Cervical Cancer with Paraaortic Metastases: Significance of Residual Paraaortic Disease after Surgical Staging Peter Y. Kim, M.D., Bradley J. Monk, M.D., 1 Sanjay Chabra, B.S., Robert A. Burger, M.D., Steven A. Vasilev, M.D., Alberto Manetta, M.D., Philip J. DiSaia, M.D., and Michael L. Berman, M.D. Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California Irvine Medical Center, 101 The City Drive, Orange, California 92668 Received May 5, 1997 Cervical carcinoma frequently metastasizes to the paraaortic region, necessitating extended field radiotherapy to effect a cure. As imaging modalities are unreliable in identifying all cases of paraaortic nodal metastases (PAN), surgical staging is often uti- lized prior to radiotherapy. This study was aimed at identifying factors predictive of survival in women with cervical carcinoma and paraaortic metastases. In particular, survival based on extent of paraaortic disease was examined. The study group consisted of 43 women (stages IB–IVB) identified between 1982 and 1993 who were treated with extended field radiation forcervical carcinoma with histologically confirmed paraaortic metastases. The esti- mated 5-year survival for the study population was 24% with a median survival of 18 months. Pelvic tumor size had a significant impact on survival with the median survival being 34 months if the primary lesion was < 6 cm compared to 14 months if >6 cm (P  0.01). Eight of the 26 (31%) women without residual PAN disease after surgical staging remain alive and disease free (mean follow- up, 74 months). In contrast, only 1 of the 17 (6%) women with gross residual PAN is alive 71 months after treatment (P  0.05). However, a comparison of Kaplan–Meiersurvival curves did not show a statistically significant advantage to the surgical excision of grossly involved PAN (P  0.98). Although long-term survival among women with grossly involved, unresected paraaortic me- tastases is uncommon, further study is necessary to elucidate the role of surgical excision of bulky aortic disease in women with cervical cancer. © 1998 Academic Press INTRODUCTION Cervical carcinoma typically advances in a predictable fash- ion locally and via the lymphatic route. Lymphatic metastases usually occur first in the pelvic nodes and later in the paraaortic nodes. Although paraaortic metastases occur frequently, they often go undetected because the imaging techniques utilized in conjunction with clinical staging are unable to reliably identify occult lymphatic spread. Since large lesions and nodal metas- tases, particularly in the paraaortic region, have been shown to correlate with poor outcome, many investigators have recom- mended pretreatment surgical staging for these high-risk pa- tients [1– 6]. In this fashion, patients with paraaortic metastases can be identified so that extended field radiotherapy might result in higher chances for survival. It is not known, however, whether there is a therapeutic value to resecting metastatic paraaortic lymph nodes prior to radiotherapy. The objective of this study was to determine the survival rate of cervical cancer patients with histologically documented paraaortic metastases and to correlate the extent of residual paraaortic disease after surgery with survival. We also assessed the impact of various histopathologic and clinical factors on survival. Finally, we examined patterns of recurrence and specific complications of therapy. MATERIALS AND METHODS We identified the patient population for this retrospective study by reviewing all cervical cancer tumor registry abstracts for the time period 1/1/82 through 12/31/93 at three institu- tions: The University of California Irvine Medical Center, (Orange, CA), Long Beach Memorial Medical Center (Long Beach, CA), and The City of Hope National Medical Center, (Duarte, CA). There were 63 women with primary, previously untreated cervical cancer with histologically confirmed paraaortic lymph node metastases. Fifty-nine women met cri- teria for enrollment with available operative and pathology reports and complete information on their radiotherapy and long-term follow-up. Sixteen women were identified as having been treated palliatively with therapy directed only toward relieving symptoms. In these cases, extended field radiotherapy was not utilized secondary to distant metastases outside of any treatment field (n = 9), underlying medical disorders (n = 1), small-cell histology (n = 2), and refusal of therapy (n = 4). As the palliatively treated patients were not treated in the same fashion, this group was excluded from analysis. 1 To whom reprint requests and correspondence should be addressed at Division of Gynecologic Oncology, Department of OB/GYN, UCI Medical Center, Chao Family Comprehensive Cancer Center, 101 The City Drive, Bldg. 23, Room 107, Rt. 81, Orange, CA 92868-3298. GYNECOLOGIC ONCOLOGY 69, 243–247 (1998) ARTICLE NO. GO985012 243 0090-8258/98 $25.00 Copyright © 1998 by Academic Press All rights of reproduction in any form reserved.