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Frontiers in Oncology 2020To evaluate the utility of sentinel lymph node mapping (SLN) in endometrial cancer (EC) patients in comparison with lymphadenectomy (LND).
Operative and Oncological Outcomes Comparing Sentinel Node Mapping and Systematic Lymphadenectomy in Endometrial Cancer Staging: Meta-Analysis With Trial Sequential Analysis.
OBJECTIVE
To evaluate the utility of sentinel lymph node mapping (SLN) in endometrial cancer (EC) patients in comparison with lymphadenectomy (LND).
METHODS
Comprehensive search was performed in MEDLINE, EMBASE, CENTRAL, OVID, Web of science databases, and three clinical trials registration websites, from the database inception to September 2020. The primary outcomes covered operative outcomes, nodal assessment, and oncological outcomes. Software Revman 5.3 was used. Trial sequential analysis (TSA) and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) were performed.
RESULTS
Overall, 5,820 EC patients from 15 studies were pooled in the meta-analysis: SLN group (N = 2,152, 37.0%), LND group (N = 3,668, 63.0%). In meta-analysis of blood loss, SLN offered advantage over LND in reducing operation bleeding (I = 74%, P<0.01). Z-curve of blood loss crossed trial sequential monitoring boundaries though did not reach TSA sample size. There was no difference between SLN and LND in intra-operative complications (I = 7%, P = 0.12). SLN was superior to LND in detecting positive pelvic nodes (P-LN) (I = 36%, P<0.001), even in high risk patients (I = 36%, P = 0.001). While no difference was observed in detection of positive para-aortic nodes (PA-LN) (I = 47%, P = 0.76), even in high risk patients (I = 62%, P = 0.34). Analysis showed no difference between two groups in the number of resected pelvic nodes (I = 99%, P = 0.26). SLN was not associated with a statistically significant overall survival (I = 79%, P = 0.94). There was no difference in progression-free survival between SLN and LND (I = 52%, P = 0.31). No difference was observed in recurrence. Based on the GRADE assessment, we considered the quality of current evidence to be moderate for P-LN biopsy, low for items like blood loss, PA-LN positive.
CONCLUSION
The present meta-analysis underlines that SLN is capable of reducing blood loss during operation in regardless of surgical approach with firm evidence from TSA. SLN mapping is more targeted for less node dissection and more detection of positive lymph nodes even in high risk patients with conclusive evidence from TSA. Utility of SLN yields no survival detriment in EC patients.
PubMed: 33520696
DOI: 10.3389/fonc.2020.580128 -
Deutsches Arzteblatt International Nov 2021Approximately 4380 cases of cervical carcinoma were diagnosed in Germany in 2016. In women who had not participated in early detection programs, cervical carcinoma was...
BACKGROUND
Approximately 4380 cases of cervical carcinoma were diagnosed in Germany in 2016. In women who had not participated in early detection programs, cervical carcinoma was usually already in an advanced stage at the time of diagnosis. Certified structures for care in conformity with the existing guidelines are available.
METHODS
The new German clinical practice guideline was revised with the participation of 50 medical societies under the expert guidance of the Guideline Program in Oncology, which includes the German Association of the Scientific Medical Societies (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). A systematic literature review was conducted. Systematic reviews, meta-analyses, and randomized controlled trials (RCTs) were considered.
RESULTS
The histologic tumor stage and lymph-node stage are essential determinants of the treatment strategy. The main innovation regarding surgical treatment is the revival of open hysterectomy (overall survival [minimally invasive vs open hysterectomy]: 94.04% vs 99.4%; hazard ratio [HR]: 6.00; 95% confidence interval [1.77; 20.30]). In addition, for tumors measuring 2 cm or less, sentinel node biopsy is recommended rather than radical pelvic lymphadenectomy. MRI-guided brachytherapy is an oblig atory component of radiochemotherapy (overall survival [radiochemotherapy with vs without brachytherapy]: 58.2% vs 46.2%, p<0.001). The standard palliative treatment consists of bevacizumab combined with a platinum-containing agent (overall survival: HR: 0.77 [0.62; 0.95]; p = 0.007).
