Lymphatic mapping and sentinel node identification as related to the primary sites of lymph node metastasis in early stage ovarian cancer

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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%).

CONCLUSIONS

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.

Hounsfield unit change in metastatic abdominal lymph nodes treated with combined hyperthermia and radiotherapy

OBJECTIVE

Hyperthermia has been safely employed in conjunction with low to moderate doses of radiotherapy (RT) to achieve notable tumor responses in cases of previously treated and recurrent malignancies. However, the radiologic monitoring of combined hyperthermia and RT (HTRT) is not extensively documented. This study aimed to assess radiological changes, including alterations in Hounsfield units (HU), in patients undergoing treatment with either HTRT or RT alone for metastatic abdominal lymph nodes.

METHODS

CT images were acquired from consecutive 40 patients who received HTRT or RT alone for metastatic abdominal lymph nodes. Target regions were delineated and pre- and post-treatment HU measurements were extracted from these targets. An additional independent t-test was performed to compare the change in mean HU values between the two groups.

RESULTS

The study included 40 patients, 20 patients in the HTRT group and 20 in the RT alone group. In the HTRT group, the average HU after treatment was 58.95 HU, while in the RT-only group, it was 71.42 HU. In the HTRT-treated group, the average HU value of the tumor was lower by 9.05%, with an average of -8.47 HU. (p =  0.011), while in the RT-only treated group, it declined by 0.57% with an average of -0.41 HU.

CONCLUSION

The HTRT group showed a greater decrease in HU both pre- and post-treatment, indicating a possible indirect marker of tumor necrosis. Sequential trends and survival analyses for comparing the two groups are warranted in subsequent investigations.

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

OBJECTIVE

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.

METHODS

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).

RESULTS

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 (99mTc), alone or in combination, compared with the use of indocyanine green alone, was associated with a higher detection rate in both the pelvic (66.6%; 95% CI 53.3 to 78.3%; p=0.1211) and para-aortic (87.1%; 95% CI 76.9 to 93.9%, p=0.0000013) fields. The use of 0.2-0.5 mL of indocyanine green was associated with higher pelvic (68%; 95% CI 53.3 to 80.4%, p=0.1057) and para-aortic (88.3%, 95% CI 77.4 to 95.2%, p=0.0000018) detection rates compared with a 2 mL indocyanine green injection. Diagnostic accuracy, sensitivity, specificity, and negative predictive value of SLN for lymph node metastasis were: 100% each for the pelvic field and 98.1%, 85.7%, 100%, and 97.8%, respectively, for the para-aortic field.

CONCLUSION

The use of 99mTc in combination with a low volume injection (0.2-0.5 mL) of indocyanine green increased SLN detection rates. In apparent early stage epithelial ovarian cancer, SLN is a feasible technique with a high diagnostic accuracy.

TRIAL REGISTRATION

PROSPERO CRD42024544812.

Contribution of the cadaveric recirculation system in the anatomical study of lymphatic drainage of the ovary: applications in the management of ovarian cancer

PURPOSE

The present knowledge about lymphatic drainage of the ovary is based on carcinological studies, but it has only rarely been studied under physiological conditions. However, it is one of the preferential routes of dissemination in ovarian cancer, and understanding it is therefore vital for optimal carcinological management.Our purpose was to evaluate the feasibility of an innovative technique to study the lymphatic drainage territories of the ovary using a recirculation module on the cadaveric model.

METHODS

We injected patent blue into the cortex of twenty "revascularised" cadaver ovaries with the Simlife recirculation model. We observed the migration of the dye live and described the drainage territories of each ovary.

RESULTS

We observed a staining of the lymphatic vessels and migration of the dye in all the subjects, systematically ipsilateral to the injected ovary. We identified a staining of the lumbo-aortic territory in 65% of cases, with a preferential lateral-caval involvement (60%) for the right ovary and lateral-aortic territory (40%) for the left ovary. A common iliac involvement was observed in only 10% of cases. In 57% of cases, the staining of the lumbo-aortic territory was associated with a staining of the suspensory ligament. The pelvic territory was involved in 50% of cases, with an external iliac staining in 25% of cases and internal in 20%.

CONCLUSION

Our study provides for a better understanding of lymphatic drainage of the ovary using a new detection method, and allows the possibility of improving the teaching for operators with a realistic model. Continuation of this work could lead to considering more targeted and thus less morbid lymph node sampling for lymph node staging in early-stage ovarian cancer.

Sentinel Node Mapping in Ovarian Tumors: A Study Using Lymphoscintigraphy and SPECT/CT

Purpose

Ovarian cancer in the early stage requires a complete surgical staging, including radical lymphadenectomy, implying subsequent risk of morbidity and complications. Sentinel lymph node (SLN) mapping is a procedure that attempts to reduce radical lymphadenectomy-related complications and morbidities. Our study evaluates the feasibility of SLN mapping in patients with ovarian tumors by the use of intraoperative Technetium-99m-Phytate (Tc-99m-Phytate) and postoperative lymphoscintigraphy using tomographic (single-photon emission computed tomography/computed tomography (SPECT/CT)) acquisition.

Materials and Methods

Thirty-two patients with ovarian mass participated in this study. Intraoperative injection of the radiopharmaceutical was performed just after laparotomy and before the removal of tumor in utero-ovarian and suspensory ligaments of the ovary just beneath the peritoneum. Subsequently, pelvic and para-aortic lymphadenectomy was performed for malignant masses, and the presence of tumor in the lymph nodes was assessed through histopathological examination. Conversely, lymphadenectomy was not performed in patients with benign lesions or borderline ovarian tumors. Lymphoscintigraphy was performed within 24 hr using tomographic acquisition (SPECT/CT) of the abdomen and pelvis.

Results

Final pathological examination showed 19 patients with benign pathology, 5 with borderline tumors, and 6 with malignant ovarian tumors. SPECT/CT identified SLNs in para-aortic-only areas in 6 (20%), pelvic/para-aortic areas in 14 (47%), and pelvic-only areas in 7 (23%) cases. Notably, additional unusual SLN locations were revealed in perirenal, intergluteal, and posterior to psoas muscle regions in three patients. We were not able to calculate the false negative rate due to the absence of patients with involved lymph nodes.

Conclusion

SLN mapping using intraoperative injection of radiotracers is safe and feasible. Larger studies with more malignant cases are needed to better evaluate the sensitivity of this method for lymphatic staging of ovarian malignancies.

Clinical relevance of sentinel lymph node biopsy in early ovarian cancer

The first-line treatment for early ovarian cancer typically involves primary debulking surgery aimed at maximal cytoreduction, alongside adjuvant chemotherapy if clinically indicated. Nodal assessment involving pelvic and para-aortic lymph node dissection is typically performed during the primary debulking surgery. However, the survival benefit of lymphadenectomy in patients with early ovarian cancer has not been well established, and the procedure is associated with longer operation time and higher perioperative complications. With the emergence of minimally invasive surgery as a potential alternative to laparotomy for early ovarian cancer, sentinel lymph node biopsy has been evaluated in this setting. In this review, we summarized the current literature regarding sentinel lymph node biopsy in patients with early ovarian cancer, focusing on the clinical relevance of this method, including its detection rate and diagnostic accuracy. Additionally, we discuss the current status of clinical trials investigating sentinel lymph node biopsy in early ovarian cancer cases.

