ESGO 2013
Emerging sentinel node in cervical cancer
Prof David Cibula - Charles University Hospital, Prague, Czech Republic
David, it’s great to have you to talk about the surgical aspects of dealing with cervical cancer and there’s quite a lot happening because you’ve got refined techniques. I should ask you, first of all, about sentinel node because this is making some improvements. Why was it needed and what are the improvements that you and your colleagues and other colleagues elsewhere in the world have been making?
Sentinel lymph node is quite a new concept which is, however, used already for many years in other cancers like in breast cancer. It’s well established in the management of vulva cancer, it’s used for many decades in melanoma management and now it comes to the management of cervical cancer as well.
What have been the challenges in staging cervical cancer up until now that potentially could be improved with sentinel node?
The biggest challenge is that we don’t have other options than to do surgical staging, meaning that we have to remove all nodes from a particular region, which is the pelvic region. Of course there are some consequences related to…
Penalties being?
Morbidity, especially the risk of lymphoceles in the pelvis and the risk of lymphedema, which is not negligible and which is for the rest of their lives.
So now you do up to three sentinel nodes, is that right?
We are not that far. We are trying to implement it into the management but definitely there are very good reasons why to use sentinel node in the management of cervical cancer already now.
And what are the advantages?
The advantage is that we can identify two or three or a maximum of four nodes and say these are the key nodes in the pelvis, send them to our pathologist and they can do very different pathologic processing.
What are the differences?
The difference is that during standard evaluation of a normal node they usually just cut the node into two pieces and evaluate one slice while if we say these are two nodes which are of special interest, they, in fact, process the entire node in very tiny distances.
Now one of the things you’re getting out of this, am I right in saying, is micrometastases and you need then to know what to do about them. What are your thoughts on that?
Yes, because by doing this, by doing this very meticulous evaluation they found very small tiny metastases which we called micrometastases but because it’s a very new entity we did not know about that, or at least we did not know that there are so many. We don’t know how to deal with them – what does it mean if we identify micrometastases in sentinel lymph nodes?
What are your guesses at the moment?
We are a bit further than at the level of guesses. This was presented here during this meeting; we conducted quite a large international study and we discovered that micrometastases may carry the same risk for the patient as the presence of macrometastases, for the survival of the patient. So, in fact, sentinel lymph node concept allows us to identify another 10% of patients who carry the same risk as the patient with macrometastases.
And what, then, do you do for them?
We should, at least based on the data which are available, we should treat them equally as patients with macrometastases. It means adjuvant treatment after the radical surgery.
So it helps you define that patient population very well?
The risk group.
I’ve got to ask you about standardising surgery, though. I know you’ve got a bee in your bonnet about this; it needs to be standardised, doesn’t it?
It’s one of my favourite subjects because we have now many arguments showing that although the majority of our treatments are very well standardised, not surgery, it’s not the surgery.
It’s difficult to standardise.
In fact, we don’t understand each other, although we call the procedure the same we can do very different jobs, very different performance. So especially for surgical trials it’s a big task to standardise our surgical performance.
Are you doing it?
We try to settle, of course, internationally in groups of international experts, try to find good guidelines, good recommendations for standardisation.
If I could get you to sum up the progress that’s being made in cervical cancer, then, from the developments you were talking about with a thought, also, to better standardisation of surgery for that disease and perhaps other cancers, in just a few seconds what are the messages that you would leave doctors with all around the world coming out of this meeting here in Liverpool?
I tried to present here a classification model for the surgery of the cervical cancer which uses in the pelvis standard and stable anatomical landmarks. So each and every procedure can be defined by those anatomical landmarks and it can help to lead each physician to do the same job whenever they do it.
And how much scope, in a few words, is there for improving the outcome for patients with cervical cancer?
Definitely, because currently we do very different procedures for our patients. So first we have to harmonise what we do and then especially for surgical trials we can test several ideas and several objectives.
And then with the improved targeting of the overall therapy, thanks to your micrometastases defining a high risk group, how much scope do you think there is for improving care and outcomes overall in cervical cancer?
Of course those are small steps but very important steps and can help us really to tailor our surgery to individual patients so not to have one surgery for all, not to have one way of treatment for all, but rather tailor our arrangement and combination of surgical treatment, the radicality of our surgical treatment, based on many factors including the status of the sentinel node and the presence of micrometastases.
David, thank you very much.
Thank you.