CONCLUSION
Despite the introduction of new treatments, the outcome of patients with advanced cervical carcinoma has not much improved. In the surgical treatment of cervical carcinoma, the open approach is now favored. The sentinel node biopsy technique has become well established for the surgical staging of small tumors. Controlled trials are needed so that the outcome of women with cervical carcinoma, particularly in its advanced and metastatic stages, can be improved.
Topics: Aftercare; Carcinoma; Female; Humans; Hysterectomy; Lymph Node Excision; Neoplasm Staging; Uterine Cervical Neoplasms
PubMed: 34755595
DOI: 10.3238/arztebl.m2021.0352 -
Annals of Coloproctology Feb 2022The surgical treatment of advanced low rectal cancer remains controversial. Extended lymphadenectomy (EL) is the preferred option in the East, especially in Japan, while...
PURPOSE
The surgical treatment of advanced low rectal cancer remains controversial. Extended lymphadenectomy (EL) is the preferred option in the East, especially in Japan, while neoadjuvant radiotherapy is the treatment of choice in the West. This review was undertaken to review available evidence supporting each of the therapies.
METHODS
All studies looking at EL were included in this review. A comprehensive search was conducted as per PRISMA guidelines. Primary outcome was defined as 5-year overall survival, with secondary outcomes including 3-year overall survival, 3- and 5-year disease-free survival, length of operation, and number of complications.
RESULTS
Thirty-one studies met the inclusion criteria. There was no significant publication bias. There was statistically significant difference in 5-year survival for patient who underwent EL (odds ratio, 1.34; 95 confidence interval, 0.09-0.5; P=0.006). There were no differences noted in secondary outcomes except for length of the operations.
CONCLUSION
There is evidence supporting EL in rectal cancer; however, it is difficult to interpret and not easily transferable to a Western population. Further research is necessary on this important topic.
PubMed: 34788526
DOI: 10.3393/ac.2021.00703.0100 -
Oncotarget Jul 2017Endometrial cancer is the most frequent tumor in the female reproductive system, while the sentinel lymph node (SLN) mapping for diagnostic efficacy of endometrial... (Meta-Analysis)
Meta-Analysis Review
Endometrial cancer is the most frequent tumor in the female reproductive system, while the sentinel lymph node (SLN) mapping for diagnostic efficacy of endometrial cancer is still controversial. This meta-analysis was conducted to evaluate the diagnostic value of SLN in the assessment of lymph nodal involvement in endometrial cancer. Forty-four studies including 2,236 cases were identified. The pooled overall detection rate was 83% (95% CI: 80-86%). The pooled sensitivity was 91% (95% CI: 87-95%). The bilateral pelvic node detection rate was 56% (95% CI: 48-64%). Use of indocyanine green (ICG) increased the overall detection rate to 93% (95% CI: 89-96%) and robotic-assisted surgery also increased the overall detection rate to 86% (95% CI: 79-93%). In summary, our meta-analysis provides strong evidence that sentinel node mapping is an accurate and feasible method that performs well diagnostically for the assessment of lymph nodal involvement in endometrial cancer. Cervical injection, robot-assisted surgery, as well as using ICG, optimized the sensitivity and detection rate of the technique. Sentinel lymph mapping may potentially leading to a greater utilization by gynecologic surgeons in the future.
Topics: Endometrial Neoplasms; Female; Humans; Reproducibility of Results; Sensitivity and Specificity; Sentinel Lymph Node; Sentinel Lymph Node Biopsy
PubMed: 28410225
DOI: 10.18632/oncotarget.16662 -
Minerva Urologica E Nefrologica = the... Aug 2018To date, bilateral pelvic lymph node dissection (PLND) represents the most accurate and reliable staging procedure for the detection of lymph node invasion in prostate... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
To date, bilateral pelvic lymph node dissection (PLND) represents the most accurate and reliable staging procedure for the detection of lymph node invasion in prostate cancer and bladder cancer. However, the procedure is not devoid of complications. In this field, Indocyanine green fluorescence-guided sentinel lymph node (SLN) identification is an emerging and promising technique, as accurate staging of urologic cancer could be enhanced by a thorough evaluation of the sentinel lymph nodes. Aim of the present review is to analyze available evidence and perform a metanalysis on ICG-guided SLN detection for urologic malignancies.
