Lymph node metastasis is one of the most important prognostic factors for cervical cancer. The recurrence rate increases dramatically when lymph nodes are involved. The standard radiation dose is effective for only two-thirds of bulky lymph nodes larger than 2 cm and as the size and the number of the metastatic lymph nodes increases, the eradication rate of the radiotherapy diminishes.1 2 In a number of retrospective series and prospective studies, resection of bulky lymph nodes before radiotherapy improved survival rates and increased the effectiveness of radiotherapy in women with bulky metastatic disease.3 4 Positron emission tomography–computed tomography (PET-CT) is also a useful tool to exclude paraaortic involvement clinically but there is still 10–20% upstaging when surgical staging is performed in case of negative PET-CT findings, particularly when pelvic lymph nodes are positive.3 In this video we present the case of a 57 year-old woman diagnosed with stage rIIIC2 squamous cell carcinoma of the cervix with a 5 cm cervical tumor. She underwent a magnetic resonance imaging (MRI) scan which revealed bulky metatstatic lymph nodes in the aortocaval and infrarenal area. Laparoscopic paraaortic resection of bulky nodes was performed (Figure 1). Total operation time was 190 minutes, total blood loss was 15 cc without any complications. A pathology report revealed 10 metastatic nodes out of 15 total resected lymph nodes. On the postoperative second day, the patient was discharged and 1 week after the surgery chemoradiotherapy was initiated. New treatment strategies are also now available such as the addition of carboplatin paclitaxel before planned chemoradiation as shown in the INTERLACE trial. Clinicians can also treat patients with the addition of checkpoint inhibitor pembrolizumab to classical chemoradiotherapy, as shown in the KEYNOTE-18 trial which saw an increase in progression-free and overall survival. As our patient was treated before publication of these studies, she was given classical concomitant chemoradiotherapy.5 6 It has been 35 months since the surgery and there was no evidence of disease at her last review. In conclusion, transperitoneal laparoscopic resection of bulky paraaortic lymph nodes is a feasible method with reasonable complication rates.3 Quick discharge is possible without significant morbidity and there is no delay in planned chemoradiation.

Mestatic bulky lymph nodes are seen overlying the vena cava and aorta on aortocaval region. Yellow star; ureter, red star; metastatic lymph node on aortocaval region, green star; aorta, black star; peritoneum overlying duodenum.

Data sharing not applicable as no datasets generated and/or analysed for this study.

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