Extraperitoneal para-aortic lymph node biopsy and irradiation in cervical carcinoma

[Para-aortic lymphadenectomy in advanced-stage cervical cancer: standard procedure in 2010?]

With tumour size, node involvement is the most important prognosis factor in advanced stage cervical cancer. Para-aortic (PA) disease is observed in 15 to 30% of these patients. CT scan and magnetic resonance imaging (MRI) are not efficient enough to detect these lesions and PET CT have false negatives. Surgical staging is useful to detect carcinosis associated and to adapt therapy (radiotherapy fields are extended if PA nodes are involved). Laparoscopy was crucial to develop this staging because its morbidity associated to chemoradiotherapy is limited. If prognosis impact of PA lymphadenectomy is well established, therapeutic impact is still discussed. The systematic extension of this staging to pelvic nodes that are included in the basic radiotherapy fields is debated because it does not modify therapeutic management and is morbid. Radiotherapy progress, especially with boost and combination to MRI (MRIT), will impact on future therapeutic management.

Extraperitoneal versus transperitoneal selective paraaortic lymphadenectomy in the pretreatment surgical staging of advanced cervical carcinoma (a Gynecologic Oncology Group study)

Two-hundred and eighty-eight patients with predominately stage IIB or IIIB cervical carcinoma underwent pretreatment surgical staging including selective paraaortic lymphadenectomy (SPAL), followed by pelvic irradiation with or without paraaortic irradiation (RT). Four patients were excluded from analysis (two received no RT and two were insufficiently documented). Of the remaining 284 patients, 128 underwent extraperitoneal (EP) SPAL and 156 transperitoneal (TP) SPAL procedures. Age, race, and stage (clinical and surgical), cell type, paraaortic nodal status, and peritoneal cytology findings were similar in both groups. Complications presumed to arise from operative staging were infection, which was similar for both groups, and vascular injury, which was higher in the TP group, although not statistically significant. Complications subsequent to RT fell into two categories: local-pelvic necrosis, vesicovaginal and rectovaginal fistulas, proctitis, etc., and regional-enterovaginal fistula, bowel obstruction, enteritis, bowel perforation, etc. The frequency of local complications was similar for both EP and TP patients. Utilizing univariant analysis, among regional complications, both bowel obstruction and nonobstructive enteric injuries were observed significantly more often in TP patients than in EP patients (11.5% vs 3.9%, P = 0.03, for both types). Multivariant analysis confirmed these observations. This report supports the conclusions that in advanced cervical carcinoma (1) EP- and TP-SPAL are of similar sensitivity in detecting nodal spread, (2) no significant differences in the frequency of surgical complications could be detected between EP- and TP-SPAL groups, and (3) TP-SPAL is associated with a higher frequency of certain postirradiation regional enteric complications.

High dose para-aortic lymph node irradiation for gynecologic cancer: technique, toxicity, and results

A technique for high dose (5600-6100 cGy) extended field irradiation to the para-aortic lymph nodes is described. Fourteen patients have been treated with this technique, of whom 10 have had histologic confirmation of para-aortic node metastases. With follow-up ranging from 11 to 78 months, 7 of 14 patients are alive and clinically cancer-free. Acute effects of extended field treatment on patient weight and circulating blood counts are analyzed, and late treatment morbidity assessed. The findings suggest that such treatment, executed with modern equipment and appropriate technique, is not significantly more hazardous than pelvic irradiation, and can result in a substantial probability of disease-free survival.

Extended field irradiation in the treatment of patients with cervical carcinoma involving biopsy proven para-aortic nodes

Between November 1974 and November 1979, 15 patients with cervical carcinoma were treated with extended field irradiation for biopsy proven para-aortic lymph node (PALN) metastases. Treatment consisted of pelvic and para-aortic irradiation at a daily dose of 180 to 200 rad per day, delivering 4000 to 6000 rad to the pelvis and 4000 to 5000 rad to the para-aortic nodes. One or two intracavitary insertions each delivered an additional 2000 to 3500 rad to point A. The three year actual disease free survival for the 12 patients with Stage I and II disease was 50%. All six survivors remain alive without evidence of disease for 41 to 93 months, with a mean and median follow-up of 65 months. All patients dying of disease did so within 26 months, all but one dying within one year. All patients with Stage III and IV are dead of disease. Pelvic disease was controlled in 11 of 12 patients with Stage I or II disease, and in one of the three patients with Stage III and IV disease. There was no clinical indication of failure in the PALN in any patient. Nine patients failed with disseminated disease. Three of 15 patients (20%) suffered serious treatment-related complications. Two of these were attributed to the pelvic irradiation, with one patient requiring a colostomy. Thus, complications resulting from the extended field irradiation were seen in only one patient (6.7%). There was no treatment related mortality. Extended field irradiation can lead to a 50% survival in patients with Stage I and II cervical carcinoma and PALN metastases, a survival comparable to that reported in patients with involved pelvic nodes.

Treatment of advanced invasive cervical cancer: changing times and trends

A retrospective analysis of the treatment results and complications in 140 patients with advanced (Stage IIB or more) invasive cervical cancer treated at the Albert Einstein College of Medicine (AECOM) from 1962-1970 and the State University of New York at Buffalo (SUNYAB) from 1974-1982 is the subject of this report. All patients were clinically staged and received external pelvic radiotherapy followed by one to two intracavitary radium insertions, and those with histologically proven positive para-aortic nodes received on additional 4,500 to 5,000 rads to the para-aortic areas. Forty-four patients had pretherapy surgical staging (26 transperitoneal, 18 extraperitoneal). In the clinical staging group, a survival time of 5 years or longer was attained in 22 of 39 patients (56%); with Stage IIB, 11 of 30 patients (37%) with Stage IIIA, two of 13 patients with Stage IIIB and two of 12 patients with Stage IVA disease. Of 26 patients staged via transperitoneal approach, two survived more than 5 years and three others were alive at last contact (after more than 3 years follow-up). The last 18 patients have been subjected to laparoscopy and retroperitoneal pelvic and para-aortic node biopsies followed by tailored radiotherapy with [12] or without [6] chemotherapy. Chemotherapy consisted of alternating weekly courses of vincristine and bleomycin and hydroxyurea. Mitomycin-C was added to this regimen at the conclusion of the course of radiotherapy. Only one patient developed a vesicovaginal fistula. At last contact, seven patients in the combined therapy group were alive and free of disease. Combined therapy following extraperitoneal surgical staging appears to be feasible and justifiable. It deserves further trials in larger series.