Unraveling the prognostic puzzle: in-depth exploration of lymph node metrics for surgically treated FIGO stage IB-IIA cervical cancer-focus on the number of positive lymph nodes and the lymph node ratio.

Background: Lymph node (LN) metastasis constitutes a major adverse prognostic factor in surgically treated cervical cancer (CC) patients. Leveraging the Surveillance, Epidemiology, and End Results database, this study aimed to evaluate the prognostic value of the number of positive LN metastases (nLNM) and LN ratio (LNR) in patients with stage IB-IIA CC who underwent surgical treatment.

Methods: A retrospective analysis was conducted on patients with histopathologically confirmed CC between 2010 and 2021, with overall survival (OS) as the primary endpoint. nLNM stratification was performed using X-title software, followed by Kaplan-Meier (K-M) analysis. For LNR, restricted cubic spline (RCS) analysis identified inflection points between the number of examined regional LNs and OS. Subsequently, X-title software and K-M analysis independently compared OS between the negative and positive LN(s) groups.

Results: A total of 100,097 LNs from 5,911 CC patients were analyzed. Among these, 856 (14.48%) patients had positive LNs. The presence of positive LNs was associated with a significantly lower 10-year OS rate compared to those with negative LNs (69.0% vs. 86.7%, P <0.001). The nLNM stratification, generated using X-title software and K-M analysis, exhibited the highest discriminatory power with categories of negative vs. 1-3 + vs. ≥ 4 + LNs metastasis (all P <0.001). RCS analysis revealed a nadir at 15 examined LNs and indicated excluding patients with fewer than 8 LNs examined during surgery. No OS difference was observed between patients with 9-15 LNs and those with ≥16 LNs examined when LNR = 0 (P = 0.365). However, an LNR ≥0.210 was associated with significantly poorer OS (P <0.01).

Conclusion: Extensive pelvic lymphadenectomy provided no survival benefit for patients with ≥16 examined, pathologically negative LNs compared to those with 9-15 LNs examined. Both nLNM ≥4 + and LNR ≥0.210 were identified as significant prognostic factors, offering valuable insights for clinical decision-making.