Article Text

other Versions

Download PDFPDF
Ultrastaging methods of sentinel lymph nodes in endometrial cancer – a systematic review
  1. Lara C Burg1,
  2. Ellen M Hengeveld1,
  3. Joanna in 't Hout2,
  4. Johan Bulten3,
  5. Peter Bult3 and
  6. Petra L M Zusterzeel1
  1. 1Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Netherlands
  2. 2Department of Health Evidence, Section Biostatistics, Radboud University Medical Center, Nijmegen, Netherlands
  3. 3Department of Pathology, Radboud University Medical Center, Nijmegen, Netherlands
  1. Correspondence to Ms Lara C Burg, Radboudumc, Nijmegen, The Netherlands; lara.burg{at}


Objective Sentinel lymph node mapping has emerged as an alternative to lymphadenectomy in evaluating the lymph node status in endometrial cancer. Several pathological methods to examine the sentinel lymph node are applied internationally. The aim of this study was to determine the value of ultrastaging and to assess the ultrastaging method with the highest detection rate of metastases.

Methods A systematic review was conducted. Inclusion criteria were: pathologically-confirmed endometrial cancer with sentinel lymph node mapping, report of the histological outcomes, metastases found by hematoxylin and eosin staining and metastases found by ultrastaging were separately mentioned, and description of the ultrastaging method. The primary outcome was the detection of metastases found by ultrastaging that were not detected by routine hematoxylin and eosin staining. The secondary outcome was the difference in detection rate of metastases between several ultrastaging methods. Random effects meta-analyses were conducted.

Results Fifteen studies were selected, including 2259 patients. Sentinel lymph nodes were examined by routine hematoxylin and eosin staining. Subsequently, multiple ultrastaging methods were used, with differences in macroscopic slicing (bread-loaf/longitudinal), number of microscopic slides, and distance between slides, but all used immunohistochemistry. A positive sentinel lymph node was found in 14% of patients. In 37% of these, this was detected only by ultrastaging. Using more ultrastaging slides did not result in a higher detection rate. Bread-loaf slicing led to a higher detection rate compared with longitudinal slicing (mean detection rates 53% and 33%, respectively).

Conclusion Pathological ultrastaging after routine hematoxylin and eosin staining in endometrial cancer patients has led to an increased detection rate of sentinel lymph node metastases. Different ultrastaging methods are used, with a preference for bread-loaf slicing. However, due to the large heterogeneity of the studies, assessing which ultrastaging method has the highest detection rate of sentinel lymph node metastases was not possible.

  • gynecologic surgical procedures
  • pathology
  • endometrial neoplasms

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • LCB and EMH are joint first authors.

  • Contributors PZ conceived of the presented idea. LB and EH performed data extraction. JH performed data analysis in collaboration with LB and EH. LB and EH contributed to the interpretation of the results and the writing of the manuscript. All authors provided critical feedback and helped shape the research, analysis, and manuscript.

  • 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.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.