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

Sentinel lymph node biopsy (SLNB) has been widely adopted in the management of early-stage gynaecological cancers such as endometrial, vulvar and cervical cancer. Comprehensive surgical staging is crucial for patients with early-stage ovarian cancer and currently, that includes bilateral pelvic and para-aortic lymph node assessment. SLNB allows the identification, excision and pathological assessment of the first draining lymph nodes, thus negating the need for a full lymphadenectomy. We systematically searched the MEDLINE, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) databases (from inception to 3 November 2022) in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Our search identified 153 articles from which 11 were eligible for inclusion. Patients with clinical stage I-II ovarian cancer undergoing sentinel lymph node biopsy were included. Statistical analysis was performed in RStudio using the meta package, where meta-analysis was performed for the detection. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies C (QUADAS-C) tool. Overall, 11 observational studies met the predetermined criteria and these included 194 women. The meta-analysis showed that the detection rate of sentinel lymph nodes in early-stage ovarian cancer was 94% (95% CI of 86% to 1.00%). Significant heterogeneity was noted among the studies with Q = 47.6, p < 0.0001, I2 = 79% and τ2 = 0.02. Sentinel lymph nodes in early-stage ovarian cancer have a high detection rate and can potentially have applicability in clinical practice. However, considering the small number of participants in the studies, the heterogeneity among them and the low quality of evidence, the results should be interpreted with caution. Larger trials are needed before a change in clinical practice is recommended.

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

BACKGROUND

A 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.

OBJECTIVE

This study aimed to evaluate the detection rate and diagnostic accuracy of sentinel lymph node mapping in patients with early-stage ovarian cancer.

METHODS

A 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.

RESULTS

After 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 and 99mTc-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.

CONCLUSION

Sentinel 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.

Patterns of spread and genetic alterations of primary endometrioid carcinomas of the ovary

OBJECTIVE

The primary objective was to characterize the rate of lymph node involvement in a cohort of patients with primary ovarian endometrioid adenocarcinoma. Additionally, we sought to quantify the recurrence rate, genetic alterations, and impact of lymphadenectomy on survival in this group of patients.

METHODS

Patients diagnosed with primary endometrioid adenocarcinoma of the ovary without synchronous carcinomas of the female genital tract between 2012 and 2021 were identified. Demographic and disease-related data were collected from pathology reports and clinical records. Kaplan-Meier survival analysis using log rank test and Cox regression was performed.

RESULTS

Sixty-three patients met inclusion criteria. Median age was 60 (range 22-90) years. Histologic grade was 1 in 20 (32%), 2 in 27 (43%), and 3 in 16 (25%) tumors. International Federation of Gynecology and Obstetrics (FIGO) stage after surgery included IA/B (n=20, 32%), IC (n=23, 37%), II (n=16, 25%), and III (n=4, 6%). Forty-one (65%) patients had pelvic and 33 (52%) had both pelvic and para-aortic lymphadenectomy. All assessed lymph nodes were negative for metastatic carcinoma. No patients with clinically pelvis-confined disease had tumors upstaged by either lymphadenectomy or omentectomy. Twenty-eight patients (44%) had germline mutational status documented; two had a germline BRCA mutation, confirmed to be pathogenic by molecular studies. Complete staging did not significantly impact progression free or overall survival, after adjusting for age and histologic grade in a Cox proportional hazards model. The recurrence rate was 15% for patients with grade 1 endometrioid carcinoma, 7% for grade 2, and 31% for grade 3, respectively.

CONCLUSION

There were no lymph node metastases in patients with comprehensively staged primary endometrioid ovarian carcinoma. Staging did not impact survival and may be omitted, regardless of grade. Germline BRCA mutations are rare in ovarian endometrioid carcinoma compared with reported rates in high-grade serous carcinomas.

Where are we going with sentinel nodes mapping in ovarian cancer?

Lymph node involvement is a major predictive indicator in early-stage epithelial ovarian cancer (EOC). There is presently no effective way to determine lymph node involvement other than surgical staging. As a result, traditional ovarian cancer surgery still includes pelvic and paraaortic lymphadenectomy. However, it might be linked to higher blood loss, lengthier operations, and longer hospital stays. The creation of a technique for accurately predicting nodal status without significant lymphadenectomy is thus the subject of ongoing research. Sentinel lymph nodes (SLN) mapping is a routine procedure in oncological surgery and has been proven to be effective and safe in cervical, vulvar, and uterine cancer. On the other hand, SLN mapping is not yet widely accepted and recognized in EOC. A thorough search of the literature was conducted between January 1995 to March 2022, using PubMed and Embase. This review included studies on lymphatic outflow of the ovaries and the sentinel lymph node method. A total of 13 studies involving 212 patients who underwent sentinel lymph node mapping for ovaries were included. Both open and laparoscopic approach are used. The most popular injection site is the ovarian ligaments, and a variety of agents are utilized, although the main markers were, technetium-99m radiocolloid (Tc-99m) or indocyanine green, either alone or in combination. Overall detection rate for SLN in ovaries is 84.5% (interquartile range: 27-100%). We suggest a standardized method for sentinel lymph node mapping in ovarian cancer. The detection rates, characterization and true positive rates of the approach in investigations support further study. The use of ultra-staging is essential for lower-volume metastasis and reproducibility. To ascertain the clinical utility of sentinel node in early ovarian cancer, larger collaborative prospective clinical trials are necessary.

Feasibility of sentinel lymph node mapping in ovarian tumors: A systematic review and meta-analysis of the literature

PURPOSE OF THE REPORT

Since the presence of lymph node metastases upstages the disease and to reduce the morbidity of total lymphadenectomy, sentinel lymph node (SLN) mapping in ovarian mass has been the focus of extensive research. This study aims to review all the literature associated with ovarian SLN mapping and assess the feasibility of ovarian SLN mapping.

MATERIALS AND METHODS

PubMed and Scopus were searched using the following keywords: (Sentinel lymph node) AND (Ovary OR Ovarian) AND (Tumor OR Neoplasm OR Cancer). All studies with information regarding sentinel node biopsy in ovaries were included. Different information including mapping material, injection sites, etc., was extracted from each study. In total, two indices were calculated for included studies: detection rate and false-negative rate. Meta-analysis was conducted using Meta-MUMS software. Pooled detection rate, sensitivity, heterogeneity, and publication bias were evaluated. Quality of the studies was evaluated using the Oxford center for evidence-based medicine checklist.