EVIDENCE ACQUISITION
A systematic review to assess the clinical value of Indocyanine green for the identification of sentinel lymphatic drainage for bladder, prostate, kidney and penile cancers was undertaken, with a meta-analysis to generate pooled detection rate concerning patients (clinical sensitivity) and nodes basin (technical sensitivity) separately. Studies reporting on the use of Indocyanine green for the detection of SLNs from the bladder, prostate and penile cancers were included.
EVIDENCE SYNTHESIS
A total of 10 clinical trials were included. Using the fixed effects model and the random effects model, the pooled patient detection rates and their 95% confidence intervals (95% CI) were 0.88 (0.82-0.92) and 0.92 (0.84-0.96), respectively. The pooled nodes detection rates were 0.71 (95% CI: 0.68-0.74) using the fixed effect model and 0.75 (95% CI: 0.56-0.87) using the random effect model. Significant heterogeneities existed among studies for patients and for nodes (I2=0.66, P<0.001 and I2=0.96, P<0.001, respectively). Significant publication bias was found in patient detection rate (P<0.001) and in nodes detection rate (P<0.001).
CONCLUSIONS
SLN mapping in bladder and prostate cancer is a method with a high detection rate, although its specificity to predict LN invasion remains poor. Large, well-constructed trails are needed to assess the impact of ICG-fluorescence guided SLN dissection on uro-oncologic surgery.
Topics: Coloring Agents; Humans; Indocyanine Green; Lymphatic Metastasis; Sentinel Lymph Node Biopsy; Urologic Neoplasms
PubMed: 29241310
DOI: 10.23736/S0393-2249.17.02932-0 -
The Cochrane Database of Systematic... Jun 2021Pelvic lymphadenectomy provides prognostic information for those diagnosed with endometrial (womb) cancer and provides information that may influence decisions regarding... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Pelvic lymphadenectomy provides prognostic information for those diagnosed with endometrial (womb) cancer and provides information that may influence decisions regarding adjuvant treatment. However, studies have not shown a therapeutic benefit, and lymphadenectomy causes significant morbidity. The technique of sentinel lymph node biopsy (SLNB), allows the first draining node from a cancer to be identified and examined histologically for involvement with cancer cells. SLNB is commonly used in other cancers, including breast and vulval cancer. Different tracers, including colloid labelled with radioactive technetium-99, blue dyes, e.g. patent or methylene blue, and near infra-red fluorescent dyes, e.g. indocyanine green (ICG), have been used singly or in combination for detection of sentinel lymph nodes (SLN).
OBJECTIVES
To assess the diagnostic accuracy of sentinel lymph node biopsy (SLNB) in the identification of pelvic lymph node involvement in women with endometrial cancer, presumed to be at an early stage prior to surgery, including consideration of the detection rate.
SEARCH METHODS
We searched MEDLINE (1946 to July 2019), Embase (1974 to July 2019) and the relevant Cochrane trial registers.
SELECTION CRITERIA
We included studies that evaluated the diagnostic accuracy of tracers for SLN assessment (involving the identification of a SLN plus histological examination) against a reference standard of histological examination of removed pelvic +/- para-aortic lymph nodes following systematic pelvic +/- para-aortic lymphadenectomy (PLND/PPALND) in women with endometrial cancer, where there were sufficient data for the construction of two-by-two tables.
DATA COLLECTION AND ANALYSIS
Two review authors (a combination of HN, JM, NW, RG, and WH) independently screened titles and abstracts for relevance, classified studies for inclusion/exclusion and extracted data. We assessed the methodological quality of studies using the QUADAS-2 tool. We calculated the detection rate as the arithmetic mean of the total number of SLNs detected out of the total number of women included in the included studies with the woman as the unit of analysis, used univariate meta-analytical methods to estimate pooled sensitivity estimates, and summarised the results using GRADE.
