Cervical cancer: pre-therapeutic investigations and clinical staging "versus" surgical staging

Accurate staging of cervical cancer is essential for optimising the results of therapy, because therapy and prognosis vary considerably with the stage. It has been agreed that the staging of a cervical cancer is predominantly a clinical process. Pelvic examination under anaesthesia is indispensable when evaluating the parametria. Cervical cancer generally spreads via local and then regional lymphatics. Lymph node status is crucial in terms of prognosis and therapy of cervical cancer, although it is not incorporated in the FIGO staging classification. The major techniques for evaluating lymph node status include lymphangiography, CT-scan, ultrasonography, MRI and PET. There is a difference in the incidence of pelvic lymph node metastasis comparing stage IB (10-15%), IIA (10-25%) and IIB (25-40%). The obturator group is the most frequently involved. Available studies suggest that the obturator nodes are the primary and sentinel nodes in cervical carcinoma. The preliminary data showed that in early stages, the sentinel node was bilateral in 96% of cases and the sensitivity of the method was 100%. The identification rate was about 80%. The incidence of paraaortic nodes is different according to clinical stages: IB (5-15%), IIB (15-30%) and IIIB (30-45%). The value of surgical staging in the management of cervical cancer is controversial. Pre-treatment surgical staging in patients with cervical cancer has some important benefits: 1. it is the most sensitive and specific of all modalities for the identification of lymph node metastases, 2. it is possible to resect enlarged tumour-containing lymph nodes improving clinical outcome, 3 according to the true extent of the disease, it is possible to modify therapy, 4. it identifies patients with poor prognostic factors, 5. it allows disease downstaging, 6. it increases survival. However, those opposed to the routine use of pre-treatment surgical staging in cervical carcinoma argue that: 1. only a small number of patients can benefit from extended field treatment (± 10%), 2. there is significant morbidity associated with the surgical procedure, 3. there is an increased risk of radiation injury after staging laparotomy, 4. there is the possibility of delaying the initiation of radiotherapy. Laparoscopic staging has been proposed as an alternative to laparotomy with a high sensitivity and specificity. Laparoscopy has several advantages, such as minimal invasion, little adhesion formation and quick recovery of the patient in comparison with laparotom