RESULTS

Overall, the systematic review included 14 studies. Ovarian SLN detection rate can vary depending on the type of tracer, site of injection, etc., which signifies an overall pooled detection rate of 86% [95% CI: 75-93]. The forest plot of detection rate pooling is provided (Cochrane Q-value = 31.57, p = 0.003; I2 = 58.8%). Trim and fill method resulted in trimming of 7 studies, which decreased the pooled detection rate to 79.1% [95% CI: 67.1-87.5]. Overall, pooled sensitivity was 91% [59-100] (Cochrane Q-value = 3.93; p = 0.41; I2 = 0%). The proportion of lymph node positive patients was 0-25% in these studies with overall 14.28%.

CONCLUSION

Sentinel lymph node mapping in ovarian tumors is feasible and seems to have high sensitivity for detection of lymph node involvement in ovarian malignant tumors. Mapping material, injection site, and previous ovarian surgery were associated with successful mapping. Larger studies are needed to better evaluate the sensitivity of this procedure in ovarian malignancies.

Role of sentinel lymph node biopsy for gynecologic cancers

PURPOSE OF REVIEW

To provide an overview of the current knowledge and recent advances of sentinel lymph node (SLN) assessment in uterine, cervical, vulvar, and ovarian cancers.

RECENT FINDINGS

In endometrial cancer, SLN evaluation has become increasingly utilized as part of the treatment of early-stage disease, with data showing improved detection of pelvic lymph node metastasis. In cervical cancer, SLN biopsy has also gained increasing traction with studies demonstrating the feasibility and accuracy of SLN detection. Evaluation with frozen section, however, remains limited in the detection of metastases. The prognostic significance of positive SLN in vulvar cancer is currently being investigated, with preliminary data showing lower recurrence rates in patients receiving adjuvant radiation.

SUMMARY

SLN evaluation remains standard of care to detect lymph node metastasis in early-staged endometrial cancer. In cervical cancer, SLN biopsy has been shown to be reliable, while decreasing morbidity without impacting disease-free survival in select patients. The technique and high sensitivity of SLN biopsy in vulvar cancer has been demonstrated in large prospective trials. There are no randomized controlled trials in ovarian cancer that evaluate the role of SLN biopsy on treatment and outcome; current SLN evaluation remains investigational.

Prognostic value of systematic lymphadenectomy in patients with ovarian cancer: A systematic review and meta-analysis

OBJECTIVE

To appraise clinical outcomes of systematic lymphadenectomy in women with ovarian cancer based on stage, control group and type of chemotherapy.

STUDY DESIGN

A literature search was conducted on SCOPUS, PUBMED, COCHRANE, MEDLINE, and WEB OF SCIENCE databases. All comparative studies that assess outcomes of systematic lymphadenectomy in patients with ovarian cancer were eligible. Overall survival was analyzed by pooling log hazard ratio (HR) and standard error of multivariable Cox regression models. MOGGE Meta-analysis Matrix is a novel illustration tool that was used to demonstrate multiple subgroup analyses of included studies.

RESULTS

Twenty-two studies were eligible. Systematic lymphadenectomy was associated with better overall survival, that was close to significance, compared to control group (HR 0.93, 95 %CI 0.86-1.00). Among women treated with adjuvant chemotherapy, overall survival improved in women with stage IIB-IV who underwent systematic lymphadenectomy (HR 0.91, 95 %CI 0.84-0.99) and was most significant among patients with stage III to IV (HR 0.85, 95 %CI 0.73-0.99). Systematic lymphadenectomy did not improve survival in women who received neoadjuvant chemotherapy (HR 0.97, 95 %CI 0.73-1.29). Systematic lymphadenectomy was associated with improved progress-free survival compared to control group (HR 0.88, 95 %CI 0.79-0.99).

CONCLUSION

Although data from clinical trials do not support role of systematic lymphadenectomy in advanced ovarian cancer, overall data conveys stage-specific survival benefit. Further clinical trials may be warranted to assess substage survival outcomes in women with advanced stages.

Current state of fertility preservation for adolescent and young adult patients with gynecological cancer

Although the incidence of the various gynecological cancers has been increasing in recent years, long-term survival is now possible for many patients thanks to advances in multimodality treatment. When treating gynecological cancer in adolescent and young adult (AYA) patients who desire future pregnancy, it is necessary to preserve the reproductive organs and their function to prevent loss of fertility. However, because treatment targets these organs, in the large majority of cases, patients must have these organs removed. In the subfield of oncofertility, treatment of the underlying disease takes priority, and the main principle is preventing delay in treatment. Close cooperation between obstetricians and gynecologists involved in reproductive medicine and oncologists involved in cancer treatment is necessary. In addition, it is important that clinicians work closely not only with other specialists but also with such medical professionals as nurses and counselors so that cancer patients of the AYA generation can be provided the support they need to fight their cancer with hope. Herein, we describe the current status of fertility-sparing therapy for AYA patients with gynecological cancer (cervical cancer, endometrial cancer, or ovarian cancer). In addition, we explain points to keep in mind during a patient's pregnancy after fertility preservation, the latest findings on assisted reproductive technology, and the challenges and prospects of fertility preservation therapy for patients with gynecologic cancer.

Sentinel lymph node identification in early stage ovarian cancer: is it still possible after prior tumor resection?

Objective

Sentinel lymph node (SLN) detection in ovarian cancer is feasible when tracers are injected before the pathological ovary is resected. This study aims to investigate whether the SLN identification is also feasible in patients whose ovarian tumor has already been resected with injection of the tracer into the ovarian ligaments stumps, i.e. in the event that a frozen section confirms malignancy.

Methods

Patients who underwent laparotomy with frozen section confirming an ovarian malignancy, and those who underwent a second staging laparotomy after prior resection of a malignant ovarian mass, were included. Blue dye and a radioactive isotope were injected in the stumps of the ligamentum ovarium proprium and the ligamentum infundibulo-pelvicum. After an interval of at least 15-min, the sentinel node(s) were identified using either the gamma-probe and / or blue dye.

Results

A total of 11 patients were included in the study, the sentinel node (SLN) procedure was completed in all 11 patients. At least one SLN was identified in 3 patients, resulting in a rather low detection rate of 27,3%.

Conclusion

In this study we showed that SLN procedure after (previous) resection of the tumor seems inferior to detect sentinel nodes when compared to injection of the tracer in the ovarian ligaments before tumor resection.

