Iria Rey

Cervical injection as an alternative to the utero-ovarian ligament for mapping pelvic sentinel lymph node in early-stage ovarian cancer

Abstract Purpose In early-stage ovarian cancer, sentinel lymph node (SLN) mapping using double injection into the utero-ovarian and infundibulo-pelvic ligaments has been postulated. Cervical injection, commonly used in other gynaecologic tumors, may provide a simpler alternative to utero-ovarian injection for pelvic-SLN detection. This study aims to demonstrate whether cervical and utero-ovarian injections drain to the same pelvic SLN using different tracers for each injection site: technetium-99m (99mTc) at cervix and indocyanine green into the utero-ovarian ligament. Methods This prospective trial enrolled endometrial cancer patients scheduled for SLN biopsy from July 2023 to May 2024. Each hemipelvis was considered a case. 99mTc was injected at the cervix preoperatively. If 99mTc migration occurred, indocyanine green was injected into the utero-ovarian ligament intraoperatively. Concordance of migration was determined in those hemipelvis with both 99mTc-cervical and indocyanine green utero-ovarian migration. Results Seventeen patients (34 hemipelvis) were included. Migration from both injection sites occurred in 17 hemipelvis, identifying the same pelvic-SLN in all cases, being the concordance rate of 100%. Migration of 99mTc or indocyanine green from cervical injection was detected in 91.2% (95% CI 81.6–100%), whereas migration of indocyanine green injection from the utero-ovarian ligament was detected in 73.9% (95% CI 56–91.9%); these detection rates were not significantly different (p = 0.077). Conclusions Lymphatic migration from the cervix to the pelvis seems to be comparable to the migration from the utero-ovarian ligament to the pelvis, with both pathways converging at the same SLN.

Sentinel lymph node detection in early ovarian cancer: the role of indocyanine green as a single tracer

This study aimed to evaluate the usefulness of indocyanine green (ICG) as a single tracer for sentinel lymph node (SLN) biopsy in apparent early-stage ovarian cancer and analyze the role of ultra-staging for metastasis detection. A retrospective, observational study was performed including patients with confirmed early-stage ovarian cancer. A total of 0.2 to 0.5 mL of ICG (1.25 mg/mL) was injected at the utero-ovarian ligament stump versus the cervix for pelvic SLN detection and at the infundibulopelvic ligament stump for para-aortic SLN detection, followed by systematic surgical staging. SLNs and non-SLNs were processed with a standard protocol, and then ultra-staging analysis was performed for the SLNs. The primary outcomes included detection rate and diagnostic accuracy (sensitivity and negative predictive value) of ICG for SLN's detection in pelvic and para-aortic fields. The secondary outcome was to determine the detection rate of SLN ultra-staging for metastasis detection. A total of 31 patients were included. The intra-operative SLN detection rates were 72% (95% CI 54.4% to 89.6%) for the pelvic field and 87.1% (95% CI 75.3% to 98.9%) for the para-aortic field. However, empty packets reduced the true detection rates to 52% (95% CI 32.4% to 71.6%) and 81% (95% CI 66.7% to 94.6%), respectively. For pelvic SLN, the negative predictive value was 100% (95% CI 82.4% to 100%), whereas the diagnostic accuracy and sensitivity could not be calculated because of the absence of metastasis. For para-aortic SLN, the diagnostic accuracy, sensitivity, and negative predictive value were 96.3% (95% CI 88% to 100%), 50% (95% CI 9.5% to 90.5%), and 96.2% (95% CI 81.1% to 99.3%), respectively. The only patient with a positive SLN (3.3%) was detected by micro-metastasis thanks to ultra-staging analysis (100%). The low volume of ICG (range; 0.2-0.5 mL) as a single tracer for SLN mapping in early-stage ovarian cancer shows a high negative predictive value but limited sensitivity and lead to empty packets detection. Ultra-staging allows low-volume metastasis detection, but its prognostic significance requires further evaluation.

Key issues in diagnostic accuracy of sentinel lymph node biopsy in early-stage ovarian cancer: systematic review and meta-analysis

Sentinel lymph node (SLN) mapping may reduce the morbidity of lymphadenectomy while maintaining diagnostic accuracy. Nevertheless, SLN mapping in epithelial ovarian cancer is still under investigation. This systematic review and meta-analysis aimed to assess the detection rate and diagnostic accuracy of SLN mapping for each field (pelvic and para-aortic), and to evaluate the tracers and doses used. A systematic search was conducted in PubMed, Cochrane Library, Scopus, and Web of Science. Patients with clinical stages I-II ovarian cancer undergoing SLN biopsy (index test) and a systematic pelvic and para-aortic lymphadenectomy (reference standard) were included. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. A meta-analysis was performed to assess SLN mapping detection rates and diagnostic accuracy for each field (pelvic and para-aortic) and by subgroups (type of tracer and dosage). 239 patients from four studies were included. The SLN detection rate was 59.5% (95% CI 50.2 to 68.1%) and 64.4% (95% CI 58.2 to 70.2%) for the pelvic and para-aortic fields, respectively. The use of technetium-99 ( The use of PROSPERO CRD42024544812.

Impact of surgical complexity on disease-free survival and overall survival in newly diagnosed advanced ovarian cancer

Ovarian cancer surgery and the complexity of the procedure may be measured with the standardized Aletti score. The main objective of this study was to establish the influence of surgical complexity using the Aletti score on disease-free survival and overall survival. A retrospective observational study was conducted in a reference gynecologic oncology department, including advanced ovarian cancer patients, newly diagnosed who underwent a primary debulking surgery or interval debulking surgery between January 2010 and December 2019 (stage IIB-IV International Federation of Gynecology and Obstetrics classification), and epithelial histology. Incomplete medical records, loss to follow-up patients, and borderline histologies were excluded. Survival analysis and multivariate analysis were performed. A total of 399 patients were included in the study. Regarding Aletti score complexity, no differences were observed in disease-free survival (median: 25 vs 24 months, p = .5) or overall survival (median: 56 vs 49 months, p = .6). Complete cytoreduction was associated with better disease-free survival (median: complete 26 vs optimal 14 vs sub-optimal 9 months, p < .0001) and overall survival (p < .0001). Furthermore, primary debulking surgery showed statistically better disease-free survival (median: 25 vs 16 months, p < .0001) and overall survival (median: 72 vs 38 months, p < .0001) compared to interval debulking surgery. The multivariable analysis showed that disease-free survival, overall survival, International Federation of Gynecology and Obstetrics classification, CA125 level at diagnosis, cytoreduction classification achieved after surgery, and the Clavien-Dindo complications did not significantly associate with the Aletti score. Disease-free survival and overall survival were not influenced by the surgical complexity in patients undergoing cytoreduction after the first diagnosis of advanced ovarian cancer. A higher Aletti score was not associated with a higher rate of complications.