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Evidence - pelvic lymphadenectomy on both sides, laparoscopic, robot-assisted laparoscopy (DaVinci)

gynecology
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Indications and performance of SLNB, systematic pelvic lymphadenectomy, and para-aortic lymphadenectomy

    ProcedureIndicationExecution
    Sentinel Lymph Node Biopsy- Tumor FIGO IA1 with L1, IA2, IB1 (<2 cm). 
    - No proven lymph node metastases. 
    - Bilateral sentinel lymph node detection possible.    		- Identification of sentinel lymph nodes with radioactive tracer, indocyanine green, or patent blue.
    - Removal and histological examination.
    Pelvic Lymphadenectomy- Tumor >2 cm or proven lymph node metastases. 
    - Inadequate sentinel lymph node detection. 
    - High-risk patients (e.g., L1, deep stromal infiltration).    		- Systematic removal of obturator, iliac, and para-iliac lymph nodes.
    Para-aortic Lymphadenectomy- Proven pelvic lymph node metastases. 
    - Tumor stage ≥ FIGO IIB. 
    - Tumor size >4 cm with suspected lymph node involvement.    		- Removal of para-aortic lymph nodes up to the level of the renal arteries.

    Important Decision Criteria:

    • If the sentinel node is negative, systematic pelvic LNE can be omitted.
    • If no sentinel lymph node is found, systematic LNE is necessary.
    • Para-aortic lymphadenectomy only in confirmed pelvic metastases to optimize staging and therapy strategy (e.g., radiochemotherapy).

    Reference:

    1. Lecuru, F., et al., Bilateral negative sentinel nodes accurately predict absence of lymph node metastasis in early cervical cancer: results of the SENTICOL study. J Clin Oncol, 2011. 29(13): p. 1686-91
    2. Denschlag, D., J. Woll, and A. Schneider, Importance of the Sentinel Lymph Node Concept in Uterine Carcinomas. Frauenarzt, 2011. 52(1): p. 46-51.
    3. Altgassen, C., et al., Multicenter validation study of the sentinel lymph node concept in cervical cancer: AGO Study Group. J Clin Oncol, 2008. 26(18): p. 2943-51.
    4. Ruscito, I., et al., Sentinel Node Mapping in Cervical and Endometrial Cancer: Indocyanine Green Versus Other Conventional Dyes-A Meta-Analysis. Ann Surg Oncol, 2016. 23(11): p. 3749-3756.
    5. Guideline Program Oncology (German Cancer Society, German Cancer Aid, AWMF): S3 Guideline Diagnosis, Therapy, and Follow-up of Patients with Cervical Cancer, Long Version 2.2, 2022, AWMF Register Number: 032/033OL

  2. Sentinel lymph node biopsy vs. systematic pelvic lymphadenectomy

    The sentinel technique offers lower morbidity than systematic LNE, but there is a risk of false-negative findings.

    Comparison of Procedures:

    CriterionSentinel Lymph Node Biopsy (SLNB)Systematic Pelvic LNE
    Sensitivity for Metastases91.4% (higher than PET-CT and MRI)99% (gold standard)
    Mortality & ComplicationsLower (less bleeding, lymphedema)Higher (10–20% risk of lymphedema, lymphoceles)
    Standard Procedure?Only for early stages (≤2 cm, no metastases)For all advanced stages or positive sentinel nodes
    Evidence BaseStudies show high safety in FIGO IA2/IB1Standard procedure according to S3 guideline
    • SLNB is a safe alternative to systematic LNE when both sentinel nodes are clearly depicted.
    • If sentinel nodes are not found or positive for metastases, a systematic LNE is required.

    Reference: 

    1. Selman, T.J., et al. Diagnostic accuracy of tests for lymph node status in primary cervical cancer: a systematic review and meta-analysis (Structured abstract). CMAJ: Canadian Medical Association Journal, 2008. 178, 855-862.
    2. Lecuru, F., et al., Bilateral negative sentinel nodes accurately predict absence of lymph node metastasis in early cervical cancer: results of the SENTICOL study. J Clin Oncol, 2011. 29(13): p. 1686-91
    3. Guideline Program Oncology (German Cancer Society, German Cancer Aid, AWMF): S3 Guideline Diagnosis, Therapy, and Follow-up of Patients with Cervical Cancer, Long Version 2.2, 2022, AWMF Register Number: 032/033OL

  3. Laparoscopic vs. open lymphadenectomy

    CriterionLaparoscopic LNEOpen LNE (Laparotomy)
    MorbiditätLess blood loss, fewer wound healing disordersHigher blood loss, longer healing
    Postoperative RecoveryShorter hospital stay (3–5 days)Longer stay (5–10 days)
    • Laparoscopy is advantageous for early stages, but for advanced tumors, open lymphadenectomy is oncologically superior.
    • The LACC study (2018) showed that laparoscopic radical hysterectomy had a higher recurrence rate and worse overall survival than the open method.

