When would you recommend surgical debulking of pelvic or para-aortic lymph nodes in cervical cancer prior to definitive chemoradiation therapy?

We have not favored dissection and treated with SIB and sometimes added sequential boost ( EQ@ dose 58-66 Gy) based on size

most current literature shows excellent regional control but high distant failure in these pts

for bowel and duodenum ( two organs which could be limiting factor) we use v55 dose to 5 cc or less and make sure it is confined to one wall and not through and through organ. here is link to our paper showing regional control and distant control in these patients

recent data from Europe also shows similar outcome with suggestion of high SUV predicting for worse control

https://www.ncbi.nlm.nih.gov/pubmed/25303889

Often these large pelvic and periaortic nodes are adherent to surrounding nerves and vessels and resection is not possible. Our usual approach in this situation is to consider neo-adjuvant chemotherapy. The hope would be that the chemotherapy would reduce the size of the nodes definitive chemo- radiotherapy would follow. At that point we would try to boost the residual node to as high a dose as we think is safe, depending on proximity to nearby small bowel.