Cervical cancer is the fourth most common cancer in women worldwide, with around 604 000 new cases and 342 000 deaths in 2018 [1]. In France, there are around 2 900 news cases per year and around 1 100 deaths from cervical cancer [2,3] In Reunion Island, standardized incidence rate (SIR) is 9,7 for 100 000 patients which puts cervical cancer in 5th place compared to mainland France, where cervical cancer is the 11th most common cancer with a SIR of 6,1 for 100 000 patients [4]. Incidence of cervical cancer is therefore 50 % higher in Reunion Island. In addition, standardized mortality rate for the period 2015-2017 was 4.2 in Reunion Island, versus 2.0 for mainland France, which is twice as high [5].

Several risk factors are recognized, including sexually transmitted diseases (mainly persistent human papillomavirus (HPV) infection, other human immunodeficiencies and herpes simplex virus), reproductive and sexual factors (multiple sexual partners, early age at first sexual intercourse and at first childbirth, and oral contraceptive pills), and behavioral factors (smoking) [6]. The average age at first intercourse is 17.6-year-old in mainland France compared to 16.1 years-old in Reunion Island [6]. In 2022, full-dose HPV vaccination among women was 14.1 % on Reunion Island compared with 41 % in mainland France. These two factors, low HPV vaccination and early sexual intercourse, could explain the higher rate of cervical cancer in Reunion Island [7].

According to the French National Cancer Institute (InCa) and European Society of Gynaecological Oncology (ESGO) guidelines, IB3 to IVA (except IIA1) FIGO (Fédération internationale de gynécologie et d'obstétrique) stages correspond to locally advanced cervical cancers (LACC) [8]. In these cases, a Positron Emission Tomography - Computed tomography (PET-CT) may be used for lymph node staging [3,8]. Para-aortic staging using a minimally invasive approach, retroperitoneal or transperitoneal approach, remains optional to assess lymph node status in cases where no para-aortic involvement is described on PET-CT with or without pelvic involvement [9,10]. Lymph node staging is crucial to guide therapeutic strategy since it may determine the radiation field (pelvic only or pelvic associated with the paraaortic area). Studies have shown that PET-CT lacks of accuracy for the detection of micro-metastases < 5 mm [11]. Extended irradiation fields including abdominal area would be required if PET-CT or pathology reveals positive para-aortic lymph nodes. However abdominal radiation induces higher morbidity and the proportions of persistent symptoms such as bowel control and fatigue range from 11.3 % to 64.9 % [12]. The presence of a persistent symptom can be associated with impaired quality of life [12]. To date, the only randomized study comparing surgical and clinical staging, Uterus 11 study, showed no difference in terms of disease free survival between both groups but surgical staging was associated with better cancer specific survival [13]. Morbidity and surgical risk should be taken into account when assessing lymph node metastases. The reliability of clinical staging by PET-CT is of paramount importance to avoid surgical morbidity of para-aortic lymphadenectomy on one hand and unnecessary abdominal irradiation on the other hand.

The aim of the study was to evaluate histological results of para-aortic lymph node dissection in patients with locally advanced cervical cancer and negative para-aortic PET-CT in Reunion Island.