    Reference:

    1. Hillemanns P, Brucker S, Holthaus B, Kimmig R, Lampe B, Runnebaum I, Ulrich U, Wallwiener M, Fehm T, Tempfer C; AGO Uterus and the AGE of the DGGG. Updated Opinion of the Uterus Commission of the Gynecological Oncology Working Group (AGO) and the Gynecological Endoscopy Working Group (AGE) of the German Society of Gynecology and Obstetrics (DGGG) on the Randomized Study Comparing Minimally Invasive with Abdominal Radical Hysterectomy for Early-stage Cervical Cancer (LACC). Geburtshilfe Frauenheilkd. 2019 Feb;79(2):145-147. doi: 10.1055/a-0824-7929. Epub 2019 Feb 18. PMID: 30792544; PMCID: PMC6379161.
    2. Ramirez, P.T., et al., Minimally Invasive versus Abdominal Radical Hysterectomy for Cervical Cancer. N Engl J Med, 2018. 379(20): p. 1895-1904.
    3. Wang, Y.Z., et al., Laparoscopy versus laparotomy for the management of early stage cervical cancer. BMC Cancer, 2015. 15: p. 928.
    4. Guideline Program Oncology (German Cancer Society, German Cancer Aid, AWMF): S3 Guideline Diagnosis, Therapy and Follow-up of Patients with Cervical Cancer, Long Version 2.2, 2022, AWMF Registration Number: 032/033OL

  4. Metastatic pattern of cervical cancer

    Cervical cancer primarily metastasizes lymphogenically, with the obturator lymph nodes being the most common first station. In later stages, cervical cancer can metastasize hematogenously. The most common distant metastases are in the lungs.

    Frequency of Lymph Node Metastases in Cervical Cancer

    Lymph Node RegionFrequency of MetastasesRemark
    Obturator/Parauterine Lymph Nodes39.3 %Most common initial manifestation of metastases in the pelvis.
    External Iliac Lymph Nodes40.4 %Often affected after obturator involvement.
    Internal Iliac Lymph Nodes13.6 %Medial to the internal iliac artery, often in combination with involvement of other pelvic lymph nodes.
    Common Iliac Lymph Nodes6.7 %Higher metastasis rate in advanced stages, rarely affected in isolation.
    Para-aortic Lymph Nodes

    5% from

    from FIGO IIb 25%

    		Usually secondary after pelvic metastasis, significant from FIGO IIB.
    Metastasis RegionFrequencyComment
    Lungs21 %Most common hematogenous metastasis.
    Liver4 %Late manifestation, often multiple lesions.
    Abdominal Cavity7 %Ascites, peritoneal metastases possible.
    Gastrointestinal Tract4 %Rectum, sigmoid colon affected by direct infiltration.
    Bones (especially spine)7 %Mostly osteolytic metastases.

    Connection Between Tumor Stage and Metastasis

    The likelihood of distant metastasis increases with the tumor stage.

    FIGO StageProbability of Distant Metastases
    IA3 %
    IB16 %
    IIA31 %
    IIB26 %
    III39 %
    IVA75 %

     

    Reference:

    1. Howlader N, N.A., Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review 1975-2016. 2019.
    2. Fagundes, H., et al., Distant metastases after irradiation alone in carcinoma of the uterine cervix. Int J Radiat Oncol Biol Phys, 1992. 24(2): p. 197-204.
    3. Perez, C.A., et al., Impact of dose in outcome of irradiation alone in carcinoma of the uterine cervix: analysis of two different methods. Int J Radiat Oncol Biol Phys, 1991. 21(4): p. 885-98.
    4. Kidd EA, Siegel BA, Dehdashti F, Rader JS, Mutch DG, Powell MA, Grigsby PW. Lymph node staging by positron emission tomography in cervical cancer: relationship to prognosis. J Clin Oncol. 2010 Apr 20;28(12):2108-13. doi: 10.1200/JCO.2009.25.4151. Epub 2010 Mar 22. PMID: 20308664.
    5. Cao L, Kong W, Li J, Song D, Jin B, Liu T, Han C. Analysis of Lymph Node Metastasis and Risk Factors in 975 Patients with FIGO 2009 Stage IA-IIA Cervical Cancer. Gynecol Obstet Invest. 2023;88(1):30-36. doi: 10.1159/000527712. Epub 2022 Nov 30. PMID: 36450266.
    6. Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF): S3-Leitlinie Diagnostik, Therapie und Nachsorge der Patientin mit Zervixkarzinom, Langversion 2.2, 2022, AWMF Registernummer: 032/033OL

  5. literature search

    Literature search on the pages of pubmed.