Beyond sentinel node algorithm. Toward a more tailored surgery for cervical cancer patients

Abstract

Nowadays cervical cancer is frequently diagnosed at early stage. For these patients lymph node metastasis (LNM) is considered the most important prognostic factor. During the last decade many efforts have been made to reduce rate of complications associated with lymphadenectomy (LND). A great interest has arisen in sentinel lymph node (SLN) biopsy as a technique able to decrease number of LND performed and, at the same time, to assess lymph nodal status. High diagnostic performances have been reached thanks to SLN surgical algorithm. However, despite the efforts, about 25% of these patients undergo at least unilateral LND to meet NCCN recommendations. Data of women with International Federation of Gynecology and Obstetrics stage IA1‐IB1/IIA1 cervical carcinoma were retrospectively collected by six Italian institutions. All patients underwent complete preoperative staging workup and were primarily treated by radical hysterectomy and pelvic bilateral LND. A total of 368 patients with early‐stage cervical cancer were identified. Among them 333 (90.5%) showed no suspicious enlarged nodes at the preoperative magnetic resonance imaging (MRI). In this subset, tumor diameter ≥20 mm was the only independent predictor of LN status (P = 0.003). None of the 106 patients with negative MRI nodal assessment, with squamous and adenosquamous histotype and a tumor diameter less than 2 cm had LNM. Based on these results we propose a new modified SLN surgical algorithm that could safely reduce LND performed in patients with very low‐risk early‐stage cervical cancer.

Should the Number of Metastatic Pelvic Lymph Nodes Be Integrated into the 2018 Figo Staging Classification of Early Stage Cervical Cancer?

“…The proportion of metastatic pelvic LNs in early stage cervical cancer is around 10–25% [ 3 , 5 , 7 , 8 , 9 ]. The reported 5-year disease-free survival (DFS) rate is 70–80% [ 2 , 8 , 9 ], while the 5 yr overall survival (OS) rate is 65–80% [ 3 , 5 , 10 ].…”

“…The proportion of metastatic pelvic LNs in early stage cervical cancer is around 10–25% [ 3 , 5 , 7 , 8 , 9 ]. The reported 5-year disease-free survival (DFS) rate is 70–80% [ 2 , 8 , 9 ], while the 5 yr overall survival (OS) rate is 65–80% [ 3 , 5 , 10 ]. It should be acknowledged, however, that patients with metastatic pelvic LNs present with different risk profiles largely due to additional features that include lymph node size, site, morphology, number and whether or not they are bilateral [ 11 , 12 , 13 , 14 ].…”

Role of one-step nucleic acid amplification (OSNA) to detect sentinel lymph node low-volume metastasis in early-stage cervical cancer

“…A significant difference in the number of different types of metastases was shown, with a higher number of micro-metastases in the OSNA group and a higher number of macro-metastases in the ultra-staging group. This could be due to the larger tumor size in the ultra-staging group, as tumor size is one of the major determinants for lymph node metastasis 5…”

“…With an estimated 570 000 cases and 311 000 deaths in 2018 worldwide, cervical cancer ranks as the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women 1. Growing evidence in the literature supports the accuracy of sentinel lymph node (SLN) biopsy in early-stage cervical cancer, particularly in the case of small volume tumors and bilateral detection 2–5. In particular, pathologic ultra-staging of SLNs potentially allows a sensitivity of 100% for the presence of both micro-metastasis and macro-metastasis in pelvic lymph nodes to be achieved 6.…”

Predictive Role of MRI and 18F FDG PET Response to Concurrent Chemoradiation in T2b Cervical Cancer on Clinical Outcome: A Retrospective Single Center Study

“…Early CC and locally advanced CC (LACC) represent two different realities with distinct therapeutic approaches and prognosis. Surgery is the preferred approach in the early stage while concurrent chemoradiation (CCRT) is the standard treatment option in LACC [3,[6][7][8]. The target of the external beam radiation therapy 2 of 13 (EBRT) includes the pelvic lymph nodes, but the irradiation field can be extended to the common iliac and para-aortic region in patients with nodal involvement [9,10].…”