Trial registration

NCT02540551

[Sentinel lymph node biopsy in the management of early-stage ovarian cancer: A systematic review of the literature]

The initial management of early-stage ovarian cancer consists of staging surgery including pelvic and para-aortic lymphadenectomy. The use of the sentinel lymph node (SLN) procedure in this setting may decrease the morbidity associated with this surgery. The objective of this review was to evaluate the feasibility of the SLN procedure in ovarian cancer diagnosed at an early stage by comparing the different techniques used and their accuracy. A systematic literature search was performed on PubMed and ClinicalTrials.gov for articles in English or French about the SLN technique in ovarian cancer. Ten studies were included in the analysis, with a total of 179 patients. The main tracers used were Technetium-99m, indocyanine green, and patent blue, and the most common site of injection was the proper ovarian and unfundibulopelvic ligaments. The overall detection rate was 87.7%. Of the small number of cases of lymph node metastasis reported, the SLN procedure had a sensitivity of 90.9% and a negative predictive value of 98.8%. The sentinel node procedure appears to be feasible and safe and could be reliable in determining the lymph node status of patients with early-stage ovarian cancer.

Women-specific routes of administration for drugs: A critical overview

The woman's body presents a number of unique anatomical features that can constitute valuable routes for the administration of drugs, either for local or systemic action. These are associated with genitalia (vaginal, endocervical, intrauterine, intrafallopian and intraovarian routes), changes occurring during pregnancy (extra-amniotic, intra-amniotic and intraplacental routes) and the female breast (breast intraductal route). While the vaginal administration of drug products is common, other routes have limited clinical application and are fairly unknown even for scientists involved in drug delivery science. Understanding the possibilities and limitations of women-specific routes is of key importance for the development of new preventative, diagnostic and therapeutic strategies that will ultimately contribute to the advancement of women's health. This article provides an overview on women-specific routes for the administration of drugs, focusing on aspects such as biological features pertaining to drug delivery, relevance in current clinical practice, available drug dosage forms/delivery systems and administration techniques, as well as recent trends in the field.

The attributive value of comprehensive surgical staging in clinically early-stage epithelial ovarian carcinoma: A systematic review and meta-analysis

BACKGROUND

Tumor positivity and upstaging rates from various surgical staging steps performed in clinically early-stage epithelial ovarian carcinoma (EOC) vary widely in literature.

AIM

To quantify tumor positivity and upstaging rates for all staging surgery steps in EOC patients. Differences between subgroups based on their clinical and histological characteristics are explored.

METHODS

A systematic search using synonyms of 'ovarian cancer', 'neoplasm staging', and 'neoplasm metastasis' was conducted in PubMed, Embase, and the Cochrane Library. Meta-analysis was performed on 23 included studies, comprising 5194 clinical stage I or II EOC patients who underwent comprehensive surgical staging. Studies were assessed using the Newcastle-Ottawa Scale risk-of-bias tool. Pooled proportions and 95% confidence intervals were calculated using an inverse variance weighted random-effects model.

RESULTS

Overall upstaging rate of clinically early-stage EOC patients was 18.7% (95%CI: 14.1-23.4%). Serous histology or high grade EOC showed the highest upstaging rate at 35.3% (95%CI: 21.8-48.7%) and 40.9% (95%CI: 35.6-46.2%). Lymph node involvement resulted in an upstaging rate of 8.7% (95%CI: 6.2-11.3%). Tumor was identified in uterus, cytology, peritoneal biopsies, omentum and appendix in 6.2% (95%CI: 1.8-10.7%), 18.4% (95%CI: 13.8-22.9%), 9.7% (95%CI: 3.8-15.6%), 5.2% (95%CI: 1.7-8.8%) and 3.6% (95%CI: 0.0-7.5%) of EOC patients. The corresponding upstaging rates were 5.9% (95%CI: 1.4-10.4%), 8.5% (95%CI: 1.8-15.2%), 3.5% (95%CI: 1.0-6.0%), 3.9% (95%CI: 1.4-6.3%) and 1.6% (95%CI: 0.0-3.4%), respectively.

CONCLUSION

The attributive value of comprehensive surgical staging in clinically early-stage EOC patients remains substantial, particularly in serous and high grade tumors.

Ultrastaging protocol in sentinel lymph node for apparent early stage ovarian cancer

OBJECTIVE

The objective of the present study is to determine the role of sentinel lymph node (SLN) ultrastaging in apparent early-stage ovarian cancer.

METHODS

We previously demonstrated the feasibility of SLN in early-stage ovarian cancer in a pilot study and in a clinical trial (NCT03452982). The SLN of the 30 patients involved in both were processed following an ultrastaging protocol. The cost of ultrastaging processing was also reported.

RESULTS

A SLN was detected in up to 91.3% and 90% in the pelvic and para-aortic region, respectively. In all cases, a SLN was detected at least in one field, pelvic or para-aortic. The mean time from injection to SLN resection was 53.3 ± 20.3 min. Two of 30 (6.6%) patients had a contralateral SLN in the para-aortic field, but no patients had contralateral SLN within the pelvic field after injection. The mean number of harvested SLN was 2.1 ± 1.4 (range: 0-5) and 2.7 ± 1.5 (range: 0-7) in the pelvic and para-aortic region, respectively. Two patients were upgraded to stage IIIA1 because of lymph node metastasis. In the first case, based on single sections and haematoxylin and eosin (H&E) examination, a pelvic SLN micrometastasis (1 mm) was found on the first H&E section. By using the ultrastaging protocol, the size of the metastasis was increased to 2.1 mm (macrometastasis). In the same patient, the ultrastaging study of the inframesenteric para-cava SLNs found isolated tumour cells in the subcapsular and interfollicular lymph nodes sinus in one of the two SLN harvested (in one of the sections at the fourth and fifth ultrastage levels). The other upstaged case was a para-aortic macrometastasis in a patient in whom the SLN was not identified in the para-aortic field because of the absence of migration from the infundibulo-pelvic stump injection. The cost of ultrastaging in each patient depended on the total number of SLN retrieved, averaging 96.8 € (range: 0-230.5) and 124.5 € (range: 0-322.7€) for pelvic and para-aortic SLN, respectively.

CONCLUSIONS

A uniform protocol for ultrastaging is essential for lower-volume metastasis detection and to provide reproducible information between upcoming studies, as evidence about SLN in ovarian cancer is growing.

The impact of lymph node dissection on apparent Stage I epithelial ovarian carcinoma: A population-based study

OBJECTIVE

To explore the impact of lymphadenectomy on the prognosis of women of reproductive age with clinically apparent Stage I epithelial ovarian cancer (EOC).

METHODS

Data of women of reproductive age with Stage I EOC, diagnosed between 2010 and 2016, were extracted from the Surveillance, Epidemiology, and End Results database. Five-year cancer-specific survival (CSS) was evaluated using the Kaplan-Meier method. Multivariate Cox analysis was performed to evaluate the effect of lymph node dissection on survival. Propensity score (PS) matching was conducted to balance various clinicopathologic factors.

