Pretreatment Surgical Staging of Patients with Cervical Carcinoma
ABSTRACT & COMMENTARY
Synopsis: Pretreatment extraperitoneal staging of patients with bulky or locally advanced cervical carcinoma may afford a survival benefit via the debulking of macroscopically positive lymph nodes without significantly increasing treatment-related morbidity or mortality.
Source: Cosin JA, et al. Cancer 1998;82:2241-2248.
The routine use of extraperitoneal surgical staging prior to radiation therapy in patients with bulky or locally advanced cervical carcinoma remains controversial. Cosin and colleagues reviewed 266 patients with cervical carcinoma who underwent extraperitoneal pelvic and para-aortic lymphadenectomy prior to receiving radiotherapy. Patients were divided into groups based on their lymph node status. Group A had negative lymph nodes; group B had resected, microscopic lymph node metastases; group C had macroscopically positive lymph nodes that were resectable at the time of surgery; and group D had unresectable lymph nodes. All patients received standard radiotherapy using external beam and brachytherapy. Patients with lymph node metastases received extended field irradiation. Lymph node metastases were detected in 50% of patients. Five- and 10-year disease-free survival rates were similar for all patients in groups B and C. All patients in group D recurred. There was a 10.5% incidence of severe radiation-related morbidity and a 1.1% incidence of treatment-related deaths. Cosin et al conclude that extraperitoneal staging of patients with bulky or locally advanced cervical carcinoma might afford a survival benefit via the debulking of macroscopically positive lymph nodes without significantly increasing treatment-related morbidity or mortality.
COMMENT BY DAVID M. GERSHENSON, MD
Pre-irradiation surgical staging of patients with cervical cancer has been controversial for more than two decades. Felix Rutledge and Gilbert Fletcher performed some of the early studies of this approach at M.D. Anderson Cancer Center in the 1960s. Subsequent reports of pretreatment lymphadenectomy from our institution, using the transperitoneal approach, indicated substantial morbidity and mortality related to irradiation damage of the gastrointestinal tract. However, later studies of pretreatment lymphadenectomy using the extraperitoneal route demonstrated an acceptable rate of complications. Nevertheless, the therapeutic efficacy of surgical staging remains uncertain. There are no large, prospective, randomized trials. In the present study, Cosin et al suggest that debulking of metastatic lymph nodes is beneficial, based on the fact that those patients with resected macroscopically positive nodes had a similar survival rate to those with microscopic nodal involvement. Other studies had noted similar findings. I do believe that, based on my own experience and reports such as this, further study of this approach is warranted. Cosin et al apparently operated on all patients with cervical cancer. It is time to seriously consider a prospective, randomized trial in this area, but I would like to see the incorporation of some type of imaging study to select and triage cervical cancer patients for such a study. Historically, we have used lymphangiography to select candidates for surgical staging prior to definitive irradiation. The information presented is intriguing, but we need more data to recommend this approach on a routine basis.
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