Originally published as JCO Early Release 10.1200/JCO.2008.19.5883 on November 3 2008

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Value of Positron Emission Tomography of the Para-Aortic Lymph Nodes in Cervical Carcinoma Stage IB2-IIIB

Ignace Vergote, Dimitris Tsolakidis, Dieter Mortier, Patrick Neven, Frederic Amant

Department of Obstetrics and Gynaecology, University Hospitals Leuven, Belgium

Felix Mottaghy

Department of Nuclear Medicine, University Hospitals Leuven, Belgium

Erik Van Limbergen

Department of Radiotherapy, University Hospitals Leuven, Belgium

To the Editor:

We read with interest the article by Boughanim et al¹ on the value of positron emission tomography combined with computed tomography (PET-CT) scans in the para-aortic (PAO) area in patients with stage IB2-II cervical cancer. However, this study was hampered by an important delay between the PET-CT and the PAO lymphadenectomy (median, 123 days; range, 31 to 196 days), which makes interpretation of the value of PET-CT in detecting PAO lymph node metastases difficult.

The authors analyzed 38 patients and observed that 8% of their patients (three patients) had histologically proven PAO involvement, despite a negative PET-CT in the PAO area. Furthermore, the authors suggest these metastatic PAO lymph nodes are usually large and have capsular rupture. Finally, they suggest treating patients with negative PET scan but metastatic PAO lymph nodes with PAO radiotherapy.

We question the statements of the authors that the PAO nodes are usually large and have capsular growth, and that the para-aortic area should be treated with PAO radiotherapy only. In our study of 44 cervical carcinoma patients (stage IB2-IIIB) without PAO metastases on PET and CT scans or PET-CT, a laparoscopic PAO lymphadenectomy was performed immediately (within 1 week) after the PET scan.² In five (11%) of our patients, metastatic PAO nodes were observed.

For this letter, we updated our series and have currently performed 85 laparoscopic PAO lymphadenectomies after negative PET and CT scans or negative PET-CT, and observed nine patients with metastases in the para-aortic nodes (11%). The characteristics of the patients with metastatic PAO lymph nodes are summarized in Table 1. All metastatic lymph nodes were smaller than 1 cm, and none had capsular rupture. The laparoscopic procedure was stopped once a PAO metastasis was found on frozen section. All patients underwent pelvic and PAO radiochemotherapy in case of PAO lymph node metastasis. Patient 9 was treated with neoadjuvant chemotherapy followed by radiochemotherapy to the pelvic and PAO area.

Furthermore, in our experience, patients with PAO lymph node metastases and negative PET scan have a poor prognosis, even when treated with PAO radiochemotherapy (Table 1). In addition, in our series, these patients often experienced recurrence outside the pelvic and PAO area. Hence, we suggest that other treatment strategies such as (neoadjuvant) chemotherapy or molecular targeted therapy should be evaluated in this group of patients.

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 November 3, 2008

REFERENCES

1. Boughanim M, Leboulleux S, Rey A, et al: Histologic results of PAO 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 15:2558-2561, 2008

2. Mortier DG, Stroobants S, Amant F, et al: Laparoscopic para-aortic lymphadenectomy and positron emission tomography scan as staging procedures in patients with cervical carcinoma stage IB2-IIIB. Int J Gynecol Cancer 2008 18:723-729, 2008

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