RESULTS

Of 2222 patients included, 1609 (72.4%) received lymph node dissection. The rate of histopathologically confirmed lymph node metastasis was highest in serous subtype (10.2%) and lowest in mucinous subtype (2.2%). No significant difference between the lymphadenectomy and non-lymphadenectomy groups in 5-year CSS was observed in the original cohort (P = 0.364) or in the PS matching cohort (P = 0.248). Nevertheless, there was a significant difference between the lymphadenectomy and non-lymphadenectomy groups for patients with Stage IC EOC (92.4% vs. 88.1%, P = 0.027). According to the multivariate analysis, performance of the lymphadenectomy was not significantly associated with CSS in the original cohort (P = 0.163) or the PS matching cohort (P = 0.101).

CONCLUSION

Dissection of lymph nodes was not significantly associated with improved prognosis for most Stage I EOC, but, lymphadenectomy may be necessary for women of reproductive age with Stage IC subtype.

Risk factors for lymph node metastasis of ovarian, fallopian tube and primary peritoneal cancer in hereditary breast and ovarian cancer syndrome

BACKGROUND

To establish an individualized surgical strategy for lymphadenectomy in ovarian cancer patients with the germline BRCA1 and BRCA2 pathogenic variants (BRCA1+ and BRCA2+), we investigated the clinicopathological characteristics that are involved in the increased risk of lymph node metastasis.

METHODS

We retrospectively reviewed the data of Japanese women registered in the database of the Japanese Hereditary Breast and Ovarian Cancer Consortium, who underwent BRCA1 and BRCA2 genetic testing.

RESULTS

We evaluated the predictors of lymph node metastasis in all patients with the information of age at the diagnosis, disease site, histological subtype, 2014 FIGO stage, personal breast cancer history and family history; 233, 153 and 32 patients in the BRCA- (no pathogenic variant), BRCA1+ and BRCA2+ groups, respectively. The prevalence of lymph node metastasis was not markedly different between BRCA- (20.0%), BRCA1+ (18.4%) and BRCA2+ (26.2%). Multivariate analysis revealed an absence of a family history of ovarian cancer as an independent predictor for an increased risk of lymph node metastasis in BRCA1+, and the prevalence of lymph node metastasis was 11.7 and 42.0% in the groups with and without a family history of ovarian cancer, respectively. This subgroup without a family history of ovarian cancer did not show any correlation with a particular variant of BRCA1, including two common variants of c.188 T > A and c.2800C > T.

CONCLUSIONS

This study suggested that certain genetic factors related to the penetrance of hereditary breast and ovarian cancer syndrome altered the frequency of lymph node metastasis in BRCA1+ ovarian cancer, and family history may be useful to personalize the indication of lymphadenectomy.

The role of sentinel-node biopsy in ovarian cancer

Lymph node involvement is an important prognostic factor in early and advanced epithelial ovarian cancer (EOC). However, to date there is no reliable method of detecting lymph node involvement, apart from surgical staging. Thus, pelvic and paraaortic lymphadenectomy (LNE) are still part of standard surgery of early ovarian cancer. There is conflicting evidence about the therapeutic value of systematic LNE in early EOC. Thus, the developmemt of a method to predict nodal status accurately, without extensive LNE, is the subject of ongoing research. Sentinel lymphadenectomy (SLN) has become a standard procedure in oncological surgery. However, SLN is not yet an established and widely accepted procedure for EOC. This review aimed at summarizing available evidence on its feasibility and reliability in EOC. Overall, evidence of SLN in early EOC is still scarce. So far, only small series of patients with a variety of tracers and injection sites were published. From the available literature, the most promising technique seems to be injection into the infundibulopelvic, as well as the proper ovarian ligament. Indocyanine green seems to be an excellent tracer for successful SLN of ovarian tumors, which can be used during laparoscopic or robotic surgery. The detection rates and true positive rates of studies support further investigation of the technique. Results from prospective studies, e.g. the ongoing SELLY trial, are necesssary to implement SLN into the standard treatment of early EOC.

Utility of Intraoperative Fluorescence Imaging in Gynecologic Surgery: Systematic Review and Consensus Statement

BACKGROUND

This study aimed to review the current knowledge on the utility of intraoperative fluorescence imaging in gynecologic surgery and to give evidence-based recommendations to improve the quality of care for women who undergo gynecologic surgery.

METHODS

A computer-based systematic review of the MEDLINE, CENTRAL, Pubmed, EMBASE, and SciSearch databases as well as institutional guidelines was performed. The time limit was set at 2000-2019. For the literature search, PRISMA guidelines were followed. A modified-Delphi method was performed in three rounds by a panel of experts to reach a consensus of conclusions and recommendations.

RESULTS

Indocyanine green (ICG) is used primarily in gynecology for sentinel node-mapping. In endometrial and cervical cancer, ICG is a feasible, safe, time-efficient, and reliable method for lymphatic mapping, with better bilateral detection rates. Experience in vulvar cancer is more limited, with ICG used together with Tc-99 m as a dual tracer and alone in video endoscopic inguinal lymphadenectomy. In early ovarian cancer, results are still preliminary but promising. Indocyanine green fluorescence imaging also is used for ureteral assessment, allowing intraoperative ureteral visualization, to reduce the risk of ureteral injury during gynecologic surgery.

CONCLUSIONS

For most gynecologic cancers, ICG fluorescence imaging is considered the tracer of choice for lymphatic mapping. The use of this new technology expands to a better ureteral assessment.

Sentinel lymph node technique in early-stage ovarian cancer (SENTOV): a phase II clinical trial

OBJECTIVE

Early-stage ovarian cancer might represent an ideal disease scenario for sentinel lymph node application. Nevertheless, the published experience seems to be limited. Our objective was to assess the feasibility and safety concerns of sentinel lymph node biopsy in patients with clinical stage I-II ovarian cancer.

METHODS

We conducted a prospective cohort study of 20 patients with histologically confirmed ovarian cancer. 99mTc and indocyanine green were injected into both the utero-ovarian and infundibulopelvic ligament stump, if they were present, during surgical staging. An intraoperative gamma probe and near-infrared fluorescence imaging were used to detect the sentinel lymph nodes. Inclusion criteria included: >18 years of age, suspicious adnexal mass (unilateral or bilateral) at ultrasound and CT imaging or confirmed ovarian tumor after previous surgery (unilateral or bilateral salpingo-oophorectomy with or without hysterectomy). Adverse events were recorded through postoperative day 30. The primary trial end point was to report adverse events related to the technique, including the use of 99mTc and ICG intraperitoneally, as well as the feasibility of the technique.

RESULTS

A total of 20 patients were included in the analysis. Sentinel lymph nodes were detected in 14/15 (93%) pelvic and all 20 (100%) para-aortic regions. Five patients did not have utero-ovarian injection because of prior hysterectomy. The mean time from injection to sentinel lymph node resection was 53±15 min (range; 30-80). The mean number of harvested sentinel lymph nodes was 2.2±1.5 (range; 0-5) lymph nodes in the pelvis and 3.3±1.8 (range; 1-7) lymph nodes in the para-aortic region. There were no adverse intraoperative events, nor any within the 30 days of follow-up related with the technique.

