|Year : 2018 | Volume
| Issue : 4 | Page : 75-79
Patterns of lymph node involvement and role of common iliac lymphadenectomy in early-stage cervical cancers: A retrospective analysis from tertiary care cancer center in Eastern India
Manoranjan Mohapatra1, Rohini Vinayak Kulkarni1, Bhagyalaxmi Nayak1, Swathi Pai2, Ashok Padhy1, Sushil Kumar Giri1, Janmejay Mahapatra1, Jita Parija1
1 Department of Gynaecological Oncology, Acharya Harihara Regional Cancer Centre, Cuttack, Odisha, India
2 Department of Obstetrics and Gynaecology, SCB Medical College, Cuttack, Odisha, India
|Date of Web Publication||26-Dec-2018|
Dr. Rohini Vinayak Kulkarni
Department of Gynaecological Oncology, Acharya Harihar Regional Cancer Centre, Cuttack - 753 007, Odisha
Source of Support: None, Conflict of Interest: None
Aims: The aim of the study was to analyze the patterns of lymph node metastasis in early cervical cancer cases operated and to measure the metastatic burden in common iliac nodes and subsequently assess the need for its dissection. Materials and Methods: The study included all the cases of early carcinoma of cervix (Stage IA to IIA) that were operated in our institute. The cases with positive (metastatic) lymph nodes were isolated incorporating the data in tabular form and the patterns of lymph node metastasis analyzed with special reference to common iliac node involvement. Results: A total of 250 patients were operated in our study cohort and 50 cases (20%) had positive lymph node metastasis. External iliac nodes (58%) were most commonly involved, whereas 20% of cases had common iliac nodal involvement and isolated common iliac nodal involvement was seen only in 8% of these cases. Among all the lymph node positive cases, 74% had two or more of the three intermediate-risk factors including deep stromal invasion, lymphovascular space invasion positivity, or large-sized lesion (>4 cm). All the isolated common iliac lymph node positive cases had either positive parametrium or at least two intermediate-risk factors. Conclusion: Isolated common iliac nodal involvement being very low (8%), and this isolated involvement having been demonstrated only in cases with other risk factors; the role of common iliac lymph node dissection in early-stage cancer cervix becomes questionable.
Keywords: Cervical cancers, common iliac lymphadenectomy, early stage, lymph node status
|How to cite this article:|
Mohapatra M, Kulkarni RV, Nayak B, Pai S, Padhy A, Giri SK, Mahapatra J, Parija J. Patterns of lymph node involvement and role of common iliac lymphadenectomy in early-stage cervical cancers: A retrospective analysis from tertiary care cancer center in Eastern India. Oncol J India 2018;2:75-9
|How to cite this URL:|
Mohapatra M, Kulkarni RV, Nayak B, Pai S, Padhy A, Giri SK, Mahapatra J, Parija J. Patterns of lymph node involvement and role of common iliac lymphadenectomy in early-stage cervical cancers: A retrospective analysis from tertiary care cancer center in Eastern India. Oncol J India [serial online] 2018 [cited 2019 May 19];2:75-9. Available from: http://www.ojionline.org/text.asp?2018/2/4/75/248530
| Introduction|| |
Cervical cancer is the second-most common cancer among women worldwide. It is the most common cancer to cause death among women in developing countries. Every year in India, 122,844 women are diagnosed with cervical cancer and 67,477 die from the disease.
Staging of cervical cancer is a clinical staging proposed by the International Federation of Gynecology and Obstetrics in 2009. In India, most of the cases are commonly diagnosed at locally advanced stages. Early cervical cancers (Stage IA to IIA) account for only 13% of the total disease burden. The standard treatment for these stages is radical hysterectomy with bilateral pelvic lymph node dissection. In majority of cancers, lymph node involvement increases as stage of the disease progresses. Incidence of pelvic lymph node involvement is said to be <1% in Stage IA1, 9% in Stage IA2, and 11%–21% in Stage IB disease, while it escalates to 39%–43% in Stage IIB disease.,,
The lymphatic drainage of cervix is complex and the lymphatic basin can be divided into four stations such as Station I: the groups below the bifurcation of common iliac vessels which includes external iliac, internal iliac, and obturator groups; Station II: it includes the common iliac, promontoral, and lateral and presacral lymph nodes; Station III: inframesenteric aortic lymph nodes; and Station IV: infrarenal aortic lymph nodes.
