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Which consequence does metastatic spread to lymph nodes have on intraoperative decision-making for early-stage CeC patients?
In case of lymph node involvement, patients proceed to surgery.
A fertility-sparing approach is only possible in patients where no metastases have been found in pelvic lymph nodes.
The nodal status does not impact the intraoperative surgical decision and only influences the therapy.
Usually, lymph nodes are not examined during surgery so that it does not have any influence.
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With an estimated 570 000 cases and 311 000 deaths in 2018 worldwide, cervical cancer ranks as the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women.1
Since cervical cancer often affects younger women, the patient’s wish of fertility preservation might play a central role in pre-treatment counselling. However, the option of fertility preservation strongly depends on the stage of disease, most importantly on the lymph node status, and can only be considered in early stages and in case no metastatic spread to pelvic lymph nodes occurred.
First, to examine the pelvis for potential lymph node involvement, clinical staging is performed using imaging. The identification of tumour spread to pelvic lymph nodes is a contraindication for a surgical intervention and directly leads to chemoradiotherapy as standard of care, thus excluding any fertility-sparing approach. Only early-stage patients without obvious nodal involvement may be eligible for surgery.
Since imaging methods have a limited sensitivity, it cannot be excluded that metastases remain undetected during clinical staging. Nowadays, sentinel lymph node biopsy (SLNB) is recommended as an initial step of a surgical intervention to assess the nodal status. Sentinel lymph nodes (SLN) are the first lymph nodes in the lymphatic drainage of a tumour and most likely to harbour metastasis. The conventional method for intraoperative assessment of SLN is histopathologic examination by frozen section which also suffers from a low sensitivity, especially in detecting low-volume disease. Consequently, surgeons might base their decision to proceed with a fertility-sparing approach on a false negative intraoperative SLN result, bearing the risk of potential undertreatment. Moreover, if postoperative, more extensive histopathology reveals nodal involvement later, the patient would require chemoradiation in addition to surgery which in contrast is regarded as overtreatment and shall be avoided according to guideline recommendations2.
The combination of a specific SLN localisation technique, as offered by the Sentimag®– Magtrace® system, and a highly sensitive intraoperative whole node analysis, as provided by the OSNA (one step nucleic acid amplification) method, enables accurate nodal staging and provides clinicians a safe basis for patient-individual treatment decisions.
- Bray F et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018; 68:394–424.
- ESGO-ESTRO-ESP Guidelines for the Management of Patients with Cervical Cancer:2018
Endomag®, Sentimag® and Magseed® are registered European Union trade marks of Endomagnetics Ltd. www.endomag.com