CONCLUSION

Sentinel lymph node mapping in early-stage ovarian cancer is feasible without major intraoperative or < 30 days safety concerns. (NCT03452982).

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, NCT03452982.

How to manage lymph nodes in ovarian cancer

The indication for staging lymphadenectomy in patients with ovarian cancer (both early- and late-stage disease) has been a major topic of debate in the last decades. Because the Lymphadenectomy in Ovarian Neoplasms (LION) study has recently demonstrated that systematic lymphadenectomy is not beneficial to patients with advanced ovarian cancer, the discussion has become more complex for patients with early-stage ovarian cancer. Further factors, such as differences in the lymph node metastasis rates of different histologic subtypes, which were not known in the past, need to be taken into account. This review is focused on the available evidence concerning lymphadenectomy in patients with newly diagnosed ovarian cancer.

Sentinel-node biopsy in early-stage ovarian cancer: preliminary results of a prospective multicentre study (SELLY)

BACKGROUND

Systematic paraaortic and bilateral pelvic lymphadenectomy is the standard of a comprehensive surgical staging in presumed early epithelial ovarian cancer, but no prospective randomized evidence suggests a possible therapeutic value. Moreover, this procedure is associated with potential severe morbidity. The Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective study designed to test whether sentinel node detection can accurately predict nodal status in a cohort of women with early epithelial ovarian cancer.

OBJECTIVES

We here present the results of the first part of the Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial, regarding the feasibility of the sentinel lymph node technique and the preliminary findings regarding its safety and accuracy.

STUDY DESIGN

The Sentinel Lymph Nodes in Early-Stage Ovarian Cancer trial is a prospective, phase II, single-arm study included patients with presumed stages I-II epithelial ovarian cancer planned for immediate or delayed minimally invasive comprehensive staging. The ovarian pedicle is injected with 2 mL of a 1.25 mg/mL indocyanine green solution. The pelvic and lumboaortic retroperitoneum is then accessed and inspected to identify and remove sentinel nodes. After sentinel node procedure, staging is completed including systematic pelvic and paraaortic lymphadenectomy. Assuming a sensitivity of 98.5% in predicting positive sentinel lymph nodes at histology, a pathological lymph node prevalence of 14.2%, a precision of estimate (ie, the maximum marginal error) d = 5%, a type I error α = 0.05, a sample size of 160 patients is needed to test the general hypothesis. Here we present the preliminary results on the first 31 patients enrolled.

RESULTS

Thirty-one patients were included. Sentinel node was identified in 21 patients (detection rate, 67.7%). The detection rate was significantly higher in women undergoing immediate vs delayed staging (88.9% vs 41.7%, P = .003). Four patients had positive nodes. In all the patients with lymphatic dissemination, a positive sentinel node was identified (sensitivity, 100%; false-negative rate, 0%; negative predictive value, 100%). One (3.2%) intra- and 2 (6.5%) postoperative grade I complications occurred.

CONCLUSION

Our data show that the detection of sentinel node in early epithelial ovarian cancer is low when patients are submitted to delayed-staging surgery. However, sentinel node procedure is feasible and has the potential to provide reliable and useful information on nodal status and may allow the avoidance of systematic lymphadenectomy in the majority of patients.

Feasibility of sentinel lymph node mapping of the ovary: a systematic review

Pelvic and para-aortic lymphadenectomy is routinely performed in early ovarian cancer to define the stage of the disease. However, it may be associated with increased blood loss, operative time, and length of hospitalization. The sentinel lymph node technique has been shown to be safe and feasible in vulvar, uterine, and cervical cancer. Data detailing feasibility and outcomes of sentinel lymph node mapping in ovarian cancer are scarce.To summarize the studies evaluating the feasibility of sentinel lymph node detection from the ovary, examining the technique and detection rate.A systematic search of the literature was performed using PubMed and Embase from June 1991 to February 2019. Studies describing the sentinel lymph node technique and lymphatic drainage of the ovaries were incorporated in this review. Ten articles were selected, comprising a total of 145 patients. A variety of agents were used, but the primary markers were technetium-99m radiocolloid (Tc-99m), patent blue, or indocyanine green, and the most common injection site was the ovarian ligaments.The overall sentinel lymph node detection rate was 90.3%.We propose a standardized technique sentinel lymph node mapping in ovarian cancer, using indocyanine green, or Tc-99m and blue dye as alternative tracers, injected in both the suspensory and the infundibulopelvic ligament of the ovary.

The role of sentinel node in early ovarian cancer: a systematic review

INTRODUCTION

Early ovarian cancer (EOC) is defined as ovarian cancer macroscopically limited to the ovaries at the time of initial diagnosis. Approximately only 25% of patients with ovarian cancer are affected by EOC. This condition requires complete surgical staging, including systematic lymphadenectomy up to the level of the renal vessels, with the consequent risk of complications and morbidity. With the aim to reduce the procedure-related morbidity, sentinel lymph node mapping (SLNm) has been introduced as an experimental procedure in EOC staging. The aim of the present study is to systematically review the available series on this interesting issue.

EVIDENCE ACQUISITION

Studies were identified by searching electronic databases. The search was systematically applied to PubMed, ClinicalTrials.gov, Scopus and Web of Science looking for records describing the use of sentinel lymph node technique in EOC from January 1st, 1989 to January 1st, 2019. A total of 10 studies were identified for inclusion. Of the 121 patients involved in these studies, only 43 had a histologically-confirmed diagnosis of EOC and were included in the present analysis.

EVIDENCE SYNTHESIS

SLN (paraaortic and/or pelvic) overall detection rate (DR) was of 97.6%. The overall sensitivity (SS) and negative predictive value (NPV) of the included cases were 66.7% and 96.6%, respectively. We calculated also NPV, SS and DR based on the anatomical lymph node district, with a value of 100% both in the lumbo-aortic and in the pelvic district and a DR of 83.3% and 43% respectively.

CONCLUSIONS

This review shows that evidence on SLNm in EOC is still scant. Based on the limited data available, SLNm may provide potentially useful information on nodal status in patients affected by this disease.

Clinical application of the sentinel lymph node technique in early ovarian cancer: a pilot study

INTRODUCTION

There is limited evidence favoring the use of the sentinel lymph node technique in ovarian cancer, and no standardized approach has been studied. The objective of the present pilot study is to determine the feasibility of the sentinel lymph node technique by applying a clinical algorithm.

METHODS

Patients with confirmed ovarian cancer were included. 99mTc and indocyanine green were injected into the ovarian and infundubulo-pelvic ligament stump. A gamma probe and near-infrared fluorescence imaging were used for sentinel lymph node detection.

RESULTS

The sentinel lymph node technique was performed in nine patients with a detection rate in the pelvic and/or para-aortic region of 100%. The tracer distribution rates of sentinel lymph nodes in the pelvic and para-aortic regions were 87.5% and 70%, respectively.

