The Role of Surgical Staging for Cervical Cancer

Recent trends in gynecologic oncology have favored surgical staging of disease not only to define local extent, but more importantly nodal involvement. For cervical cancer, surgical staging includes intraperitoneal exploration, cytological washings, direct tumor palpation, and para-aortic with or without pelvic lymph node (LN) dissection. In the Gynecologic Oncology Group (GOG) experience, extraperitoneal selective para-aortic lymphadenectomy was associated with a lower risk of enteric complications following radiation for advanced cervical cancer and was, therefore, judged to be the preferred surgical procedure. In the GOG data base, para-aortic LN involvement was the most significant prognostic factor in multivariate analysis. If para-aortic LN were negative, pelvic LN metastases and tumor size were the most significant independent prognostic factors. Progression-free interval at 5 years decreased from 57% for patients with negative nodes to 34% and 12% for patients with pelvic or para-aortic LN metastases, respectively. As such, surgical staging must retain an integral role in protocol development to assure equal stratification of prognostic variables and, thereby, assess the benefit of innovative treatments for locally advanced cervical cancer in randomized prospective trials. The potential for lymphanglography and laparoscopy as alternatives to laparotomy are reviewed.