In 2010, classification for types of lymph node dissection was proposed by Cibula and Abu-Rustum. In this, Type I lymphadenectomy involves dissection of external iliac nodes up to the deep circumflex iliac vein, obturator nodes above the obturator nerve, and superficial common iliac nodes up to the mid common iliac level.
With minimally invasive surgery making significant inroads into oncological practice, it was about time laparoscopic radical hysterectomy came into vogue. It had a long learning curve, more so with respect to dissection of lymph nodes, especially above the common iliac bifurcation which was more technically challenging.
Hence, we decided to undertake this study to record and analyze the patterns of lymph node metastasis in early cervical cancer cases operated in our institute and measure the metastatic burden in the common iliac nodes and subsequently assess the need for its dissection.
| Materials and Methods|| |
The study was conducted on all the cases of early-staged carcinoma of cervix (Stage IA to IIA) that were operated in the gynecological oncology department of a tertiary care cancer center during the period from January 2000 to May 2018. All the data were retrospectively collected from the record with respect to different parameters such as: age, stages, different histological types, histological grading, tumor size, lymphovascular space invasion (LVSI), deep stromal invasion, margin positivity, and lymph node positivity. Tumor sizes, LVSI, and stromal invasion were considered under intermediate-risk factors. The cases which had positive lymph nodes on postoperative histopathological examination were isolated. The data were tabulated and the patterns of lymph node metastasis analyzed with special reference to common iliac node involvement. The above parameters, especially both intermediate- and high-risk factors, were analyzed thoroughly for all the positive lymph node cases. The cases having locally advanced or metastatic cervical cancer or diagnosis of second malignancy were excluded from the study.
The study used only descriptive statistics and data were reported in proportion and percentages.
| Results|| |
We had retrieved a total of 250 patients who had undergone Type II radical hysterectomy with bilateral pelvic lymphadenectomy in our study cohort [Table 1]. Majority of patients (31.6%) presented in the age group of 50–59 years with the median age of presentation being 54 years. Most of the patients were presenting in Stage IB disease and constitute of 74.8% among all the cases. Most common histology was squamous cell carcinoma consisting of 87.2% of the cases. Adenocarcinoma, adenosquamous, and clear cell carcinoma were the other different histological types. Most of the cases (77.2%) were having moderately differentiated histological grading.
|Table 1: Clinicopathological characteristics of all the operated early-staged cervical carcinoma (n=250)|
Click here to view
Fifty out of these 250 patients (20%) had been detected with lymph node metastasis [Table 2]. On further analysis, external iliac group of lymph nodes was most commonly involved consisting of 58%, followed by obturator nodes (52%), internal iliac nodes (42%), and common iliac lymph nodes (20%). Only 4 out of 50 lymph node positive cases (8%) demonstrated independent involvement of common iliac nodes which was 1.6% (4/250) of the total early operated cervical cancer cases. Most of the cases with positive lymph nodes (46%) were seen in women aged more than 55 years. Most common histology was squamous cell carcinoma constituting 84% of the cases, followed by five cases of adenocarcinoma (10%), two cases of adenosquamous carcinoma (4%), and one case of clear cell carcinoma (2%). More than half of the cases (56%) presented in Stage IB1 at diagnosis followed by Stages IB2 and IIA.
|Table 2: Comparison of clinicopathological characteristics of patients between overall lymph node positive and common iliac lymph node positive|
Click here to view
Out of the ten cases which had positive common iliac nodes, 50% had tumor size >4 cm [Table 2]. When the other two intermediate-risk factors for early cancer cervix are considered, depth of stromal invasion (DOSI) was found to be ≥10 mm in 82% of the total positive lymph node cases. Whereas, six out of ten (60%) common iliac node-positive cases had ≥10 mm DOSI [Table 2]. LVSI was positive in 64% of overall lymph node positive cases, while the figure was 50% when common iliac nodes were considered singularly [Table 2]. Finally, when we tried to correlate the number of intermediate-risk factors (size of lesion >4 cm, DOSI ≥10 mm, LVSI positivity) with lymph node involvement, we found that 74% of the overall lymph node positive cases and all ten cases with positive common iliac nodes had two or more intermediate-risk factors [Table 2]. Three out of all the lymph node positive cases (6%) had parametrial positive. Two of these cases with parametrial involvement were positive for common iliac node involvement as well. One out of all lymph node positive cases had vaginal margin positive, whereas common iliac node positive group of cases had no margin positivity.
