Received Date: 19-Dec-2016

Accepted Date: 04-Feb-2017

Accepted Article
Article Type: Mini-commentary

Mini-commentary on 2016-OG-17921R1: ‘Survival effect of laparoscopic para-aortic staging in

Locally Advanced Cervical Cancer (LACC): a retrospective cohort analysis’

Locally advanced cervix cancer: staging by scan or by surgery?

Jeroen H Becker1 and Rene H.M. Verheijen2

Corresponding author email id: jeroenbecker@gmail.com

1) Zuwe Hofpoort Hospital

Obstetrics and Gynaecology
Polanerbaan 2
Woerden, Utrecht 3474 GN
Netherlands

2) University Medical Centre Utrecht

Woman and Baby
Heidelberglaan 100
Utrecht, 3508 GA
Netherlands

In this study the authors try to elucidate the existing uncertainties on imaging versus surgically
staging of para-aortic lymph node involvement in locally advanced cervical cancer. In previous
studies, as summarized in this new study, it remained undecided whether imaging would suffice
to detect lymph node metastases in order to determine the extent of the radiation field,
specifically to the para-aortic area.

Para-aortic lymph node involvement is common in locally advanced cervical cancer, ranging
between 11 and 50%, with and average of about 20% (Gil-Moreno et al. Gynecol Oncol. 2012
May;125(2):312-4). This should be taken into account to optimize treatment for these women,

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/1471-0528.14596
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 at the same time avoiding morbidity of para-aortic radiation in women who do not need this. In
many countries surgical staging is therefore routinely performed in women with locally
advanced cervical cancer, adding to the morbidity of diagnostics and treatment.
Accepted Article
In several studies, pre-treatment staging by imaging has shown that up to 15% of lymph nodes
that were normal on imaging appeared to be positive on histological examination. This also
holds for sensitive methods, such as PET-CT/SPECT detection (Smits et al. Int J Gynecol Cancer.
2014 Jul;24(6):973-83). These numbers seem to be large enough to advocate surgical staging,
but at the same time the differences in survival that one might expect when comparing surgical
staging to clinical staging do not support this. In fact, both Lai et al. and the current RCT by
Pomel et al. show a deleterious effect of surgical staging. Both studies are, however, not perfect
in their methodology. Lai et al. published a prospective, randomized trial, powered to include
120 women, but due to a significant difference in survival at the time of interim analysis, patient
accrual stopped when 61 patients had been enrolled. The current study by Pomel et al. managed
to select 187 patients, though retrospectively.

Despite the shortcomings of the available studies, the results consistently point towards a
disadvantage of surgical staging, despite the fact that this approach is better in detecting
microscopic disease than imaging. This difference apparently is not due to a difference in
chemoradiation rate between surgical and image guided staging. It is a pity that this study was
not designed to detect the reasons for the rather unexpected finding that the less accurate
staging by imaging results in better survival. Specifically, the morbidity of the surgical staging,
even when performed laparoscopically, has not been documented. In addition, it could well be
that this approach has added to the morbidity of para-aortal radiation. This also shows that in
prospective studies, apart from statistical considerations, also shortcomings of previous studies
need to be taken into account and considered for powering.

At this moment we could of course adopt the existing literature as being ‘the best available
evidence’ and abort surgical staging only to rely on sensitive imaging methods for planning the
extent of irradiation for locally advanced cervical cancer. Alternatively, it can be argued that in
the wake of shortcomings of the few existing studies we should continue surgical staging, at the
same time identifying this subject as being a knowledge gap that calls for well powered
randomized trials..

No disclosures. The ICMJE disclosure forms are available as online supporting information.

This article is protected by copyright. All rights reserved.