Sentinel lymph node detection in early-stage ovarian cancer: a systematic review and meta-analysis

Abstract

BackgroundA systematic pelvic and para-aortic lymphadenectomy remains the surgical standard management of early-stage epithelial ovarian cancer. Sentinel lymph node mapping is being investigated as an alternative procedure; however, data reporting sentinel lymph node performance are heterogeneous and limited.ObjectiveA systematic pelvic and para-aortic lymphadenectomy remains the surgical standard management of early-stage epithelial ovarian cancer. Sentinel lymph node mapping is being investigated as an alternative procedure; however, data reporting on the sentinel lymph node performance are heterogeneous and limited. This study aimed to evaluate the detection rate and diagnostic accuracy of sentinel lymph node mapping in patients with early-stage ovarian cancer.MethodsA systematic search was conducted in Medline (through PubMed), Embase, Scopus, and the Cochrane Library. We included patients with clinical stage I–II ovarian cancer undergoing a sentinel lymph node biopsy and a pelvic and para-aortic lymphadenectomy as a reference standard. We conducted a meta-analysis for the detection rates and measures of diagnostic accuracy and assessed the risk of bias using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with identifying number CRD42022351497.ResultsAfter duplicate removal, we identified 540 studies, 18 were assessed for eligibility, and nine studies including 113 patients were analyzed. The pooled detection rates were 93.3% per patient (95% CI 77.8% to 100%; I2=74.3%, p<0.0001), and the sentinel lymph node technique correctly identified 11 of 12 patients with lymph node metastases, with a negative predictive value per patient of 100% (95% CI 97.6% to 100%; I2=0%). The combination of indocyanine green and99mTc-albumin nanocolloid had the best detection rate (100% (95% CI 94% to 100%; I2=0%)) when injected into the utero-ovarian and infundibulo-pelvic ligaments.ConclusionSentinel lymph node biopsy in early-stage ovarian cancer showed a high detection rate and negative predictive value. The utero-ovarian and infundibulo-pelvic injection using the indocyanine green and technetium-99 combination could increase sentinel lymph node detection rates. However, given the limited quality of evidence and the small number of reports, results from ongoing trials are awaited before its implementation in routine clinical practice.

Feasibility of Sentinel Lymph Node Biopsy in Early-Stage Epithelial Ovarian Cancer: A Systematic Review and Meta-Analysis

“…In our meta-analysis, the pooled detection rate of SLNB in early-stage ovarian cancer was 94% (95% CI 86% to 100%, I 2 = 79%, p < 0.0001). This is in agreement with a recent meta-analysis on lymph node detection in early-stage ovarian cancer, which included nine studies and reported a detection rate of 93.3% per patient (95% CI 77.8% to 100%; I 2 = 74.3%, p < 0.0001) [38]. This is also comparable to the detection rates in other more well-established malignancies such as endometrial cancer, with a detection rate of 87%; breast cancer, with a detection rate of 97.9% with ICG; vulvar cancer, with a detection rate of 98% with blue dye and 99mTc radioisotope; and cervical cancer, with a detection rate of 98% with ICG [12,13,16,39].…”

Future of sentinel node biopsy in ovarian cancer

“…In particular, the overall mean (per patient) SLN detection rate in case of ICG alone was reported to be 58.6% (99/169) [13 ▪▪ ] compared with 95% (57/60) in case of ICG + technetium [14 ▪▪ ,15 ▪ ], and with 52.9% (9/17) in case of technetium alone or in combination with blue dye [16 ▪ ,17 ▪ ] ( P < 0.001). Despite this difference, a recently published meta-analysis did not find a statistically significant difference in SLN detection rate when different tracers were compared, but a large heterogeneity between the included studies was reported [18 ▪ ]. Volume of tracer injection was also different across the studies, ranging from 0.2 ml to 2 ml per site of injection [13 ▪▪ ,14 ▪▪ ,15 ▪ ,16 ▪ ,17 ▪ ].…”

“…More recently, indocyanine green (ICG) has been proposed to map SLN in OC after its large application in SLN detection in uterine cancers with demonstrated superiority when compared to other tracers [11,12]. Nevertheless, the use of ICG alone [13 ▪▪ ,14 ▪▪ ] has been associated with lower SLN detection rates compared with ICG + radioisotope [15 ▪ ,16 ▪ ] but similar to those obtained with radioisotope ± blue dye [17 ▪ ,18 ▪ ]. In particular, the overall mean (per patient) SLN detection rate in case of ICG alone was reported to be 58.6% (99/169) [13 ▪▪ ] compared with 95% (57/60) in case of ICG + technetium [14 ▪▪ ,15 ▪ ], and with 52.9% (9/17) in case of technetium alone or in combination with blue dye [16 ▪ ,17 ▪ ] ( P < 0.001).…”

Sentinel lymph node biopsy in ovarian cancer: more questions than certainties

“…In this month's Lead Article, Agustí and colleagues describe their systematic review and meta-analysis aimed at evaluating the detection rate and diagnostic accuracy of sentinel lymph node biopsy mapping in patients with early stage ovarian cancer. 1 The study showed a 92% pooled detection rate and 100% negative predictive value of sentinel lymph node biopsy. In particular, the dual tracers, technetium-99 and indocyanine green, and dual site injection (utero-ovarian and infundibolo-pelvic ligament), gave optimal detection when injected before adnexectomy.…”