| Discussion|| |
In our study, majority of early-stage operable cancer of cervix (Stage IA–IIA) belonged to Stage IB and the most common histology being squamous cell carcinoma. Most common age group in our cohort belonged to 50–59 years which was in comparison with our national data.
Lymph node involvement is one of the most important prognostic factors in the management of early-stage operable cervical cancers. Both parametrial involvement and vaginal margin positivity are considered as high risk for recurrence and hence is always followed up with adjuvant therapy. There are intermediate-risk factors also come into play such as LVSI, deep stromal invasion, and size of the disease, which have been included as indications for adjuvant treatment in the presence of two or more of them.
Our cohort of early operable cervical cancer patients had 20% lymph node positivity which was much lower when compared to the study published by Sironi et al. in 2006 which stood at 32% and at 25% as per Sun et al., However, our figures were much higher than 4.5% which was noted by Nanthamongkolkul and Hanprasertpong. This may be due to the fact that their study included only patients with small lesions (<4 cm) compared to ours which included all patients between Stage IA and IIA including IB2 (>4 cm). This reinforces the fact that higher stage of disease and bigger lesions have higher chances of lymph node metastasis which has been established in previous studies., External iliac nodes (58%) in close succession by obturator nodes (52%) were most commonly involved in our data and common iliac nodes constituted 20% of the cases with lymph node positivity which correlated well with other studies. In our study, 82% and 64% of the cases with lymph node positivity were associated with stromal invasion ≥ 10 mm and LVSI positivity, respectively. These findings have been described previously in other studies which have found deep stromal invasion and LVSI as predictors of lymph node metastasis.,,, The patients who had positive parametrium involvement and vaginal margins, all had positive lymph nodes but vice versa was not true. This is in contradiction to Benedetti-Panici et al. who proposed that parametrium might be the first site of extracervical spread followed by lymph node dissemination. This was based on a three-dimensional pathological assessment of paracervical involvement in early-stage cervical cancers. However, our contradictory findings may be in view of the fact that our cases might not have been that critically scrutinized for parametrial involvement with three-dimensional assessments.
Historically, the three factors – parametrial involvement, vaginal margins, and lymph node status have been aptly designated as high-risk factors for recurrence-free survival (RFS) and overall survival of early-stage cervical cancers with a requirement of further adjuvant therapy. In our study, we have noted that parametrial and vaginal margin involvement stands as risk factors for lymph node positivity as well. Having said that, as stated previously, we also looked into the other risk factors associated with increased risk of lymph node involvement: LVSI, DOSI, and size of the tumors. Seventy-four percent of the patients with lymph node positivity had two or more of these factors. These also have been shown to influence the RFS and OS and hence can be classified as intermediate-risk factors.
Now delving into specifically common iliac nodal involvement, we found that it was seen in 20% (10/50) of the overall lymph node positive cases which was much lower when compared to the figures by Benedetti-Panici et al. which was 44%. Of this 20% common iliac lymph node positivity, 8% (4/50) of cases were involved independently. Hence, the rest 12% of the cases would have been picked up even if the common iliac lymph nodes were not addressed. Further, when we analyzed these four cases of isolated common iliac lymph node metastases, we found that two of them had parametrial involvement. The other two cases had at least two intermediate-risk factors. One case had a tumor size of 4.5 cm, stromal invasion of 12 mm, and was LVSI positive, while the other case had a stromal invasion of 11 mm and LVSI positivity. Furthermore, point to be noted is that all the cases of common iliac node metastases had at least two intermediate-risk factors which would have made them candidates for adjuvant radiation therapy irrespective of lymph node involvement. This brings us to the question of whether common iliac lymph nodes need to be assessed to prognosticate early cervical cancer cases and add to the intraoperative and postoperative morbidity of the patient.