MAIN RESULTS
The search revealed 6259 unique records after removal of duplicates. After screening 232 studies in full text, we found 73 potentially includable records (for 52 studies), although we were only able to extract 2x2 table data for 33 studies, including 2237 women (46 records) for inclusion in the review, despite writing to trial authors for additional information. We found 11 studies that analysed results for blue dye alone, four studies for technetium-99m alone, 12 studies that used a combination of blue dye and technetium-99m, nine studies that used indocyanine green (ICG) and near infra-red immunofluorescence, and one study that used a combination of ICG and technetium-99m. Overall, the methodological reporting in most of the studies was poor, which resulted in a very large proportion of 'unclear risk of bias' ratings. Overall, the mean SLN detection rate was 86.9% (95% CI 82.9% to 90.8%; 2237 women; 33 studies; moderate-certainty evidence). In studies that reported bilateral detection the mean rate was 65.4% (95% CI 57.8% to 73.0%) . When considered according to which tracer was used, the SLN detection rate ranged from 77.8% (95% CI 70.0% to 85.6%) for blue dye alone (559 women; 11 studies; low-certainty evidence) to 100% for ICG and technetium-99m (32 women; 1 study; very low-certainty evidence). The rates of positive lymph nodes ranged from 5.2% to 34.4% with a mean of 20.1% (95% CI 17.7% to 22.3%). The pooled sensitivity of SLNB was 91.8% (95% CI 86.5% to 95.1%; total 2237 women, of whom 409 had SLN involvement; moderate-certainty evidence). The sensitivity for of SLNB for the different tracers were: blue dye alone 95.2% (95% CI 77.2% to 99.2%; 559 women; 11 studies; low-certainty evidence); Technetium-99m alone 90.5% (95% CI 67.7% to 97.7%; 257 women; 4 studies; low-certainty evidence); technetium-99m and blue dye 91.9% (95% CI 74.4% to 97.8%; 548 women; 12 studies; low-certainty evidence); ICG alone 92.5% (95% CI 81.8% to 97.1%; 953 women; 9 studies; moderate-certainty evidence); ICG and blue dye 90.5% (95% CI 63.2.6% to 98.1%; 215 women; 2 studies; low-certainty evidence); and ICG and technetium-99m 100% (95% CI 63% to 100%; 32 women; 1 study; very low-certainty evidence). Meta-regression analyses found that the sensitivities did not differ between the different tracers used, between studies with a majority of women with FIGO stage 1A versus 1B or above; between studies assessing the pelvic lymph node basin alone versus the pelvic and para-aortic lymph node basin; or between studies that used subserosal alone versus subserosal and cervical injection. It should be noted that a false-positive result cannot occur, as the histological examination of the SLN is unchanged by the results from any additional nodes removed at systematic lymphadenectomy.
AUTHORS' CONCLUSIONS
The diagnostic test accuracy for SLNB using either ICG alone or a combination of a dye (blue or ICG) and technetium-99m is probably good, with high sensitivity, where a SLN could be detected. Detection rates with ICG or a combination of dye (ICG or blue) and technetium-99m may be higher. The value of a SLNB approach in a treatment pathway, over adjuvant treatment decisions based on uterine factors and molecular profiling, requires examination in a high-quality intervention study.
