Laparoscopic Staging Compared with Imaging Techniques in the Staging of Advanced Cervical Cancer

doi:10.1006/gyno.2002.6722

Gynecologic Oncology

Volume 87, Issue 1, October 2002, Pages 46-51

https://doi.org/10.1006/gyno.2002.6722 Get rights and content

Abstract

Objective. We evaluated the evidence of laparoscopy for decision regarding treatment options in advanced cervical cancer patients.

Methods. One hundred nine consecutive patients with cervical cancer FIGO stage Ib2 and higher underwent laparoscopic staging of the extent of disease. Laparoscopic and histopathologic evaluation of tumor involvement of the paraaortic and pelvic lymph nodes, wall of the bladder, and rectal pillar was compared with preoperative findings of MRI and/or CT.

Results. Paraaortic lymphadenectomy was performed in 101 (92.7%) patients and 21 (19.3%) patients had positive paraaortic lymph nodes. Pelvic lymphadenectomy was performed in 75 (68.8%) patients and 20 (26.7%) patients had positive pelvic lymph nodes. In 11 patients (11.5%) infiltration of the bladder and in 6 patients (6.25%) infiltration of the rectal pillar or cul-de-sac was found. Intraoperative complications associated with laparoscopic staging occurred in 3.7% of patients. The negative predictive value for the evaluation of paraaortic or pelvic lymph nodes, the bladder wall, rectal pillar, and cul-de-sac ranged from 73% (CT for pelvic lymph nodes) to 96% (MRI for bladder wall). Lack of information about the extent of disease was adjusted on the basis of laparoscopic findings in 24 (22%) patients and improved treatment plans.

Conclusion. Laparoscopic staging of patients with advanced cervical cancer is accurate, associated with low morbitity, and helps to adjust treatment according to extent of disease.

References (28)

LD Lagasse et al.
Results and complications of operative staging in cervical cancer
Experience of the Gynecologic Oncology Group. Gynecol Oncol
(1980)
L Subak et al.
Cervical carcinoma: computed tomography and magnetic resonance imaging for preoperative staging
Obstet Gynecol
(1995)
LD Lagasse et al.
Results and complications of operative staging in cervical cancer: experience of the Gynecologic Oncology Group
Gynecol Oncol
(1980)
JP LaPolla et al.
The influence of surgical staging on the evaluation and treatment of patients with cervical carcinoma
Gynecol Oncol
(1986)
N Kadar
Laparoscopic pelvic and aortic lymphadenectomy
Bailliere's Clin Obstet Gynecol
(1995)
D Querleu
Laparoscopic paraaortic node sampling in gynecologic oncology: a preliminary experience
Gynecol Oncol
(1993)
M Possover et al.
Laparoscopic paraaortic and pelvic lymphadenectomy: experience with 150 patients and review of the literature
Gynecol Oncol
(1998)
S Malur et al.
Sentinel lymph detection in patients with cervical cancer
Gynecol Oncol
(2001)
TH Su et al.
Laparoscopic paraaortic lymph node sampling of invasive cervical carcinoma: including a comparative study of 21 laparotomy cases
Int J Gynecol Obstet
(1995)
J Vidaurreta et al.
Laparoscopic staging in locally advanced cervical carcinoma: a new possible philosophy?
Gynecol Oncol
(1999)

M Possover et al.

Laparoscopic assistance for extended radicality of radical vaginal hysterectomy: description of a technique

Gynecol Oncol

(1998)

BA Goff et al.

Impact of surgical staging in women with locally advanced cervical cancer

Gynecol Oncol

(1999)

SG Levrant et al.

Anterior abdominal wall adhaesions after laparotomy or laparoscopy

J Am Assoc Gynecol Laparosc

(1997)

Cited by (102)