CONCLUSION

The detection of sentinel lymph nodes in early-stage ovarian cancer appears to be achievable. Based on these results, a clinical trial entitled SENTOV (SENtinel lymph node Technique in OVarian cancer) will be performed.

How to evaluate the adequacy of staging for nodal-negative epithelial ovarian cancer? Use of nodal staging score

OBJECTIVE

No guideline has been provided to assess the minimal number of lymph nodes (LNs) that should be dissected for accurate staging in patients with epithelial ovarian cancer (EOC). The aim of the study was to develop a nodal staging score (NSS) as an index to assess whether a pathologic (p)N0 EOC patient is indeed free of a nodal disease.

METHODS

A total of 16,361 EOC patients staged I-III between 2004 and 2013 were identified from the Surveillance, Epidemiology and End Result database. With a β-binomial model, NSS was calculated to assess the probability of true-negative findings of LN status.

RESULTS

With an increased number of LNs examined, the probability of missing a nodal disease decreased and varied among different pT stages. Given 1 LN examined, an NSS of 93.76% calculated could ensure a high adequacy of nodal-negative classification for pT1N0 EOC patients. For pT2N0 patients, 5 LNs examined could guarantee an NSS of 90% for adequate staging. Likewise, 11 and 29 LNs examined in pT3N0 patients could maintain NSS at the level of 80% and 90%, respectively. Our study suggested the optimal number of LNs that could be examined and stratified by the pT stages for EOC patients based on this statistical model derived from large pathologic data of clinical surgery patients.

CONCLUSION

NSS, as an auxiliary tool, not only could assist the International Federation of Gynecology and Obstetrics staging more precisely, but also would provide a statistical basis for postoperative evaluation for further clinical decision-making.

Carbon Nanomaterials for Targeted Cancer Therapy Drugs: A Critical Review

Cancer represents one of the main causes of human death in developed countries. Most current therapies, unfortunately, carry a number of side effects, such as toxicity and damage to healthy cells, as well as the risk of resistance and recurrence. Therefore, cancer research is trying to develop therapeutic procedures with minimal negative consequences. The use of nanomaterial-based systems appears to be one of them. In recent years, great progress has been made in the field using nanomaterials with high potential in biomedical applications. Carbon nanomaterials, thanks to their unique physicochemical properties, are gaining more and more popularity in cancer therapy. They are valued especially for their ability to deliver drugs or small therapeutic molecules to these cells. Through surface functionalization, they can specifically target tumor tissues, increasing the therapeutic potential and significantly reducing the adverse effects of therapy. Their potential future use could, therefore, be as vehicles for drug delivery. This review presents the latest findings of research studies using carbon nanomaterials in the treatment of various types of cancer. To carry out this study, different databases such as Web of Science, PubMed, MEDLINE and Google Scholar were employed. The findings of research studies chosen from more than 2000 viewed scientific publications from the last 15 years were compared.

Update on rare epithelial ovarian cancers: based on the Rare Ovarian Tumors Young Investigator Conference

There has been significant progress in the understanding of the pathology and molecular biology of rare ovarian cancers, which has helped both diagnosis and treatment. This paper provides an update on recent advances in the knowledge and treatment of rare ovarian cancers and identifies gaps that need to be addressed by further clinical research. The topics covered include: low-grade serous, mucinous, and clear cell carcinomas of the ovary. Given the molecular heterogeneity and the histopathological rarity of these ovarian cancers, the importance of designing adequately powered trials or finding statistically innovative ways to approach the treatment of these rare tumors has been emphasized. This paper is based on the Rare Ovarian Tumors Conference for Young Investigators which was presented in Tokyo 2015 prior to the 5th Ovarian Cancer Consensus Conference of the Gynecologic Cancer InterGroup (GCIG).

Role of robotic surgery in ovarian malignancy

As part of minimally invasive surgery, robotic-assisted approach is becoming increasingly popular in gynecologic oncology. It has been shown to be effective and feasible for staging and treating endometrial and cervical cancer, but its role in the context of primary and recurrent ovarian cancers is presently debated. Scanty data are available in the literature, and the level of evidence supporting its use in ovarian cancer is quite low. However, from a retrospective case-control series, robotic surgery seems to be safe and feasible for early-stage ovarian cancer. Its use in treating patients with advanced-stage or relapsed ovarian cancer is still highly controversial, suggesting the choice of robotic approach in a highly selected population.

Is lymphadenectomy necessary in mucinous ovarian cancer? A single institution experience

BACKGROUND

According to the International Federation of Gynecology and Obstetrics (FIGO) guidelines, every patient diagnosed with ovarian cancer (OC) should undergo a complete staging procedure to adequately assess tumor spread. The role of lymphadenectomy in the initial management of primary early mucinous ovarian cancer (MOC) remains unclear.

OBJECTIVE

To describe the prevalence of pelvic and para-aortic node metastases in MOC.

MATERIALS AND METHODS

The records of patients with MOC treated at our Institute during January 2005 to December 2011 were assessed. A descriptive and comparative analysis was conducted. Overall survival (OS) and diseases-free period (DFP) were calculated with the Kaplan-Meier method and were compared with the log-rank test.

RESULTS

Of 31 patients with MOC, 14 (45.16%) underwent lymphadenectomy, obtaining 190 pelvic nodes, with a median of 9 pelvic lymph nodes removed per patient (interquartile range = 15). There was no evidence of metastatic disease in the dissected pelvic nodes.

CONCLUSION

These results suggest that complete surgical staging with lymph node dissection has no effect on recurrence, disease-free period, and overall survival of patients with early stage MOC.

Near-infrared Fluorescence-guided Sentinel Node Mapping of the Ovary With Indocyanine Green in a Minimally Invasive Setting: A Feasible Study

Sentinel lymph node (SLN) mapping has increased its feasibility in both early-stage cervical and endometrial cancer. There are few SLN studies regarding the ovary because of the risk of tumor dissemination and perhaps because the ovary represents an inconvenient site for injection. In this preliminary study, we have shown the feasibility of SLN mapping of the ovary with indocyanine green during laparoscopic retroperitoneal aortic surgical staging. The 10 women who were included in this study underwent aortic with pelvic laparoscopic staging, which included SLN biopsy, extrafascial total hysterectomy, and bilateral salpingo-oophorectomy in case of an ovarian tumor. The fluorescent dye was injected on the dorsal and ventral side of the proper ovarian ligament and the suspensory ligament, close to the ovary and just underneath the peritoneum. In all cases except 1, SLNs were detected soon after the injection in the aortic compartment and in 3 cases also in the common iliac region. Only 1 intraoperative complication occurred: a superficial lesion of the vena cava that was recovered with a laparoscopic suture. Laparoscopic ovarian SLN mapping performed by means of an injection of indocyanine green fluorescent tracer in the ovarian ligaments seems feasible and promising. Further investigation are encouraged and necessary to evaluate the possible applications of this new technique for staging patients with early-stage ovarian cancer.