Topics: Coloring Agents; Endometrial Neoplasms; Female; Fluorescent Antibody Technique; Humans; Indocyanine Green; Lymph Node Excision; Lymph Nodes; Pelvis; Radioactive Tracers; Sentinel Lymph Node Biopsy; Spectroscopy, Near-Infrared; Technetium
PubMed: 34106467
DOI: 10.1002/14651858.CD013021.pub2 -
Journal of Clinical Medicine Mar 2024Endometrial cancer is the most incident gynecological cancer. Lymph node dissemination is one of the most important factors for the patient's prognosis. Pelvic lymph... (Review)
Review
Endometrial cancer is the most incident gynecological cancer. Lymph node dissemination is one of the most important factors for the patient's prognosis. Pelvic lymph nodes are the primary site of extra-uterine dissemination in endometrial cancer (EC), setting the 5-year survival to 44-52%. It is standard practice for radiation therapy (RT) and/or chemotherapy (CTX) to be given as adjuvant treatments to prevent the progression of micrometastases. Also, administration of EC patients with RT and/or CTX regimens before surgery may decrease micrometastases, hence the need for lymphadenectomy. The primary aim of the systematic review and meta-analysis is to assess whether adjuvant RT and/or CTX improve oncological outcomes through the management of micrometastases and nodal recurrence. We performed systematic research using the string "Endometrial Neoplasms" [Mesh] AND "Lymphatic Metastasis/therapy" [Mesh]. The methods for this study were specified a priori based on the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Outcomes were 5-year overall survival, progression-free survival, recurrence rate, and complications rate. We assessed the quality of studies using the Newcastle-Ottawa Scale (NOS). A total of 1682 patients with stage I-to-IV EC were included. Adjuvant treatment protocols involved external-beam RT, brachytherapy, and CTX either alone or in combination. The no-treatment group showed a non-statistically significant higher recurrence risk than any adjuvant treatment group (OR 1.39 [95% CI 0.68-2.85] = 0.36). The no-treatment group documented a non-statistically significant higher risk of death than those who underwent any adjuvant treatment (RR 1.47 [95% CI 0.44-4.89] = 0.53; I2 = 55% = 0.000001). Despite the fact that early-stage EC may show micrometastases, adjuvant treatment is not significantly associated with better survival outcomes, and the combination of EBRT and CTX is the most valid option in the early stages.
PubMed: 38592342
DOI: 10.3390/jcm13051496 -
Gynecologic Oncology Mar 2022Accurate staging of para-aortic nodal status in cervical cancer is of great importance for individualizing treatment and impacting outcomes. Three-dimensional imaging... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Accurate staging of para-aortic nodal status in cervical cancer is of great importance for individualizing treatment and impacting outcomes. Three-dimensional imaging (i.e. PET, CT, MRI) may miss para-aortic lymph node (PALN) metastases. The aim of this study was to systematically review and meta-analyze the proportion of upstaging by PALN dissection in patients with locally advanced cervical cancer without suspicious PALNs on imaging.
METHODS
PubMed/MEDLINE and Embase were systematically searched. The analysis included diagnostic studies that reported on 3D imaging and pre-therapeutic surgical assessment of PALN status in patients with cervical cancer. An overall pooled upstaging rate was calculated using a random-effects model.
RESULTS
The search identified 16 eligible studies including 18 cohorts with a total of 1530 patients. Pooling of 12 cohorts demonstrated an upstaging rate of 12% (95% confidence interval [CI] 10-15%) by PALN dissection after negative PET or PET-CT. Pooling of 6 cohorts demonstrated a pooled upstaging rate of 11% (95% CI: 8-16%) by PALN dissection after negative MRI or CT. No significant heterogeneity in upstaging proportions across cohorts was observed (I = 0% and 27%, respectively). In 7 cohorts including only patients with pelvic nodal metastases on imaging (but no suspicion of PALN involvement) a pooled upstaging rate by PALN dissection of 21% (95% CI: 17-26%) was found (I = 0%).
CONCLUSIONS
This meta-analysis demonstrates that in case of no suspicious PALN on PET-CT or MRI, PALN dissection still identifies lymph node metastases in a considerable amount of patients with locally advanced cervical cancer and especially in those patients with confirmed pelvic nodal metastases.
Topics: Female; Humans; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Neoplasm Staging; Positron Emission Tomography Computed Tomography; Uterine Cervical Neoplasms
PubMed: 34969533
DOI: 10.1016/j.ygyno.2021.12.026 -
International Journal of Surgery... Dec 2018Trans-anal total mesorectal resection (TaTME) is a novel approach for rectal cancer. However, the perioperative and pathological outcomes of this procedure remain... (Meta-Analysis)
Meta-Analysis
Trans-anal or trans-abdominal total mesorectal excision? A systematic review and meta-analysis of recent comparative studies on perioperative outcomes and pathological result.
BACKGROUND
Trans-anal total mesorectal resection (TaTME) is a novel approach for rectal cancer. However, the perioperative and pathological outcomes of this procedure remain controversial.
METHOD
A systematic literature search was performed using PubMed, Embase, Wanfang (China) and the Cochrane Library databases without restriction to regions or languages. We included 17 trials comparing TaTME with Laparoscopic TME (LaTME) for meta-analysis (MA). Fixed and random-effect models were used to measure the pooled estimates.
