The article by Kim et al is a comprehensive summary of several decades of research in the management of cervical and vulvar cancer. It describes the current status of treatment and possible future trials.
For the management of cervical cancer, two issues need to be further addressed. The first is surgical staging of cervical cancer. For decades it has been known that nodal metastasis to the pelvic and para-aortic regions is common in cervical cancer including clinical stage I disease. Moreover, nodal metastasis is a well-documented indicator of poor prognosis, particularly in apparent early-localized disease. Identification of microscopic nodal disease may alter the treatment plan, especially if the para-aortic nodes are involved.
Despite the poor accuracy of currently available imaging modalities in detecting pelvic and para-aortic metastasis, cervical cancer continues to be clinically staged in most institutions in the United States. The use of clinical staging may be justified in the absence of technology to accurately determine disease status, particularly in developing nations with limited medical resources. However, with the advent of minimally invasive surgical approaches, surgical staging of apparent local cervical cancer can be adequately performed through transperitoneal or extraperitoneal laparoscopic pelvic and bilateral para-aortic lymph node dissection with minimal morbidity and delay in treatment.
The laparoscopic approach has been used for the past decade by many national and international investigators with excellent lymph node yield, limited operative time, short hospital stay, and a very low overall complication rate.[1-4] Pathologic evaluation of retroperitoneal lymph nodes remains the gold standard for detecting metastasis.
Until accurate imaging techniques are commonly available, surgical staging should be offered to women with cervical cancer who have access to minimally invasive surgery and are at risk for para-aortic nodal metastasis as well as to those for whom identification of retroperitoneal nodal metastasis will modify the treatment plan. The results of randomized trials in cervical cancer are most informative when the protocol mandates pretreatment surgical staging.