Originally published as JCO Early Release 10.1200/JCO.2008.18.9928 on October 6 2008

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Occult Para-Aortic Lymph Node Metastasis After Negative Positron Emission Tomography/Computed Tomography Scan

Sokbom Kang, Sang Soo Seo, Sang Yoon Park

Research Institute and Hospital, National Cancer Center, Goyang, South Korea

To the Editor:

We read the article by Boughanim et al¹ with great interest. The authors observed that 8% of patients (three of 38 patients) with stage IB/II cervical cancer who had no evidence of para-aortic node metastasis on their pretreatment positron emission tomography/computed tomography (PET/CT) scan actually had para-aortic nodal metastasis at the time of surgery. In the study, one of the suggested explanations for the nonvisualization of positive para-aortic nodes was the metastasis during the interval between PET/CT scan and the lymphadenectomy. Recently, we completed a prospective study to determine the accuracy of PET/CT for detecting lymph node metastasis in patients with cervical cancer who underwent laparoscopic surgical staging.^2-4

Between October 2003 and January 2006, 27 patients with stage IB-IVA squamous cell cervical carcinoma were enrolled. Twenty-four patients (88.9%) had no evidence of para-aortic node involvement at PET/CT scan. The median age was 49 years (range, 26 to 67 years), and the distribution of International Federation of Gynecology and Obstetrics stage was as follows: IB2 (n = 1), IIA (n = 1), IIB (n = 19), and IIIA (n = 3). After laparoscopic staging, two patients (8.3%) were shown to have para-aortic node metastasis. Although we performed surgical staging before treatment, the frequency of false-negative PET/CT scan was strikingly similar to the data provided by Boughanim et al.¹ Moreover, two recently published studies reported that para-aortic lymph node assessment by PET/CT had false negativity rates from 4.3% (one of 23) to 16.7% (two of 12).^5,6 The pooled analysis of the three studies^2,5,6 suggests that negative para-aortic status assessed by PET/CT has a false-negative rate of 8.5% (95% CI, 3.2% to 19.4%). Therefore, it is more likely that para-aortic node assessment by PET/CT has innate false negativity.

If correct, this notion raises an important concern regarding the role of concurrent chemotherapy. If the false-negative rate of PET/CT for para-aortic nodal status does not differ pre- and post-treatment, it would suggest that concurrent chemotherapy has little role in eradicating occult para-aortic nodal metastasis without extended-field radiation. However, the routine use of surgical staging in patients with locally advanced disease will impose unnecessary physical and economic burden to the majority of patients with truly negative para-aortic nodes. Therefore, we need to determine how to select the appropriate patients who will benefit from surgical staging. In our data, among 24 patients with negative para-aortic nodes on PET/CT scan, 12 patients (50.0%) had positive pelvic nodal involvement on PET/CT scan. All patients with histologically proven, para-aortic node–positive status were included in these 12 cases. Accordingly, in these patients the frequency of false-negative para-aortic metastasis would be increased (16.6%). Therefore, we suggest to the authors that stratification of patients according to variables, such as positive PET/CT finding in pelvic nodes, could help better identify the high-risk group for occult para-aortic metastasis. This action may help stratify patients in future clinical trials that test the role of surgical staging of para-aortic nodes in locally advanced cervical cancer.

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

NOTES

published online ahead of print at www.jco.org on October 6, 2008

REFERENCES

1. Boughanim M, Leboulleux S, Rey A, et al: Histologic results of para-aortic lymphadenectomy in patients treated for stage IB2/II cervical cancer with negative [18F]fluorodeoxyglucose positron emission tomography scans in the para-aortic area. J Clin Oncol 26:2558-2561, 2008[Abstract/Free Full Text]

2. Choi HJ, Roh JW, Seo SS, et al: Comparison of the accuracy of magnetic resonance imaging and positron emission tomography/computed tomography in the presurgical detection of lymph node metastases in patients with uterine cervical carcinoma: A prospective study. Cancer 106:914-922, 2006[CrossRef][Medline]

3. Roh JW, Seo SS, Lee S, et al: Role of positron emission tomography in pretreatment lymph node staging of uterine cervical cancer: A prospective surgicopathologic correlation study. Eur J Cancer 41:2086-2092, 2005[CrossRef][Medline]

4. Chung HH, Lee S, Sim JS, et al: Pretreatment laparoscopic surgical staging in locally advanced cervical cancer: Preliminary results in Korea. Gynecol Oncol 97:468-475, 2005[CrossRef][Medline]

5. Loft A, Berthelsen AK, Roed H, et al: The diagnostic value of PET/CT scanning in patients with cervical cancer: A prospective study. Gynecol Oncol 106:29-34, 2007[CrossRef][Medline]

6. Yildirim Y, Sehirali S, Avci ME, et al: Integrated PET/CT for the evaluation of para-aortic nodal metastasis in locally advanced cervical cancer patients with negative conventional CT findings. Gynecol Oncol 108:154-159, 2008[CrossRef][Medline]

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• Histologic Results of Para-Aortic Lymphadenectomy in Patients Treated for Stage IB2/II Cervical Cancer With Negative [¹⁸F]Fluorodeoxyglucose Positron Emission Tomography Scans in the Para-Aortic Area
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