The impact of pre-therapy extraperitoneal surgical staging on the evaluation and treatment of patients with locally advanced cervical cancer

Objective: The use of extraperitoneal surgical staging prior to treatment i n patients with bulky or locally advanced cervical cancer allows the detect ion and treatment of disease beyond the standard pelvic radiation fields. T his study was conducted to evaluate the impact of extraperitoneal surgical staging in the treatment and outcome of patients with locally advanced cerv ical cancer. Methods: 51 patients with locally advanced cervical cancer treated between 1985 and 1998 were retrospectively reviewed. Information on morbidity, usef ulness, and results of surgery and patterns of disease recurrence were obta ined. Survival distributions were calculated by the Kaplan-Meier product li mit method and compared with the log-rank test. Results: All 51 women were surgically staged by an extra-peritoneal approac h. Preoperative CT scans (n=27) when compared with surgical findings showed sensitivity for pelvic and para-aortic lymph node metastasis of 39%, speci ficity of 88%, positive predictive value of 39% and negative predictive val ue of 88%. Lymph node metastases were found in 30/51 patients (59%). There were no significant treatment delays or surgical morbidity as a result of e xtra-peritoneal surgical staging. In 21 patients (41%), the highest level o f involved nodes was in the pelvis and they were treated with pelvic radiat ion. The para-aortic nodes were involved in nine patients (18%) and were tr eated with extended field radiation. All patients also received concurrent radiosensitization with chemotherapy. The estimated survival for the entire group was 60% at 5 years. For node negative patients, estimated 5-year sur vival was 67% while it was 54% for all node positive patients (p=0.17). Ana lysis according to anatomic site of involved nodes showed that the estimate d 2-year and 5-year survival for those with pelvic nodal involvement was 81 % and 64%, respectively. However, in the group of nine patients with para-a ortic nodal disease, the estimated 2-year survival was 44%. Five (56%) were dead of disease with a median time to death of 16.0 months and four patien ts (44%) were alive with a median duration of follow up of 16.1 months. The re was a statistically significant difference in survival for the group of patients with positive pelvic nodes only compared to the group with positiv e para-aortic nodes (p=0.03). The estimated 5-year survival by FIGO stage w as 80%, 70% and 51% for stages Ib, II, III, disease, respectively, Factors that did not significantly affect survival included age, histology and type of chemotherapy. Conclusions: Pre-therapy extra-peritoneal surgical staging resulted in trea tment modification in 18% of patients with locally advanced cervical cancer . The morbidity from surgery and subsequent radiation therapy was acceptabl e. The procedure is recommended to allow for individualization of treatment in patients with local-regional cervical cancer.