Sentinel lymph node mapping in early-stage ovarian cancer: surgical technique in 10 steps ========================================================================================= * Nuria Agusti * Pilar Paredes * Sergi Vidal-Sicart * Ariel Glickman * Aureli Torne * Berta Díaz-Feijoo * Sentinel Lymph Node * Ovarian Cancer * Surgical Oncology Systematic pelvic and para-aortic lymphadenectomy is part of early-stage epithelial ovarian cancer staging surgery.1 Although lymph node involvement rate is only 15% (6%–30%), this procedure is associated with a potential severe morbidity with no evidence suggesting a therapeutic value. Detection of the sentinel lymph node (SLN) in patients with early-stage epithelial ovarian cancer is in an experimental phase.2 Standardization and description of the technique are the main objectives of this video article. It has been performed in the context of a clinical trial called MELISA (Mapping Sentinel Lymph Node in Initial Stages of Ovarian Cancer-[NCT05184140](http://ijgc.bmj.com/lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT05184140&atom=%2Fijgc%2F32%2F8%2F1082.atom)). We present a step-by-step video demonstration (Video 1) of the technique performed at the Hospital Clinic of Barcelona. We divided the surgical procedure into the 10 following steps: (1) selection of the patient; (2) materials; (3) radiotracer injection; (4) adnexectomy; (5) frozen section; (6) ovarian lymphatic mapping with a portable gamma camera; (7) indocyanine green injection; (8) detection of a SLN with a fluorescence camera and gamma probe; (9) excision of SLN and performance of staging surgery; (10) ultrastaging of SLN. Video 1 Sentinel lymph node mapping in early-stage ovarian cancer Unlike other gynecologic cancers, the choice of a particular tracer and the injection time remain the most controversial aspects since final diagnosis is usually done intra-operatively after the frozen section. As the 99mTc- albumin nanocolloid radiotracer remains trapped in the lymph nodes for a long period it can be injected before the adnexectomy. The injection at this time is supposed to be the ideal setting since the lymphatic pathways have not yet been disrupted. As evidence suggests that a dual method allows a better detection rate,3 4 the injection of indocyanine green is performed after confirmation of the malignancy. The small size of indocyanine green molecules causes rapid lymphatic migration and makes it difficult to accurately identify the first node, especially after a few minutes. In order to identify the first lymphatic node in real time, a lymphatic mapping is checked with the portable gamma camera (Figure 1). ![Figure 1](http://ijgc.bmj.com/https://ijgc.bmj.com/content/ijgc/32/8/1082/F2.medium.gif) [Figure 1](http://ijgc.bmj.com/content/32/8/1082/F2) Figure 1 Schematic surgical image showing the 99mTc-albumin nanocolloid injection in the utero-ovarian ligament before performing the adnexectomy In conclusion, the description of this new surgical procedure in 10 steps allows its standardization and distribution among surgical teams. ## Data availability statement All data relevant to the study are included in the article. ## Ethics statements ### Patient consent for publication Consent obtained directly from patient(s). ### Ethics approval This study involves human participants and was approved by the ethics committee of the Hospital Clinic of Barcelona (reference number HCB/2021/0130). Participants gave informed consent to participate in the study before taking part. ## Footnotes * Collaborators Investigators collaboration: Pere Fusté, Núria Carreras, Tiermes Marina, Andrea Ritsch, Jordi Ribera, Xavi Cases, Adela Saco, Jaume Ordi. * Contributors NA: Accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish. Conceptualization, video editing, surgery, and writing original draft. PP: Conceptualization, video editing collaboration, surgery, and writing original draft. SV-S: Conceptualization, project administration, surgery, and writing review. AG: Conceptualization, surgery, and writing review. AT, BD-F: conceptualization, project administration, surgery and video recording, supervision, and writing review. * Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. * Competing interests None declared. * Provenance and peer review Not commissioned; externally peer reviewed. * Accepted March 29, 2022. * © IGCS and ESGO 2022. No commercial re-use. See rights and permissions. Published by BMJ. ## References 1. Colombo N , Sessa C , du Bois A , et al . ESMO-ESGO consensus conference recommendations on ovarian cancer: pathology and molecular biology, early and advanced stages, borderline tumours and recurrent disease†. Ann Oncol 2019;30:672–705.[doi:10.1093/annonc/mdz062](http://dx.doi.org/10.1093/annonc/mdz062) pmid:http://www.ncbi.nlm.nih.gov/pubmed/31046081 [CrossRef](http://ijgc.bmj.com/lookup/external-ref?access_num=10.1093/annonc/mdz062&link_type=DOI) [PubMed](http://ijgc.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fijgc%2F32%2F8%2F1082.atom) 2. Dell'Orto F , Laven P , Delle Marchette M , et al . Feasibility of sentinel lymph node mapping of the ovary: a systematic review. Int J Gynecol Cancer 2019;29:1209–15.[doi:10.1136/ijgc-2019-000606](http://dx.doi.org/10.1136/ijgc-2019-000606) pmid:http://www.ncbi.nlm.nih.gov/pubmed/31474589 [Abstract/FREE Full Text](http://ijgc.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiaWpnYyI7czo1OiJyZXNpZCI7czo5OiIyOS83LzEyMDkiO3M6NDoiYXRvbSI7czoyMDoiL2lqZ2MvMzIvOC8xMDgyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 3. Lago V , Bello P , Montero B , et al . Sentinel lymph node technique in early-stage ovarian cancer (SENTOV): a phase II clinical trial. Int J Gynecol Cancer 2020;30:1390–6.[doi:10.1136/ijgc-2020-001289](http://dx.doi.org/10.1136/ijgc-2020-001289) pmid:http://www.ncbi.nlm.nih.gov/pubmed/32448808 [Abstract/FREE Full Text](http://ijgc.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiaWpnYyI7czo1OiJyZXNpZCI7czo5OiIzMC85LzEzOTAiO3M6NDoiYXRvbSI7czoyMDoiL2lqZ2MvMzIvOC8xMDgyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 4. Scambia G , Nero C , Uccella S , et al . Sentinel-node biopsy in early stage ovarian cancer: a prospective multicentre study (SELLY). Int J Gynecol Cancer 2019;29:1437–9.[doi:10.1136/ijgc-2019-000886](http://dx.doi.org/10.1136/ijgc-2019-000886) pmid:http://www.ncbi.nlm.nih.gov/pubmed/31601646 [Abstract/FREE Full Text](http://ijgc.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiaWpnYyI7czo1OiJyZXNpZCI7czo5OiIyOS85LzE0MzciO3M6NDoiYXRvbSI7czoyMDoiL2lqZ2MvMzIvOC8xMDgyLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==)