients were identified in our databases that met the abovementioned criteria. In two of these patients (1.94%), parametrial involvement was found. Both patients had LVSI. Literature review revealed 696 patients described in three studies that satisfied the selection criteria. Three (0.43%) of these patients had parametrial involvement. In patients with early stage cervical carcinoma, tumor size<2 cm, infiltration depth<10 mm, negative pelvic lymph nodes and absent LVSI the risk of parametrial involvement is 0.63%.

CONCLUSION

Because of a very low risk on parametrial involvement, patients who fulfil strict selection criteria could be candidates for conization and pelvic lymphadenectomy instead of more extensive surgery. Morbidity and pregnancy complications may decrease while it is unlikely that survival will be compromised.

Dilution of dye improves parametrial SLN detection in patients with cervical cancer

OBJECTIVE

Aim of this study to improve the detection rate of parametrial sentinel nodes in patients with early cervical cancer by using a new dosage of blue dye in a randomized trial.

METHODS

Standard labelling volume of 4 ml Patent Blue was compared to 2 ml Patent Blue diluted with 8 ml NaCl 0.9% in 60 patients using a randomized protocol. Tc-99 was not applied in any patient. All patients underwent open lymphadenectomy.

RESULTS

In each arm 30 patients were enrolled. Overall detection rate of sentinel nodes was 93.3%. Both groups did not differ with regard to patient's age, BMI, tumor stage, number of lymph nodes harvested, number of sentinel nodes detected and detection rate. Significantly more patients with parametrial sentinel nodes were detected in the diluted protocol (37.0% vs. 10.3%) which is due to the lateral part of the cardinal ligament (29.6% vs. 6.9%).

CONCLUSION

In our study overall detection of sentinel nodes using a dye was high. The diluted solution of Patent Blue led to a higher detection rate of parametrial sentinel nodes. These findings might help explain the discrepancy between the high reported rate of parametrial lymph nodes in anatomical studies compared with the low rates in clinical sentinel series.

Lymph node involvement in locally advanced cervical cancer patients administered preoperative chemoradiation versus chemotherapy

BACKGROUND

A retrospective study was planned in 127 locally advanced cervical cancer (LACC) to investigate: (1) the rate and pattern of metastatic lymph node involvement in patients administered preoperative chemoradiation (CT/RT) versus neoadjuvant chemotherapy (NACT), and (2) the profile of clinico-pathological parameters predictive of metastatic lymph node involvement in these two clinical settings. Finally, we investigated whether the pathologically assessed status of lower pelvic nodes (LPN) was able to predict the pathologically assessed status of upper pelvic nodes (UPN) and parametrium in cases administered CT/RT.

METHODS

Patients were selected including LACC patients who were administered concomitant CT/RT (n = 87) or NACT (n = 40), before radical surgery.

RESULTS

Metastatic pelvic lymph node involvement was significantly lower in cases administered CT/RT (11.5%) compared to cases administered NACT (30.0%) (P value = 0.009). In the CT/RT group, only MRI-assessed pelvic node status (both at staging and post-treatment evaluation) was associated with pathologic pelvic node status. In patients administered CT/RT, the status of LPN appeared associated with the status of UPN.

CONCLUSIONS

(1) Preoperative CT/RT treatment is associated with a lower rate of pelvic node disease in LACC patients compared to NACT; (2) there is no association between the preoperative extent of residual cervical disease after CT/RT and pathologically assessed pelvic node status; (3) the pathological status of LPN is predictive of the pathological status of UPN and parametrium.