Management of cervical cancer patients with isolated para-aortic lymph node metastases

To the editor: For patients with locally advanced cervical cancer, the current guidelines recommend primary chemoradiation [1]. Therefore, pretherapeutic staging has an important role in the management of female patients with locally advanced cervical cancer. Assessment of the nodal involve ment of the para-aortic lymph node (PALN) is critical for determining the field of radiation therapy (RT). Extended-field RT, concurrent cisplatin-containing chemotherapy, and brachytherapy should be considered in the case of PALN metastasis. Jang et al. [2] report the outcomes of 40 cervical cancer patients with isolated PALN metastases at initial diagnosis. This interesting and valuable article demonstrates the association between treatment outcomes and the features of PALN metastasessuch as size, site, and number. The number and size of PALNs were shown to correlate with progression-free survival. The authors suggest that the radiologic features of PALN can be used to determine the prognosis of patients with isolated PALN metastases. As the authors define PALN involvement based on imaging, the criteria for lymph node involvement should be clarified. In addition, it should also be noted that there are limitations including the false-positive and false-negative results of conventional imaging studies (magnetic resonance imaging or computed tomography) in detecting PALN metastases. It makes hard for clinicians to determine whether to perform extended-field RT based solely on imaging studies. It would be even more interesting if the authors were to show the correlation between the radiologic and pathologic findings in seven patients who underwent radical hysterectomy. In recent years, positron emission tomography/computed tomography (PET/CT) has been recommended for stage IB2 or advanced disease as it is considered to be more sensitive than conventional imaging studies in detecting node or distant metastases [3]. Future studies based on PET/CT are required in order to identify prognostic factors and treatment outcomes for locally advanced cervical cancer. Furthermore, survival data for patients with PALN metastases detected surgically and treated by extended-field RT in a randomized trial setting is rare [4]. Therefore, the impact of surgical staging in women with locally advanced cervical cancer should be evaluated in future trials, considering the high rate of false-negative PALN involvement from imaging studies. Bearing in mind that postoperative complications and the delay of definite chemoradiation can occur from nodal staging surgery, a comprehensive cost-effective analysis is required to clarify the best treatment strategy for locally advanced stage cervical cancer.