Surgical or imaging lymph node assessment in locally advanced cervical cancer: a systematic review and meta-analysis

OBJECTIVE: To evaluate the survival impact of imaging vs surgical nodal assessment in patients with cervical cancer stage IB2–IVA prior to definitive chemoradiotherapy (CRT). METHODS: PubMed, MEDLINE, Cochrane Library, and ClinicalTrials.gov were used to search for publications in English and Chinese over a 50-year period. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols was used to conduct this review. Inclusion criteria were studies that compared survival outcomes in International Federation of Gynecology and Obstetrics 2009 stage IB2–IVA cervical cancer patients with pre-therapy pelvic and/or aortic lymphadenectomy (LND) or imaging. One or more of the following modalities were used for nodal assessment: computed tomography (CT), magnetic resonance imaging, or positron emission tomography-CT. The National Institutes of Health Quality Assessment Tool was utilized to assess study quality. RESULTS: The initial search identified 65 studies, and five met the inclusion criteria. There were a total of 1,112 patients. Seven hundred and fifty-four underwent pelvic and/or aortic LND and 358 had imaging. When compared to LND, imaging had a sensitivity and specificity of 88.9% and 22.2% for pelvic lymph node (LN), and 33%–62.5% and 92%–95.5% for para-aortic LN. There were no differences in progression-free survival (PFS) (hazard ratio [HR]=1.13; 95% confidence interval [CI]=0.73–1.74; I(2)=75%; p<0.01) and overall survival (OS) (HR=1.06; 95% CI=0.66–1.69; I(2)=75%; p<0.01) between surgical and imaging nodal assessment. CONCLUSIONS: Imaging and surgical nodal assessment has comparable PFS and OS in patients with cervical cancer stage IB2–IVA. TRIAL REGISTRATION: PROSPERO Identifier: CRD42020155486