In-transit metastatic lymph nodes in cervical cancer : A new staging and therapeutic concept
(2025) In European Journal of Obstetrics and Gynecology and Reproductive Biology 312.- Abstract
Objective: 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. Methods: 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... (More)
Objective: 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. Methods: 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. Results: 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. Conclusion: 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.
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- author
- Pavone, Matteo ; Bizzarri, Nicolò ; Rychlik, Agnieszka ; Persson, Jan LU ; Fagotti, Anna ; Fanfani, Francesco ; Scambia, Giovanni and Querleu, Denis
- organization
- publishing date
- 2025-08
- type
- Contribution to journal
- publication status
- published
- subject
- keywords
- Cervical cancer, Intransit nodes, Lateral paracervical lymphatic tissue, Parauterine lymphovascular tissue, Sentinel lymph node
- in
- European Journal of Obstetrics and Gynecology and Reproductive Biology
- volume
- 312
- article number
- 114523
- publisher
- Elsevier
- external identifiers
-
- pmid:40516499
- scopus:105007729584
- ISSN
- 0301-2115
- DOI
- 10.1016/j.ejogrb.2025.114523
- language
- English
- LU publication?
- yes
- additional info
- Publisher Copyright: © 2025 The Author(s)
- id
- c188bfd0-2d46-41e4-bcfa-3d0b055c49a1
- date added to LUP
- 2025-12-12 13:51:19
- date last changed
- 2025-12-12 13:51:35
@article{c188bfd0-2d46-41e4-bcfa-3d0b055c49a1,
abstract = {{<p>Objective: 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. Methods: 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. Results: 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. Conclusion: 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.</p>}},
author = {{Pavone, Matteo and Bizzarri, Nicolò and Rychlik, Agnieszka and Persson, Jan and Fagotti, Anna and Fanfani, Francesco and Scambia, Giovanni and Querleu, Denis}},
issn = {{0301-2115}},
keywords = {{Cervical cancer; Intransit nodes; Lateral paracervical lymphatic tissue; Parauterine lymphovascular tissue; Sentinel lymph node}},
language = {{eng}},
publisher = {{Elsevier}},
series = {{European Journal of Obstetrics and Gynecology and Reproductive Biology}},
title = {{In-transit metastatic lymph nodes in cervical cancer : A new staging and therapeutic concept}},
url = {{http://dx.doi.org/10.1016/j.ejogrb.2025.114523}},
doi = {{10.1016/j.ejogrb.2025.114523}},
volume = {{312}},
year = {{2025}},
}