Isolated para-aortic nodal metastasis or recurrence absent after radical hysterectomy for stage IA-IIA cervical carcinoma (401)

Abstract

Objectives: Accumulating evidence suggests that due to the low risk of initially metastatic para-aortic lymph nodes (PaLNs), patients undergoing surgical management of early-stage cervical cancer could potentially be spared the operative and long-term morbidity of PaLN dissection. We sought to explore the upfront and downstream implications of this management philosophy in women undergoing radical hysterectomy for stage IA - IIA cervical cancer. Methods: A review of institutional data identified women undergoing curative-intent radical hysterectomy with concurrent lymphad- enectomy of any kind for FIGO stage IA - IIA cervical carcinoma from 2004 to 2021. Demographics and clinical-pathologic data were collected. Recurrence rates and locations were analyzed. Patients with no follow-up were excluded. Chi-square and Fisher’s exact test were used for statistical analysis. Results: Three hundred patients were identified, of whom 265 were included in the analysis. The Median follow-up was 56 months. Regarding tumor stages, 31 patients had stage IA, 195 stage IB1, 34 stage IB2, and five had stage IIA. Seventy-one percent of patients underwent pelvic lymphadenectomy only (PLND), with 29% undergoing both pelvic and para-aortic lymphadenectomy (PPaLND). Demographic distribution was similar between groups. LVSI was present in 37% of PLND compared to 32% of PPaLND groups (p = NS). High-risk features (GOG 109 criteria: positive nodes, parametria, or margins) were present in 13% and 15% of patients of each group, respectively (p = NS). Para-aortic nodal metastasis was not detected in any patient with early-stage cervical cancer. Disease recurrence was diagnosed in 13.8% of PLND compared to 10.3% of PPaLND patients (p =NS), of which 65% included distant or multisite recurrences. Among recurrences, median PFS was 15.5 months (IQR 8.2 - 29.7), and OS was 34 months (IQR 21.5 - 54.4). There were no isolated first disease recurrences involving the para-aortic nodal chain. Less than 3% of patients (n = 1) with multi-site recurrence had involvement of the PaLN chain, which was in the setting of receiving no adjuvant treatment with high-risk disease (positive pelvic LNs) on initial surgery. Most common distant and multi-site recurrences occurred in the liver, lungs, and brain. Conclusions: Isolated para-aortic nodal recurrence was absent in patients after surgical management of early-stage cervical cancer, irrespective of histologic type. PaLN involvement in multi-site recurrence was also very uncommon, less than 3%. These findings could potentially be utilized to further refine individualized treatment planning in the upfront setting to spare unnecessary surgical morbidity. Objectives: Accumulating evidence suggests that due to the low risk of initially metastatic para-aortic lymph nodes (PaLNs), patients undergoing surgical management of early-stage cervical cancer could potentially be spared the operative and long-term morbidity of PaLN dissection. We sought to explore the upfront and downstream implications of this management philosophy in women undergoing radical hysterectomy for stage IA - IIA cervical cancer. Methods: A review of institutional data identified women undergoing curative-intent radical hysterectomy with concurrent lymphad- enectomy of any kind for FIGO stage IA - IIA cervical carcinoma from 2004 to 2021. Demographics and clinical-pathologic data were collected. Recurrence rates and locations were analyzed. Patients with no follow-up were excluded. Chi-square and Fisher’s exact test were used for statistical analysis. Results: Three hundred patients were identified, of whom 265 were included in the analysis. The Median follow-up was 56 months. Regarding tumor stages, 31 patients had stage IA, 195 stage IB1, 34 stage IB2, and five had stage IIA. Seventy-one percent of patients underwent pelvic lymphadenectomy only (PLND), with 29% undergoing both pelvic and para-aortic lymphadenectomy (PPaLND). Demographic distribution was similar between groups. LVSI was present in 37% of PLND compared to 32% of PPaLND groups (p = NS). High-risk features (GOG 109 criteria: positive nodes, parametria, or margins) were present in 13% and 15% of patients of each group, respectively (p = NS). Para-aortic nodal metastasis was not detected in any patient with early-stage cervical cancer. Disease recurrence was diagnosed in 13.8% of PLND compared to 10.3% of PPaLND patients (p =NS), of which 65% included distant or multisite recurrences. Among recurrences, median PFS was 15.5 months (IQR 8.2 - 29.7), and OS was 34 months (IQR 21.5 - 54.4). There were no isolated first disease recurrences involving the para-aortic nodal chain. Less than 3% of patients (n = 1) with multi-site recurrence had involvement of the PaLN chain, which was in the setting of receiving no adjuvant treatment with high-risk disease (positive pelvic LNs) on initial surgery. Most common distant and multi-site recurrences occurred in the liver, lungs, and brain. Conclusions: Isolated para-aortic nodal recurrence was absent in patients after surgical management of early-stage cervical cancer, irrespective of histologic type. PaLN involvement in multi-site recurrence was also very uncommon, less than 3%. These findings could potentially be utilized to further refine individualized treatment planning in the upfront setting to spare unnecessary surgical morbidity.