The role of surgical assessment of lymph nodes before treatment for women with locally advanced cervical cancer

Cervical cancer arises from the neck of the womb (cervix). Cervical screening programmes have decreased the rate of advanced cervical cancer. However, a significant number of cases still present with locally advanced disease that involves large cervical tumours (> 4 cm) or tumours that extend to the upper vagina. The larger the primary tumour, the greater the likelihood of metastasis (spread of cancer to other areas of the body). Cervical cancer spreads to the lymph nodes in the pelvis and around the aorta (one of the major blood vessels in the abdomen). Stage is a standardised assessment of the size of the cancer and if it has spread to adjacent or distant sites. Stage for stage, women with para-aortic lymph node metastases at presentation have a lower survival than those who do not have para-aortic metastases at presentation.

Accurate detection of involved para-aortic lymph nodes helps to tailor radiotherapy so that it includes this area (extended-field radiotherapy). It also provides prognostic information. Different methods have been used to detect para-aortic lymph node metastases including surgical and radiological (various types of x-rays) techniques; however, it is unclear which is more accurate.

The purpose of this review was to assess the available literature on the effectiveness and safety of pre-treatment surgical para-aortic lymph node assessment for locally advanced cervical cancer. We found only one randomised controlled trial (RCT) that assessed non-surgical staging versus surgical staging. We found limited evidence that suggested that clinical staging may offer a survival benefit (in terms of overall and progression-free survival) compared with surgical staging, but the strength of the evidence from this small trial is weak and the trial was at moderate risk of bias. There was no statistically significant difference in any of the reported outcomes between two surgical staging techniques examined in the trial.

Due to the small number of women with locally advanced cervical cancer in only one included trial there was insufficient evidence to conclude that any of the staging techniques are superior to each other. This review highlights the need for future good-quality, well-designed trials that report not only survival and severe adverse event outcomes but also examine quality of life (QoL) outcome data.

Authors' conclusions: 

Since the last version of this review no new studies were found.

From the one available RCT we found insufficient evidence that pre-treatment surgical para-aortic lymph node assessment for locally advanced cervical cancer is beneficial, and it may actually have an adverse effect on survival. However, this conclusion is based on analysis of a small single trial and therefore definitive guidance or recommendations for clinical practice cannot be made.

Therefore, the decision to offer surgical pre-treatment assessment of para-aortic lymph nodes in locally advanced cervical cancer needs to be individualised. The uncertainty regarding any impact on survival from pre-treatment para-aortic lymph node assessment should be discussed openly with the women.

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Background: 

This is an updated version of the original Cochrane review published in The Cochrane Library, Issue 4, 2011.

Cervical cancer is the most common cause of death from gynaecological cancers worldwide. Locally advanced cervical cancer, FIGO stage (International Federation of Gynaecology and Obstetrics) equal or more than IB1 is treated with chemotherapy and external beam radiotherapy followed by brachytherapy. If there is metastatic para-aortic nodal disease, radiotherapy is extended to cover this area. Due to increased morbidity, ideally extended-field radiotherapy is given only when para-aortic nodal disease is confirmed. Therefore, accurate assessment of the extent of the disease is very important for planning the most appropriate treatment.

Objectives: 

To evaluate the effectiveness and safety of pre-treatment surgical para-aortic lymph node assessment for woman with locally advanced cervical cancer (FIGO stage IB2 to IVA).

Search strategy: 

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2012, Issue 10), MEDLINE and EMBASE (up to November 2012). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

Selection criteria: 

Randomised controlled trials (RCTs) that compared surgical para-aortic lymph node assessment and dissection with radiological staging techniques, in adult women diagnosed with locally advanced cervical cancer.

Data collection and analysis: 

Two review authors independently assessed whether potentially relevant trials met the inclusion criteria, abstracted data and assessed risk of bias. One RCT was identified so no meta-analyses were performed.

Main results: 

We found only one trial, which included 61 women, that met our inclusion criteria. This trial reported data on surgical versus clinical staging and an assessment of the two surgical staging techniques; laparoscopic (LAP) versus extraperitoneal (EXP) surgical staging. The clinical staging was either a contrast-enhanced computed tomography (CT) scan or magnetic resonance imaging (MRI) scan of the abdomen and pelvis to determine nodal status.

In this trial, clinical staging appeared to significantly prolong overall and progression-free survival compared to surgical staging. There was no statistically significant difference in the number of women who experienced severe (grade 3 or 4) toxicity.

There was no statistically significant difference in the risk of death, disease recurrence or progression, blood loss, severe toxicity and the duration of the operational procedure between LAP and EXP surgical staging techniques.

The strength of the evidence is weak in this review as it is based on one small trial that was at moderate risk of bias.

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