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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).
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.
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).
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
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.