Role of minimally invasive surgery in gynecologic malignancies
2023, DiSaia and Creasman Clinical Gynecologic Oncology
Minimally invasive surgery (MIS) is practiced by more than 90% of gynecologic oncologists. Knowledge of anatomy, the disease process, and surgical technique is key during these complicated surgical procedures. Several studies have shown that 10 to 20 cases are needed to gain proficiency with a certain procedure. MIS reduces blood loss, transfusions, length of hospital stay, and wound complications without compromising adequacy of the procedure or staging even in (extremely) morbidly obese patients. Survival outcomes for endometrial and ovarian cancer are similar after MIS and laparotomy, while survival outcomes with MIS have been shown to be worse for cervical cancer. Several safe methods exist to extract an enlarged uterus after MIS. Morcellation is not recommended when there is suspicion or proven preinvasive or invasive disease. Laparoscopy can be used in ovarian cancer to assess the extent of disease and chance of complete debulking surgery. MIS in advanced or recurrent ovarian cancer and its utilization in interval debulking is still under investigation, and prospective trials to confirm safety and feasibility are ongoing.
Prophylactic extended-field irradiation for locally advanced cervical cancer
2022, Gynecologic Oncology
Concomitant chemoradiotherapy is the standard treatment for locally advanced cervical cancer. Pelvic irradiation is commonly recommended for patients with negative para-aortic lymph nodes(PALNs). However, owing to the development of imaging-guided brachytherapy, distant failure has become the main failure pattern. The PALNs are a vital site of distant metastasis, and the para-aortic region may contain occult microscopic metastases that are barely detected owing to imaging technology restriction. The prognostic of patients who experienced PALN failure is dismal. Typically, there are four ways to decrease PALN failure. First, surgical staging can be performed to assess the occurrence of metastasis in the para-aortic region; however, the application of surgical staging is decreasing owing to controversial survival benefits and accompanying complications of surgery. Second, regular imaging surveillance and timely salvage of early recurrences could reduce PALN failure. Third, better systemic adjuvant therapy could be recommended since it has enormous potential to reduce distant metastases and improve overall survival. Fourth, performing prophylactic extended-field irradiation (EFI), including pelvic and para-aortic region irradiation, can sterilize occult microscopic metastases in the para-aortic region and improve survival. Prior investigations have revealed that prophylactic EFI could reduce PALN failure as well as distant metastasis and present the benefit of survival. Yet, owing to the serious morbidity induced by enlarged irradiation field in the era of conventional irradiation techniques, further research on EFI is stagnated. Nowadays, with the development of new technologies, intensity modulated radiation therapy can deliver a higher dose to tumors with acceptable toxicity. Prophylactic EFI regained attention. However, the inclusion criteria of prophylactic EFI in existing studies reveal great discrepancies. Thus, it is urgent to precisely identify indications for better survival and lower complications in patients with cervical cancer. In this review, we identify indications and summary guidelines for prophylactic EFI, which may provide a foundation for further trials and clinical applications.
Interest of para-aortic lymphadenectomy for locally advanced cervical cancer in the era of PET scanning
2022, European Journal of Obstetrics and Gynecology and Reproductive Biology
Treatment of locally advanced cervical cancer (LACC) involves pelvic chemoradiotherapy, using an extended field in the case of para-aortic involvement. 18-Fluoro-D-glucose positron emission tomography combined with computer tomography (PET-CT) is an accurate method for the detection of metastatic nodes. The objective of this study was to evaluate the performance of PET-CT for lymph node staging of LACC.
This bicentric retrospective study included patients with LACC who had a PET-CT scan followed by para-aortic lymphadenectomy between January 2015 and December 2019. Based on pathological findings, sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and false-negative (FN) rates of PET-CT for para-aortic node involvement were evaluated.
Seventy-one patients who had undergone laparoscopic lymphadenectomy were included in this study. The intraoperative complication rate was 2.8%. Sensitivity, specificity, NPV and PPV for PET-CT were 55% [95% confidence interval (CI) 44.6–67.1], 84% (95% CI 75–92), 93% (95% CI 87–99) and 33% (95% CI 22–44), respectively. FN rates in the case of negative or positive pelvic PET-CT were 5.7% and 9.5%, respectively.
Para-aortic lymphadenectomy is recommended for lymph node staging in the case of negative para-aortic PET-CT. In view of the low FN rate of PET-CT, surgical staging should be discussed regardless of pelvic status if the patient presents high surgical risk, or if this delays the commencement of chemoradiotherapy.
Upstaging by para-aortic lymph node dissection in patients with locally advanced cervical cancer: A systematic review and meta-analysis
2022, Gynecologic Oncology
Citation Excerpt :
These articles were not part of the initial search result, because the title nor abstract included the ‘lymphadenectomy’ search term or synonyms. The final analysis included 16 studies [14,15,18,19,25–36] reporting on 18 cohorts which were suitable for quantitative meta-analysis with pooling of upstaging outcomes. Characteristics of the 18 cohorts within 16 studies included in the quantitative synthesis are outlined in Table 2.
