Pavone Matteo, Bizzarri Nicolò, Rychlik Agnieszka, Persson Jan, Fagotti Anna, Fanfani Francesco, Scambia Giovanni, Querleu Denis
UOC Ginecologia Oncologica, Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; IHU Strasbourg, Institute of Image-Guided surgery, Strasbourg, France; ICube, Laboratory of Engineering, Computer Science and Imaging, Department of Robotics, Imaging, Teledetection and Healthcare Technologies, University of Strasbourg, CNRS, UMR 7357, Strasbourg, France; Research Institute against Digestive Cancer, IRCAD Strasbourg, France.
UOC Ginecologia Oncologica, Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
Eur J Obstet Gynecol Reprod Biol. 2025 Aug;312:114523. doi: 10.1016/j.ejogrb.2025.114523. Epub 2025 Jun 10.
It has been reported that metastatic lymph nodes can be present in the parauterine lymphovascular (PULT) and in lateral paracervical lymphatic tissue as in-transit disease in patients with cervical cancer. This study aimed to clarify the understanding of in-transit positive lymph nodes in PULT and lateral paracervix and its clinical management in patients with cervical cancer, based on insights gathered from an international expert survey.
A 29-question survey was emailed to experts identified through a systematic literature search related to sentinel lymph nodes in gynecological cancer. The survey was divided into four sections: 1. Resection of parauterine lymphovascular tissue; 2. Discontinuous lymphatic paracervical involvement; 3. Positive para-uterine or paracervical nodes in fertility-sparing surgery; 4. The impact of positive in-transit nodes on the extent of nodal staging. Consensus was defined as an agreement among at least 70% of the respondents.
Responders where only corresponding or last authors of articles addressing sentinel lymph nodes procedures. Results show general agreement on referring to the areas as "para-uterine lymphovascular tissue (PULT)" (84.85 %), with lymph nodes in these regions considered sentinel nodes if stained with indocyanine green (80 %). However, there is no consensus on surgical staging for isolated positive lymph nodes. Most respondents favour adjuvant treatment for in-transit macro or micrometastases (>95 %) but acknowledge the lack of conclusive evidence. In fertility-sparing settings, most would remove PULT while preserving uterine arteries (59 %) and would remove lateral paracervical tissue in low-risk cases (66.7 %). For isolated metastasis, most would recommend chemoradiation over fertility-sparing options (81.8 %). Finally, if a positive in-transit node is found, experts would request additional imaging (80.3 %), though there is no consensus on aortic lymphatic dissection or extended-field radiation without prior aortic staging.
The survey highlights expert awareness of the clinical importance of in-transit positive lymph nodes. However, it is essential for the international societies to urgently address the impact of these nodes on staging and treatment guidelines, as current recommendations and evidence are lacking.
据报道，在宫颈癌患者中，转移性淋巴结可存在于子宫旁淋巴管（PULT）和宫颈旁外侧淋巴组织中，表现为途中转移。本研究旨在基于一项国际专家调查所收集的见解，阐明对PULT和宫颈旁外侧区域中途中转移阳性淋巴结的认识及其在宫颈癌患者中的临床管理。
通过与妇科癌症前哨淋巴结相关的系统文献检索确定专家，向其发送一份包含29个问题的调查问卷。该调查分为四个部分：1.子宫旁淋巴血管组织的切除；2.宫颈旁间断性淋巴受累；3.保留生育功能手术中子宫旁或宫颈旁淋巴结阳性；4.途中转移阳性淋巴结对淋巴结分期范围的影响。共识定义为至少70%的受访者达成一致。
受访者均为涉及前哨淋巴结程序文章的通讯作者或最后作者。结果显示，对于将这些区域称为“子宫旁淋巴血管组织（PULT）”，普遍达成了共识（84.85%），如果这些区域的淋巴结用吲哚菁绿染色，则被视为前哨淋巴结（80%）。然而，对于孤立阳性淋巴结的手术分期尚无共识。大多数受访者倾向于对途中出现的宏观或微观转移进行辅助治疗（>95%），但承认缺乏确凿证据。在保留生育功能的情况下，大多数人会切除PULT同时保留子宫动脉（59%），并且在低风险病例中会切除宫颈旁外侧组织（66.7%）。对于孤立转移，大多数人会推荐放化疗而非保留生育功能的方案（81.8%）。最后，如果发现途中转移阳性淋巴结，专家们会要求进行额外的影像学检查（80.3%），尽管对于未经主动脉分期的主动脉淋巴清扫或扩大野放疗尚无共识。
该调查突出了专家对途中转移阳性淋巴结临床重要性的认识。然而，由于目前缺乏相关建议和证据，国际社会迫切需要解决这些淋巴结对分期和治疗指南的影响。
