title: Should Systematic Infrarenal Para-aortic Dissection Be the Rule in the Pretherapeutic Staging of Primary or Recurrent Locally Advanced Cervix Cancer Patients With a Negative Preoperative Para-aortic PET Imaging?
abstract: BACKGROUND
  Extended-field chemoradiation is the usual management of patients with locally advanced cervical cancer (LACC) and para-aortic node metastases (PA pN1). It is efficient but not without morbidity. Assessment of PA lymph node positivity by PA lymphadenectomy is the most accurate method to select the candidates for this treatment. Hence, to clarify the dissection pattern, we wanted to test the true incidence of isolated/skip node metastasis, above the level of the inferior mesenteric artery (IMA).
  
  
  METHODS
  All patients with LACC and negative magnetic resonance imaging and positron emission tomography-computed tomography imaging at the PA level were offered a laparoscopic staging encompassing a diagnostic laparoscopy followed, if negative, by an extraperitoneal PA lymphadenectomy. All nodes were removed from both common iliac bifurcations up to the left renal vein. Node groups, below and above the IMA, were separately sent to the pathologist for definitive examination.
  
  
  RESULTS
  From January 2010 to December 2013, 196 stage IB1 with pelvic pN1, IB2, to IVA LACC patients from 2 cancer centers who fulfilled the criteria were included in this institutional review board-approved study after informed consent. Thirty patients (15%) had PA pN1. Only 1 patient had positive nodes exclusively located above the IMA (3.3% of the pN1 group; 95% confidence interval, 0%-9.7%). Complications were observed in 15 (7.6%) of 196 patients.
  
  
  CONCLUSIONS
  Given the very low rate of skip metastases above the IMA and the potential additional morbidity of a systematic extended dissection, a bilateral ilioinframesenteric dissection seems to be an acceptable pattern of PA lymphadenectomy in LACC patients.
authors.affiliation: *Centre Oscar Lambret, Lille; †Institut Gustave Roussy, Villejuif; and ‡Centre Claudius Regaud, Toulouse, France.
authors.forename: Eric
authors.initials: E
authors.lastname: Leblanc
authors.forename: Ninad
authors.initials: N
authors.lastname: Katdare
authors.forename: Fabrice
authors.initials: F
authors.lastname: Narducci
authors.forename: Lucie
authors.initials: L
authors.lastname: Bresson
authors.forename: Sebastien
authors.initials: S
authors.lastname: Gouy
authors.forename: Philippe
authors.initials: P
authors.lastname: Morice
authors.forename: Gwenael
authors.initials: G
authors.lastname: Ferron
authors.forename: Denis
authors.initials: D
authors.lastname: Querleu
authors.forename: Alejandra
authors.initials: A
authors.lastname: Martinez
mesh_terms: D000328:Adult; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007091:Image Processing, Computer-Assisted; D007668:Kidney / Q000098:blood supply / Q000473:pathology / Q000601:surgery*; D010535:Laparoscopy; D008137:Longitudinal Studies; D008197:Lymph Node Excision; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000601:surgery; D009367:Neoplasm Staging; D010220:Para-Aortic Bodies / Q000473:pathology*; D049268:Positron-Emission Tomography / Q000379:methods*; D011379:Prognosis; D011446:Prospective Studies; D014057:Tomography, X-Ray Computed; D002583:Uterine Cervical Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery*; D055815:Young Adult