Accurate staging of para-aortic nodal status in cervical cancer is of great importance for individualizing treatment and impacting outcomes. Three-dimensional imaging (i.e. PET, CT, MRI) may miss para-aortic lymph node (PALN) metastases. The aim of this study was to systematically review and meta-analyze the proportion of upstaging by PALN dissection in patients with locally advanced cervical cancer without suspicious PALNs on imaging.
PubMed/MEDLINE and Embase were systematically searched. The analysis included diagnostic studies that reported on 3D imaging and pre-therapeutic surgical assessment of PALN status in patients with cervical cancer. An overall pooled upstaging rate was calculated using a random-effects model.
The search identified 16 eligible studies including 18 cohorts with a total of 1530 patients. Pooling of 12 cohorts demonstrated an upstaging rate of 12% (95% confidence interval [CI] 10–15%) by PALN dissection after negative PET or PET-CT. Pooling of 6 cohorts demonstrated a pooled upstaging rate of 11% (95% CI: 8–16%) by PALN dissection after negative MRI or CT. No significant heterogeneity in upstaging proportions across cohorts was observed (I² = 0% and 27%, respectively). In 7 cohorts including only patients with pelvic nodal metastases on imaging (but no suspicion of PALN involvement) a pooled upstaging rate by PALN dissection of 21% (95% CI: 17–26%) was found (I² = 0%).
This meta-analysis demonstrates that in case of no suspicious PALN on PET-CT or MRI, PALN dissection still identifies lymph node metastases in a considerable amount of patients with locally advanced cervical cancer and especially in those patients with confirmed pelvic nodal metastases.
New FIGO classification and management of cervical cancer
2019, Imagerie de la Femme
De grands progrès ont été réalisés pour réduire l’augmentation de l’incidence du cancer du col utérin. Dans plus de 80 pays, la vaccination contre le papillomavirus est maintenant incluse dans les programmes nationaux de vaccination. Le dépistage a également vu des avancées majeures avec la mise en œuvre des tests pour l’infection par le papillomavirus à plus grande échelle. Cependant, ces interventions prendront quelques années à montrer leur impact. Actuellement, l’incidence du cancer du col utérin est de plus d’un demi-million de nouveaux cas par an. Les développements récents en imagerie et le recours accru à la chirurgie mini-invasive ont changé le paradigme pour la prise en charge de ces cas. Le comité d’oncologie gynécologique de la Fédération internationale de gynécologie obstétrique a révisé le système de stadification du cancer du col utérin sur la base de ces avancées. Cet article présente cette nouvelle classification.
Since the publication of the last report on cancer from the International Federation of Gynecology and Obstetrics (FIGO), there have been great strides in the global effort to reduce the burden of cervical cancer. In over 80 countries, papillomavirus vaccination is now included in the national program. Screening has also seen major advances with implementation of papillomavirus testing on a larger scale. However, these interventions will take a few years to show their impact. Meanwhile, over half a million new cases are added each year. Recent developments in imaging and increased use of minimally invasive surgery have changed the paradigm for management of these cases. The FIGO Gynecologic Oncology Committee has revised the staging system based on these advances. This article presents this new staging system.
Comparison of pelvic and para-aortic lymphadenectomy versus para-aortic lymphadenectomy alone for locally advanced FIGO stage IB2 to IIB cervical cancer using a propensity score matching analysis: Results from the FRANCOGYN study group
2018, European Journal of Surgical Oncology
Pre-treatment evaluation of nodal status is crucial in women presenting with locally advanced cervical cancer (LACC). However, the prognostic impact of surgical staging remains to be proved, as published results comparing surgical versus radiological staging are contradictory. The aim of this study was to compare the prognosis of women with FIGO stage IB2–IIB CC who underwent surgical nodal staging including either exclusive para-aortic lymphadenectomy (PAL) or comprehensive pelvic + para-aortic lymphadenectomy (P-PAL).
Data of 314 women with FIGO stage IB2 to IIB CC treated between January 2000 and January 2015 were retrospectively abstracted from nine French institutions. The prognosis and outcomes were compared by Propensity score (PS) matching (PSM) analysis.
The median follow-up was 33 months (2–114). When comparing women who underwent PAL vs P-PAL, the recurrence rates were 26% (37/144) and 28% (41/144), respectively (p = 0.595). The respective 3-year recurrence free survival (RFS) for P-PAL and PAL were 72.9% (95% CI, 65.7–81.0) and 70.7% (95% CI, 62.4–80.2), (p = 0.394). The respective 3-year overall survival (OS) rates for P-PAL and PAL were 86.8% (95% CI, 81.1–92.9) and 78.6% (95% CI, 70.4–87.7) (p = 0.592). In the sub-group of women with lymph node metastases, RFS was improved for women who underwent P-PAL compared to those with exclusive PAL (p = 0.027), with no difference in OS (p = 0.187).
Comprehensive P-PAL does not seem to be of significant therapeutic benefit compared to exclusive PAL.

View all citing articles on Scopus

¹: To whom correspondence and reprint requests should be addressed. Fax: ++49-3641-933064. E-mail: [email protected].

View full text

Regular ArticleLaparoscopic Staging Compared with Imaging Techniques in the Staging of Advanced Cervical Cancer

Abstract

Experience of the Gynecologic Oncology Group. Gynecol Oncol

Obstet Gynecol

Gynecol Oncol

Gynecol Oncol

Bailliere's Clin Obstet Gynecol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Int J Gynecol Obstet

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

J Am Assoc Gynecol Laparosc

Regular Article
Laparoscopic Staging Compared with Imaging Techniques in the Staging of Advanced Cervical Cancer