Surgical nodal staging in cervical cancer, a narrative review from the French cervical cancer guidelines group.

OBJECTIVE

To synthesize contemporary evidence on surgical lymph-node staging in cervical cancer especially its indications, techniques, extent, morbidity, and impact on oncologic outcomes.

BACKGROUND

Nodal status is a key prognostic factor that guides treatment decisions and radiotherapy field planning. While 18F-FDG PET/CT is the imaging reference, false-negative rates for para-aortic disease remain clinically relevant, especially when pelvic nodes are positive, motivating selective surgical staging.

METHODS

We conducted a narrative review of published studies investigating the prognostic and therapeutic impact of pelvic and/or para-aortic lymph-node assessment, including sentinel lymph-node (SLN) mapping in patients with cervical cancer.

RESULTS

In early-stage disease, SLN mapping achieves high overall and bilateral detection, enables ultrastaging to uncover micrometastases and isolated tumor cells, and reduces morbidity compared with systematic pelvic lymphadenectomy while maintaining oncologic safety in contemporary series and trials. Survival advantages of surgical over imaging-only staging remain heterogeneous across studies. In locally-advanced cancers, surgical para-aortic staging identifies occult metastases in roughly one in ten patients with negative para-aortic PET/CT and in a higher proportion when pelvic nodes are PET-positive, often leading to adaptation of chemoradiation fields but the effect on survival remain debated. Minimally invasive extraperitoneal and transperitoneal approaches provide comparable node yields and similar timelines to chemoradiation, with low severe morbidity in experienced centers. Extending dissection from infra-mesenteric to infra-renal increases node counts but data regarding identification of additional lymph node metastasis are inconsistent.

CONCLUSIONS

Surgical staging refines the assessment of lymph node involvement and enables appropriate tailoring of chemo-radiotherapy fields to include the para-aortic area when indicated. Standardized reporting of technique, extent, and downstream radiotherapy is needed.