New horizons of sentinel lymph node technique in early ovarian cancer

Abstract

We have read with great interest the article of Uccella et al1Uccella S. Nero C. Vizza E. et al.Sentinel-node biopsy in early-stage ovarian cancer: preliminary results of a prospective multicentre study (SELLY).Am J Obstet Gynecol. 2019; 221: 324.e1-324.e10Abstract Full Text Full Text PDF Scopus (37) Google Scholar in a recent issue of the Journal. The authors presented the preliminary results of the first 31 patients enrolled in a prospective study about sentinel lymph node technique in ovarian cancer. The authors should be congratulated on their well-designed study in a novel topic that represents a new horizon of sentinel lymph node technique in gynecological cancer. Notwithstanding the aforementioned, there are some critical points that would need to be reconsidered by the authors to improve the validity of the study findings. First, the authors considered only a minimally invasive surgery approach. Nevertheless, laparotomy is the standard surgical approach recommended to treat and stage patients with apparent early-stage ovarian cancer, whereas minimally invasive surgery can be carried out for re-staging.2Colombo N. Sessa C. Bois A.D. et al.ESMO–ESGO Ovarian Cancer Consensus Conference Working Group. ESMO-ESGO consensus conference recommendations on ovarian cancer: pathology and molecular biology, early and advanced stages, borderline tumours and recurrent disease.Ann Oncol. 2019; 30: 672-705Abstract Full Text Full Text PDF PubMed Scopus (460) Google Scholar Not including open case surgery may limit the applicability of the study results. In our experience, open sentinel lymph node technique is feasible.3Lago V. Bello P. Montero B. et al.Clinical application of the sentinel lymph node technique in early ovarian cancer: a pilot study.Int J Gynecol Cancer. 2019; 29: 377-381Crossref PubMed Scopus (19) Google Scholar Our proposal gives a real clinical application to the technique, according to the actual guideline approach recommendations. Finally, the use of the indocyanine green as a single agent to detect sentinel lymph nodes may have influenced the sentinel lymph node detection rate, lower than previously reported.3Lago V. Bello P. Montero B. et al.Clinical application of the sentinel lymph node technique in early ovarian cancer: a pilot study.Int J Gynecol Cancer. 2019; 29: 377-381Crossref PubMed Scopus (19) Google Scholar The combined use of technetium99m nanocolloid and indocyanine green may be key to achieving an accurate detection rate. The results of the clinical trial NCT03452982, which will be published soon, will shed light on this particular issue. We also agree that it is a challenging procedure that cannot be easily be embraced at any center. The authors stablished an objective of 176 patients to be enrolled. One important fact to be considered is that most of early ovarian carcinomas are not high-grade tumors, thereby presenting a lower rate of lymph node metastasis.4Lago V. Minig L. Fotopoulou C. Incidence of lymph node metastases in apparent early-stage low-grade epithelial ovarian cancer: a comprehensive review.Int J Gynecol Cancer. 2016; 26: 1407-1414Crossref PubMed Scopus (27) Google Scholar This fact may condition the estimated number of patients needed. As the authors mention, the only way to achieve this sample is by performing a multicenter study. As far as we are concerned, our group will be pleased to collaborate with the Uccella et al clinical trial and to contribute to the findings of this important study. Sentinel-node biopsy in early-stage ovarian cancer: preliminary results of a prospective multicentre study (SELLY)American Journal of Obstetrics & GynecologyVol. 221Issue 4PreviewSystematic 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. Full-Text PDF ReplyAmerican Journal of Obstetrics & GynecologyVol. 222Issue 1PreviewWe thank Dr. Lago and Dr. Domingo for their insightful comments regarding the preliminary results of the SELLY trial.1 They show their sincere interest in our prospective experience. Moreover, they suggest 2 possible amendments to the study protocol, namely, the inclusion of open surgery and the incorporation of Tc99 as a second tracer to detect sentinel nodes (SNs), with the purpose of increasing the overall detection rate. Full-Text PDF