Marta Arnáez

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.

Cross-Sectional Study on the Detection of HPV Infections for Cervical Cancer Screening Using a Self-Sampling Device

Objectives This study evaluates a new vaginal self-sampling device for high-risk human papillomavirus (HR-HPV) detection compared to clinician-collected samples using real-time polymerase chain reaction (PCR). Methods A total of 345 women aged between 23 and 72 were enrolled in this study. After receiving information about the study, women were provided with a vaginal collecting device to collect self-sample, and then a medical professional collected the cervical sample. All the clinician-collected samples were processed using the Cobas 4800 HPV assay, and the self-samples were processed with the automated MAIS extraction system. These results were used to compare the new device's performance to the clinician-collected cervical samples. All the clinician-collected samples were also analyzed with a new HPV screening assay to compare the performance of this assay on 2 different types of samples. Results Overall agreement for detecting any HR-HPV between clinician-collected samples and self-samples was 93.7% with a Cohen κ coefficient of 0.842. As both assays allow to identify genotypes 16, 18 and to detect the same 12 HR-HPV genotypes in a pool, the authors analyzed the agreement between self- and clinician-collected samples by genotypes and it was shown to be also excellent for HPV16 and the pool of other HR-HPV. Conclusions This self-sampling device has demonstrated detection rates that are comparable to those of samples collected by clinicians.

Alternatives of the pelvic sentinel lymph node migration pathway in early ovarian cancer: the simplest the best

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.

SENECA study: staging endometrial cancer based on molecular classification

Management of endometrial cancer is advancing, with accurate staging crucial for guiding treatment decisions. Understanding sentinel lymph node (SLN) involvement rates across molecular subgroups is essential. To evaluate SLN involvement in early-stage (International Federation of Gynecology and Obstetrics 2009 I-II) endometrial cancer, considering molecular subtypes and new European Society of Gynaecological Oncology (ESGO) risk classification. The SENECA study retrospectively reviewed data from 2139 women with stage I-II endometrial cancer across 66 centers in 16 countries. Patients underwent surgery with SLN assessment following ESGO guidelines between January 2021 and December 2022. Molecular analysis was performed on pre-operative biopsies or hysterectomy specimens. Among the 2139 patients, the molecular subgroups were as follows: 272 (12.7%) p53 abnormal (p53abn, 1191 (55.7%) non-specific molecular profile (NSMP), 581 (27.2%) mismatch repair deficient (MMRd), 95 (4.4%) POLE mutated (POLE-mut). Tracer diffusion was detected in, at least one side, in 97.2% of the cases; with a bilateral diffusion observed in 82.7% of the cases. By ultrastaging (90.7% of the cases) or one-step nucleic acid amplification (198 (9.3%) of the cases), 205 patients were identified with affected sentinel lymph nodes, representing 9.6% of the sample. Of these, 139 (67.8%) had low-volume metastases (including micrometastases, 42.9%; and isolated tumor cells, 24.9%) while 66 (32.2%) had macrometastases. Significant differences in SLN involvement were observed between molecular subtypes, with p53abn and MMRd groups having the highest rates (12.50% and 12.40%, respectively) compared with NSMP (7.80%) and POLE-mut (6.30%), (p=0.004); (p53abn, OR=1.69 (95% CI 1.11 to 2.56), p=0.014; MMRd, OR=1.67 (95% CI 1.21 to 2.31), p=0.002). Differences were also noted among ESGO risk groups (2.84% for low-risk patients, 6.62% for intermediate-risk patients, 21.63% for high-intermediate risk patients, and 22.51% for high-risk patients; p<0.001). Our study reveals significant differences in SLN involvement among patients with early-stage endometrial cancer based on molecular subtypes. This underscores the importance of considering molecular characteristics for accurate staging and optimal management decisions.

A restrictive stoma policy after colorectal anastomosis in ovarian cancer based on ghost ileostomy use

The incidence of anastomotic leak after colorectal anastomosis in ovarian cancer has been reported to be much lower than that in colorectal cancer patients. Regarding the use of protective manoeuvres (diverting ileostomy) as suggested by clinical guidelines, the goal should be the implementation of a restrictive stoma policy for ovarian cancer patients, given the low rate of anastomotic leakage in this population. Patients who underwent cytoreduction surgery in a single centre (University Hospital La Fe, Valencia Spain) due to ovarian cancer between January 2010 and June 2023 were classified according to two groups: a non-restrictive stoma policy group (Group A) and a restrictive stoma policy group (Group B). A total of 256 patients were included in the analysis (group A 52 % vs group B 48 %). The use of protective diverting ileostomy was lower in the restrictive stoma policy group (14 % vs 6.6 %), and the use of ghost ileostomy was 32 % vs 87 % in groups A and B, respectively (p < 0.00001). No differences were found in the anastomotic leak rate, which was 5.2 % in the non-restrictive group and 3.2 % in the restrictive stoma policy group (p = 0.54). The use of a restrictive stoma policy based on the use of ghost ileostomy reduces the rate of diverting ileostomy in patients with ovarian cancer after colorectal resection and anastomosis. Furthermore, this policy is not associated with an increased rate of anastomotic leakage nor with an increased rate of morbi-mortality related to the leak.

Laparoscopic sigmoidectomy with ghost ileostomy in ovarian cancer recurrence

Patent Blue SLN in Early Ovarian Cancer Prospective Study (FIGO I-II) Evaluating Patent Blue SLN Mapping. Injection Into IP/UO Ligaments in Situ. Goals: Assess Feasibility and Accuracy vs Standard Lymphadenectomy to Minimize Surgical Morbidity

the standard of care in case of early ovarian cancer (stage I or II) is a complete surgery. This surgery includes : hysterectomy (remove of the uterus), bilateral salpingo-oophorectomy (remove of the adnexa), omentectomy (remove of the epiploon), bilateral pelvic lymphadenectomy (remove of pelvic lymph nodes) and para-aortic lymphadenectomy (remove of para-aortic lymph nodes). This procedure is diagnostic, curative and prognostic surgery. In fact, it allows us provider care giver to stratify the stage of the cancer, hence we give the appropriate adjuvant therapy. However, this surgery, especially the extended lymphadenectomy, is associated with some risks: lymphocele, vessel injury, blood loss, morbidity, long recovery period ... In order to reduce these risks, we propose a sentinel lymph node biopsy. This intervention allows us to detect first lymph node relay whether pelvic or para-aortic. In our study, we chose the patent blue dye as a tracer. This tracer is widely used in oncologic surgery (for example in breast cancer) and approved but not in ovarian cancer yet. During surgery for early stage ovarian cancer, we will inject the patent blue dye on both side of the ovarian tumor. Then, we will check for first colorful lymph node, in both pelvic and para-aortic regions. We will send these dissected lymph node to pathology for analysis. Finally, we will continue the procedure as the standard of care. Our objective is to compare the results between the sentinel lymph node and the complete lymphadenectomy and to study the technique of sentinel lymph node biopsy using the blue patent dye as tracer.