Risk of aortic nodal metastases in cancer of the uterine cervix
Cervical cancer is one of the most preventable cancer since the introduction of Papanicolau test. However in nearly 30% of cases it is diagnosed in an advanced stage. Standard treatment for locally advanced cervical cancer (FIGO stage IB2-IIB) is concomitant chemo-radiation (no surgery). Nevertheless neoadjuvant chemotherapy (a pre-treatment with chemotherapy) followed by radical surgery (radical hysterectomy + lymphadenectomy) is an alternative used in several countries. Lymph-node status in cervical cancer patients is an independent risk factor for survival. The presence of nodal involvement worsen prognosis. A patient with nodal involvement has a risk of relapse/death that is 3 fold the risk of a patient without nodal metastases. The rate of aortic nodal involvement in stage IB2-IIB ranges from 10 % to 30%, so the evaluation of nodal status is of utmost importance to tailor treatment (i.e.: field of irradiation). However no consensus exist on the role of aortic surgical staging before chemo-radiation, as well as on the role of aortic lymphadenectomy during surgical treatment of locally advanced cervical cancer.
The aim of this study was to evaluate the rate of aortic nodal involvement/relapses in patients submitted to neoadjuvant chemotherapy followed by radical surgery.
Among the 261 women with locally advanced [FIGO stage: IB2: 100 (38.3%); IIA: 50 (19.2%); IIB: 111 (42.5%)] cervical cancer treated with neoadjuvant chemotherapy followed by radical surgery, 81% presented with a squamous carcinoma. In 56 women (21.5%) lymph node metastasis were found. Four out of 83 women (5%) who underwent both pelvic and aortic LN dissection had aortic LN metastases. Only one woman out of 178 (0.5%) who underwent pelvic lymphadenectomy only, had an aortic LN recurrence discovered during regular follow-up. Overall only in 5 out of 261 cases (2%) the aortic region was involved after neoadjuvant chemotherapy. All cases with aortic nodal involvement had also pelvic nodal metastases; meaning that aortic area could be involved only in case of pelvic area involvement (no skip metastases were found). Globally we found a lower rate (2%) of aortic nodal involvement in respect to published series without neoadjuvant chemotherapy (10-30%), the same was found for the pelvic area (22% vs 50%). These data, as well as data on survival benefits of adjuvant chemotherapy after treatment with exclusive chemo-radiation, suggest a role of chemotherapy in sterilizing aortic nodal metastases.
This study found that when neoadjuvant chemotherapy is administered, aortic lymphadenectomy should be reserved only in case of enlarged/suspicious nodes due to the low (2%) rate of aortic nodal involvement/ (0.5%) relapse.
Gynecologic Oncology Department,
IRCCS Foundation, National Cancer Institute, Milan, Italy
Is aortic lymphadenectomy indicated in locally advanced cervical cancer after neoadjuvant chemotherapy followed by radical surgery? A retrospective study on 261 women.
Martinelli F, Signorelli M, Bogani G, Ditto A, Chiappa V, Perotto S, Scaffa C, Lorusso D, Raspagliesi F
Eur J Surg Oncol. 2016 Oct
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