Lymphatic mapping and sentinel node biopsy in ovarian tumors: a study using intra-operative Tc-99m-Phytate and lymphoscintigraphy imaging

BACKGROUND

Experience on sentinel node mapping in ovarian tumors is very limited. We evaluated the sentinel node concept in ovarian tumors using intra-operativeTc-99m-Phytate injection and lymphoscintigraphy imaging.

METHODS

Thirty-five patients with a pelvic mass due to an ovarian pathology were included in the study. The radiotracer was injected just after laparotomy and before removal of the tumor either beneath the normal cortex (10 patients) or in the utero-ovarian and suspensory ligaments of the ovary just beneath the peritoneum two injections of the radiotracer (25 patients). For malignant masses, the sentinel nodes were identified using a hand held gamma probe. Then standard pelvic and para-aortic lymphadenectomy was performed. In case of benign pathologies or borderline ovarian tumors on frozen section, lymphadenectomy was not performed. The morning after surgery, all patients were sent for lymphoscintigraphy imaging of the abdomen and pelvis.

RESULTS

Sentinel node was identified only in 4 patients of the cortical injection group. At least one sentinel node could be identified in 21 patients of the sub-peritoneal group. Sentinel nodes were identified only in the para-aortic area in 21, pelvic/para-aortic areas in 2, and pelvic only area in 2 patients. Three patients had lymph node involvement and all had involved sentinel nodes (no false negative case).

CONCLUSION

Sentinel node mapping using intra-operative injection of the radiotracer (in the utero-ovarian and suspensory ligaments of the ovary just beneath the peritoneum) is feasible in ovarian tumors. Technical aspects of this method should be explored in larger multicenter studies in the future.

Clinical Practice of Adjuvant Chemotherapy in Patients with Early-Stage Epithelial Ovarian Cancer

BACKGROUND

Adjuvant platinum-based chemotherapy improves survival in women with early-stage epithelial ovarian cancer (EOC). Yet, there is a wide variety in clinical practice.

METHODS

All patients diagnosed with FIGO I and IIa EOC (2006-2010) in the south of the Netherlands were analyzed. The percentage of patients that received adjuvant chemotherapy was determined as well as the comprehensiveness of staging and outcome.

RESULTS

Forty percent (54/135) of the patients with early-stage EOC received adjuvant chemotherapy. Treatment with adjuvant chemotherapy was associated with FIGO stage, clear-cell histology and nonoptimal staging. Optimal staging was achieved in 50%, and nonoptimal staging was associated with advanced age, comorbidity and treatment in a non-referral hospital. Overall, there was no difference in outcome between patients with and without adjuvant chemotherapy. Yet, in grade 3 tumors, adjuvant chemotherapy seems beneficial.

CONCLUSIONS

Selective treatment of patients with early-stage EOC might reduce adjuvant chemotherapy without compromising outcome.

Understanding Lymphatic Drainage Pathways of the Ovaries to Predict Sites for Sentinel Nodes in Ovarian Cancer

OBJECTIVE

In ovarian cancer, detection of sentinel nodes is an upcoming procedure. Perioperative determination of the patient's sentinel node(s) might prevent a radical lymphadenectomy and associated morbidity. It is essential to understand the lymphatic drainage pathways of the ovaries, which are surprisingly up till now poorly investigated, to predict the anatomical regions where sentinel nodes can be found. We aimed to describe the lymphatic drainage pathways of the human ovaries including their compartmental fascia borders.

METHODS

A series of 3 human female fetuses and tissues samples from 1 human cadaveric specimen were studied. Immunohistochemical analysis was performed on paraffin-embedded transverse sections (8 or 10 μm) using antibodies against Lyve-1, S100, and α-smooth muscle actin to identify the lymphatic endothelium, Schwann, and smooth muscle cells, respectively. Three-dimensional reconstructions were created.

RESULTS

Two major and 1 minor lymphatic drainage pathways from the ovaries were detected. One pathway drained via the proper ligament of the ovaries (ovarian ligament) toward the lymph nodes in the obturator fossa and the internal iliac artery. Another pathway drained the ovaries via the suspensory ligament (infundibulopelvic ligament) toward the para-aortic and paracaval lymph nodes. A third minor pathway drained the ovaries via the round ligament to the inguinal lymph nodes. Lymph vessels draining the fallopian tube all followed the lymphatic drainage pathways of the ovaries.

CONCLUSIONS

The lymphatic drainage pathways of the ovaries invariably run via the suspensory ligament (infundibulopelvic ligament) and the proper ligament of the ovaries (ovarian ligament), as well as through the round ligament of the uterus. Because ovarian cancer might spread lymphogenously via these routes, the sentinel node can be detected in the para-aortic and paracaval regions, obturator fossa and surrounding internal iliac arteries, and inguinal regions. These findings support the strategy of injecting tracers in both ovarian ligaments to identify sentinel nodes.

The EANM clinical and technical guidelines for lymphoscintigraphy and sentinel node localization in gynaecological cancers

The accurate harvesting of a sentinel node in gynaecological cancer (i.e. vaginal, vulvar, cervical, endometrial or ovarian cancer) includes a sequence of procedures with components from different medical specialities (nuclear medicine, radiology, surgical oncology and pathology). These guidelines are divided into sectione entitled: Purpose, Background information and definitions, Clinical indications and contraindications for SLN detection, Procedures (in the nuclear medicine department, in the surgical suite, and for radiation dosimetry), and Issues requiring further clarification. The guidelines were prepared for nuclear medicine physicians. The intention is to offer assistance in optimizing the diagnostic information that can currently be obtained from sentinel lymph node procedures. If specific recommendations given cannot be based on evidence from original scientific studies, referral is made to "general consensus" and similar expressions. The recommendations are designed to assist in the practice of referral to, and the performance, interpretation and reporting of all steps of the sentinel node procedure in the hope of setting state-of-the-art standards for high-quality evaluation of possible metastatic spread to the lymphatic system in gynaecological cancer. The final result has been discussed by a group of distinguished experts from the EANM Oncology Committee and the European Society of Gynaecological Oncology (ESGO). The document has been endorsed by the SNMMI Board.

Synchronous adrenal metastasis and an inferior vena cava tumor thrombus from an ovarian carcinoma

A 60-year-old woman presented with synchronous adrenal metastasis and an inferior vena cava tumor thrombus in the adrenal vein that developed from an ovarian carcinoma. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and right adrenalectomy with caval tumor thrombectomy for treatment. Microscopic examination revealed a clear cell ovarian carcinoma and a metastatic adrenal tumor. The patient is clinically free of disease after 6 years of follow-up. There have been no reports of synchronous adrenal metastasis with an inferior vena cava thrombus that developed from an ovarian carcinoma. As several reports have described the long-term survival after adrenalectomy for the treatment of isolated adrenal metastasis, clinicians should be aware of this potential occurrence so that patients can be appropriately treated.