Come from behind.

One issue with cervical cancer is that, when it involves large portions of the cervix, it can drain to a lot of different nodal regions. Typically all the pelvic—meaning iliac and presacral—regions are covered during definitive radiation, but is that enough? This large retrospective review of 122 women receiving definitive chemoradiation for locally-advanced cervical cancer evaluates incidence of clinically-involved mesorectal nodes, which currently get no love in consensus guidelines. Clinically-involved was defined here as pelvic nodes ≥1 cm, mesorectal nodes ≥0.5 cm (typical criteria for rectal cancer), and any nodes with an SUV >2.5. The overall incidence of upfront mesorectal nodal involvement was 7% and was even greater among FIGO stage III-IV disease (10%) and pelvic node positivity (12%). As expected, the highest rate was seen with mesorectal fascia invasion where it was present in 3 of 9 cases. TBL: Mesorectal invasion, pelvic node involvement, and advanced FIGO stage are reasons to consider elective mesorectal radiation coverage for cervical cancer. | Cordero, Int J Gynecol Cancer 2019