Noninvasive radiologic methods to detect paraaortic
lymph node metastases are reliable when combined with FNA of enlarged lymph nodes. However, the sensitivity is low, and undetected microscopic
metastases leads to treatment failure. These patients with paraaortic
lymph node metastasis are not treated with extended-field radiation, and they all die within 3 years. The CT scanning is probably the best diagnostic method to evaluate
cervical cancer, because it can assess the primary
tumor, the urinary tract, gastrointestinal tract, liver parenchyma, and retroperitoneum. It also permits the guidance of FNA and the arrangement of radiation ports. Surgical staging provides the direct assessment of the peritoneal cavity and the retroperitoneal spaces. Metastatic
tumor, including enlarged lymph nodes, can be resected, but this is of dubious benefit. The operative morbidity is acceptable, with fewer intestinal complications when the extraperitoneal approach is used, and long-term morbidity is minimal when appropriate paraaortic radiation doses are employed (less than 5,000 cGy). Surgical staging has provided data on the frequency of paraaortic
lymph node metastasis by stage of
cervical cancer, and thus, treatment strategies can be better developed. Extended-field radiation results in 5-year survival rates of 20-25% in patients with microscopic paraaortic
lymph node metastasis, patients who would not survive without the treatment. However, surgical staging has produced only a modest boost in survival rates, because of the high rate of pelvic and systemic failure. When extended-field radiation is used prophylactically or in patients with probable
lymph node metastasis seen on radiographic studies, survival rates are similar to patients irradiated after surgical staging finds paraaortic lymph node disease. As our ability to predict, and detect nonsurgically, positive paraaortic node disease improves, extended radiation (or other adjuvant
therapy) could be used more frequently without operation in patients who are at high risk for metastatic disease. In a study by Haie et al, prophylactic paraaortic radiation was given to patients at high risk for paraaortic
metastasis. In patients with a high probability of local disease control, paraaortic radiation significantly reduced the incidence of paraaortic and distant
metastases. Patients with known paraaortic
lymph node metastases frequently have occult systemic
metastases. In these same patients, pelvic failure is also common. Thus, until effective systemic
therapies emerge, a marked improvement in survival is unlikely in patients who have paraaortic
lymph node metastasis.(ABSTRACT TRUNCATED AT 400 WORDS)