{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T05:28:20Z","timestamp":1788931700167,"version":"build-2803163510"},"reference-count":52,"publisher":"MDPI AG","issue":"21","license":[{"start":{"date-parts":[[2025,10,30]],"date-time":"2025-10-30T00:00:00Z","timestamp":1761782400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Background\/Objectives: This study aims to critically appraise the role of para-aortic surgical staging in locally advanced cervical cancer (LACC) in the era of advanced imaging, and to outline how selective surgery and biomarkers could be integrated within modern, quality-assured treatment pathways. Methods: Narrative review of randomized trials, large databases, and prospective\/retrospective series comparing para-aortic lymphadenectomy with imaging-based staging; focused appraisal of Uterus-11, NCDB analyses, and ongoing prospective trials (PAROLA with Senti-PAROLA as one of its sub-studies and PALDISC). Emerging technologies (PET\/MRI, radiomics\/AI) and molecular assays (OSNA, HPV-ctDNA) were also assessed. Results: PET\/CT remains the standard for distant staging, but sensitivity for low-volume nodal disease (&lt;5 mm) is poor; in pelvic-positive\/para-aortic-negative patients, occult para-aortic metastases approach ~21%. Para-aortic surgical staging modifies radiotherapy planning in ~18% of cases and can act as a de-escalation tool by avoiding unnecessary extended-field CRT (EF-CRT) when para-aortic nodes are negative. Uterus-11 showed no overall survival difference versus CT-based staging, but suggested benefit in FIGO 2009 stage IIB; its design (CT comparator, optimistic assumptions, limited power) constrains inference. Minimally invasive extraperitoneal\/transperitoneal staging is feasible with low morbidity in expert centers, yet real-world management may worsen outcomes. The role of systemic intensification in node-positive disease remains undefined: PALN-positive patients were excluded from the INTERLACE trial. In the KEYNOTE-826 study, subgroup analyses according to nodal status were not reported, although the benefit of pembrolizumab remained consistent irrespective of bevacizumab use. Sentinel para-aortic mapping and biomarkers (e.g., HPV-ctDNA) may refine selection and reduce morbidity. Conclusions: Surgical staging is the most accurate method to detect occult para-aortic disease. Its routine use is not justified, but it may benefit selected high-risk patients, particularly where decisions on EF-CRT or systemic therapy hinge on para-aortic status. Future practice should integrate advanced imaging, selective surgery, and biomarkers within accredited centers, guided by large collaborative trials conducted under international quality frameworks such as ESGO\/ESTRO\/ESP guidelines.<\/jats:p>","DOI":"10.3390\/cancers17213487","type":"journal-article","created":{"date-parts":[[2025,10,31]],"date-time":"2025-10-31T03:33:07Z","timestamp":1761881587000},"page":"3487","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Surgical Staging in Locally Advanced Cervical Cancer: Precision, Risks, and the \u2018Helmet\u2019 Analogy"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5150-2797","authenticated-orcid":false,"given":"Mikel","family":"Gorostidi","sequence":"first","affiliation":[{"name":"Obstetrics and Gynecology, Hospital Universitario Donostia (San Sebasti\u00e1n, Gipuzkoa), 20014 Donostia-San Sebasti\u00e1n, Spain"},{"name":"Biogipuzkoa Health Research Institute, 20014 Donostia-San Sebasti\u00e1n, Spain"},{"name":"Department of Medical and Surgical Specialties, Faculty of Medicine and Nursing, University of the Basque Country (UPV\/EHU), 48940 Leioa, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4401-3084","authenticated-orcid":false,"given":"Martina","family":"\u00c1ngeles","sequence":"additional","affiliation":[{"name":"Gynecologic Oncology Unit, Vall d\u2019Hebron Barcelona Hospital Campus, Universitat Aut\u00f2noma de Barcelona, 08035 Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0361-8741","authenticated-orcid":false,"given":"Blanca","family":"Gil-Ib\u00e1\u00f1ez","sequence":"additional","affiliation":[{"name":"Gynecologic Oncology and Minimally Invasive Surgery Unit, Gynecology and Obstetrics Department, University Hospital 12 de Octubre, 28041 Madrid, Spain"},{"name":"Research Institute i+12, 28041 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arantxa","family":"Lekuona","sequence":"additional","affiliation":[{"name":"Obstetrics and Gynecology, Hospital Universitario Donostia (San Sebasti\u00e1n, Gipuzkoa), 20014 Donostia-San Sebasti\u00e1n, Spain"},{"name":"Biogipuzkoa Health Research Institute, 20014 Donostia-San Sebasti\u00e1n, Spain"},{"name":"Department of Medical and Surgical Specialties, Faculty of Medicine and Nursing, University of the Basque Country (UPV\/EHU), 48940 Leioa, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alejandra","family":"Martinez","sequence":"additional","affiliation":[{"name":"Universit\u00e9 de Toulouse Oncopole Claudius Regaud, Institut Universitaire du Cancer Toulouse Oncopole, 31100 Toulouse, France"},{"name":"CRCT UMR 1037 INSERM, 31100 Toulouse, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9175-7767","authenticated-orcid":false,"given":"Ignacio","family":"Zapardiel","sequence":"additional","affiliation":[{"name":"Gynecologic Oncology Unit, La Paz University Hospital, 28046 Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,10,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1652","DOI":"10.2214\/AJR.07.3372","article-title":"Accuracy of 18F-FDG PET\/CT in Detecting Pelvic and Paraaortic Lymph Node Metastasis in Patients with Endometrial Cancer","volume":"190","author":"Kitajima","year":"2008","journal-title":"Am. 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