Limitations of our study include retrospective nature, heterogeneous study cohorts, pathological, and surgical assessments.
| Conclusion|| |
With many risk factors already in place for the role of adjuvant therapy in early-stage cervical cancer, isolated common iliac nodal involvement in the present study is very low (8%), and this isolated involvement having been demonstrated only in cases with other risk factors; the role of common iliac lymph node dissection in early-stage cancer cervix becomes questionable. Further larger prospective studies are encouraged to shed more light on this issue.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Denny L. Cervical cancer: Prevention and treatment. Discov Med 2012;14:125-31.
Sreedevi A, Javed R, Dinesh A. Epidemiology of cervical cancer with special focus on India. Int J Womens Health 2015;7:405-14.
Jain A, Ganesh B, Bobdey SC, Sathwara JA, Saoba S. Sociodemographic and clinical profile of cervical cancer patients visiting in a tertiary care hospital in India. Indian J Med Paediatr Oncol 2017;38:291-5.
] [Full text]
Elliott P, Coppleson M, Russell P, Liouros P, Carter J, MacLeod C, et al.
Early invasive (FIGO stage IA) carcinoma of the cervix: A clinico-pathologic study of 476 cases. Int J Gynecol Cancer 2000;10:42-52.
Takeshima N, Yanoh K, Tabata T, Nagai K, Hirai Y, Hasumi K. Assessment of the revised international federation of gynecology and obstetrics staging for early invasive squamous cervical cancer. Gynecol Oncol 1999;74:165-9.
Gavrilescu MM, Todosi AM, Ioanid N, Scripcariu V. Role of sentinel lymph node in early stage of uterine cervical cancer. J Surg [Jurnalul de Chirurgie] 2014;10:197-202.
Cibula D, Abu-Rustum NR. Pelvic lymphadenectomy in cervical cancer – Surgical anatomy and proposal for a new classification system. Gynecol Oncol 2010;116:33-7.
Sironi S, Buda A, Picchio M, Perego P, Moreni R, Pellegrino A, et al.
Lymph node metastasis in patients with clinical early-stage cervical cancer: Detection with integrated FDG PET/CT. Radiology 2006;238:272-9.
Sun JR, Zhang YN, Sun XM, Feng SY, Yan M. Prediction model of pelvic lymph node metastasis in early stage cervical cancer and its clinical value. Minerva Chir 2011;66:537-45.
Nanthamongkolkul K, Hanprasertpong J. Predictive factors of pelvic lymph node metastasis in early-stage cervical cancer. Oncol Res Treat 2018;41:194-8.
Yanaranop M, Sathapornteera N, Nakrangsee S. Risk factors of pelvic lymph node metastasis in cervical adenocarcinoma following radical hysterectomy and pelvic lymphadenectomy. J Med Assoc Thai 2014;97 Suppl 11:S87-95.
Togami S, Kamio M, Yanazume S, Yoshinaga M, Douchi T. Can pelvic lymphadenectomy be omitted in stage IA2 to IIB uterine cervical cancer? Int J Gynecol Cancer 2014;24:1072-6.
Wang Y, Yao T, Yu J, Li J, Chen Q, Lin Z. Can pelvic lymphadenectomy be omitted in patients with stage IA2, IB1, and IIA1 squamous cell cervical cancer? Springerplus 2016;5:1262.
Zhou J, Ran J, He ZY, Quan S, Chen QH, Wu SG, et al.
Tailoring pelvic lymphadenectomy for patients with stage IA2, IB1, and IIA1 uterine cervical cancer. J Cancer 2015;6:377-81.
Benedetti-Panici P, Maneschi F, D'Andrea G, Cutillo G, Rabitti C, Congiu M, et al.
Early cervical carcinoma: The natural history of lymph node involvement redefined on the basis of thorough parametrectomy and giant section study. Cancer 2000;88:2267-74.
Sevin BU, Nadji M, Lampe B, Lu Y, Hilsenbeck S, Koechli OR, et al.
Prognostic factors of early stage cervical cancer treated by radical hysterectomy. Cancer 1995;76:1978-86.
[Table 1], [Table 2]