RESULTS
A total of 17 trials including 1346 patients were eligible for this MA. Pooled perioperative data using TaTME was associated with a significant reduction in estimated blood loss (WMD: 41.40, CI: 76.83 to -5.97; p = 0.02), hospital stay (WMD: 1.27, CI: 2.32 to -0.23; p = 0.02), conversion (OR: 0.28 CI: 0.15-0.52; p < 0.0001), readmission rates (OR: 0.42, CI: 0.25-0.69; p = 0.0007) and overall postoperative complications (OR: 0.73, CI: 0.56-0.95; p = 0.02). TaTME did not compromise surgical duration (WMD: 11.61, CI: 26.62-3.41; p = 0.13) or enhance complications including anastomotic leakage, ileus, urinary dysfunction, wound infection and pelvic abscess. Concerning pathological outcomes, the TaTME group demonstrated longer circumferential resection margins (CRM) (WMD: 0.91, CI: 0.58-1.24; p < 0.00001) and reduced CRM involvement (OR: 0.47, CI: 0.29-0.75; p = 0.002), whilst the distal resection margin (DRM) quality of the mesorectum and harvested lymph node were comparable.
CONCLUSION
TaTME achieves similar surgical outcomes to LaTME, with the added advantage of a safe CRMs, reduced blood loss, shorter hospital stay, lower conversion and readmission rates, and lower postoperative morbidity. Long-term oncological and functional data are now required to confirm these findings.
Topics: Female; Humans; Length of Stay; Lymph Nodes; Male; Mesocolon; Patient Readmission; Postoperative Complications; Rectal Neoplasms; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 30415089
DOI: 10.1016/j.ijsu.2018.11.003 -
Urologia Internationalis 2022Robot-assisted radical prostatectomy (RARP) including pelvic lymph node dissection (PLND) is the current state of the art in surgical therapy of localized prostate... (Meta-Analysis)
Meta-Analysis
Clinical Importance of a Peritoneal Interposition Flap to Prevent Symptomatic Lymphoceles after Robot-Assisted Radical Prostatectomy and Pelvic Lymph Node Dissection: A Systematic Review and Meta-Analysis.
BACKGROUND
Robot-assisted radical prostatectomy (RARP) including pelvic lymph node dissection (PLND) is the current state of the art in surgical therapy of localized prostate cancer with intermediate or high risk. PLND in particular is associated with morbidity inherent to this method; the rate of symptomatic lymphoceles (sLCs), for example, ranges up to 10%.
OBJECTIVE
Various intraoperative modifications have been developed with the aim of reducing the sLC rate. Based on current studies, a peritoneal interposition flap (PIF) appears to be one of the most effective methods for this purpose. Under the criteria of a systematic review, 5 retrospective studies have been identified until now, 4 of which showed a positive effect of PIF on the sLC rate.
RESULTS AND LIMITATIONS
A total of 1,308 patients were included in the aggregated analysis of these 5 studies. The amount of sLCs was 1.3% (8/604) and 5.7% (40/704) in the PIF and standard groups, respectively (p < 0.001). The resulting odds ratio (OR) was 0.23 (95% confidence interval [CI]: 0.05-0.99), taking in-to account a noteworthy heterogeneity of the 5 studies (Q = 9.47, p = 0.05; I2 = 58%). In addition, a prospective randomized and blinded study (Pianoforte trial) with corresponding sLC rates of 8.3% (9/108) versus 9.7% (12/124) (p = 0.820) exists. In this study, the OR was 0.85 (95% CI: 0.34-2.10, p = 0.722).
CONCLUSION
Despite positive results from retrospective studies with indirect evidence, the role of the PIF in the reduction of sLC in RARP could not be conclusively assessed yet. The results of the first prospective randomized study do not show a positive effect of PIF, declaring a research gap for further studies with direct evidence.
Topics: Humans; Lymph Node Excision; Lymphocele; Pelvis; Peritoneum; Postoperative Complications; Prostatectomy; Robotic Surgical Procedures; Surgical Flaps
PubMed: 33567440
DOI: 10.1159/000512960