title: Detection of lymph node metastases by gadolinium-enhanced magnetic resonance imaging: systematic review and meta-analysis.
abstract: BACKGROUND
  Gadolinium-based contrast agents are used with magnetic resonance imaging (MRI) to highlight tumor vascularity in organs. They are also widely used for primary tumor visualization. We conducted a systematic review and meta-analysis of the existing evidence of the accuracy of gadolinium-enhanced MRI for staging lymph node metastases.
  
  
  METHODS
  We systematically searched the MEDLINE, Cochrane, CANCERLIT, and EMBASE databases for studies published in English or German from January 1, 1988, to January 1, 2008, that assessed the diagnostic accuracy of gadolinium-enhanced MRI in the evaluation of lymphatic metastases compared with histopathologic examination as the reference test. Based on a priori-defined clinical considerations, we studied three subgroups of studies: those that used a single malignancy criterion and those that used multiple malignancy criteria with or without contrast highlighting. Summaries of MRI sensitivity and specificity for detecting lymph node metastases were calculated using a bivariate regression model. All statistical tests were two-sided.
  
  
  RESULTS
  The literature search yielded 43 full-text papers that were considered for inclusion in the meta-analysis. We performed quantitative pooled analyses on the 32 studies that provided data on patient-level diagnosis. The weighted estimates of sensitivity and specificity for all studies combined were 0.72 (95% confidence interval [CI] = 0.66 to 0.79) and 0.87 (95% CI = 0.82 to 0.91). Estimates of sensitivity and specificity were essentially unchanged for studies that used a single malignancy criterion (0.71 [95% CI = 0.61 to 0.79] and 0.88 [95% CI = 0.80 to 0.93], respectively; n = 11 studies) or multiple malignancy criteria without contrast enhancement (0.70 [95% CI = 0.58 to 0.79] and 0.86 [95% CI = 0.68 to 0.94], respectively; n = 6 studies). The sensitivity increased to 0.84 (95% CI = 0.70 to 0.92), with a specificity of 0.82 (95% CI = 0.72 to 0.89) for the nine studies that incorporated contrast enhancement in their multiple malignancy criteria. Six studies did not define the malignancy criteria they used.
  
  
  CONCLUSIONS
  The overall accuracy of gadolinium-enhanced magnetic resonance imaging for the detection of nodal metastases is moderate. Incorporating contrast enhancement in the malignancy criteria substantially improves the accuracy of this diagnostic test.
authors.affiliation: Department of Gynecology and Obstetrics, University Medical Center Utrecht, Utrecht, The Netherlands. w.klerkx@umcutrecht.nl
authors.forename: Wenche M
authors.initials: WM
authors.lastname: Klerkx
authors.forename: Leon
authors.initials: L
authors.lastname: Bax
authors.forename: Wouter B
authors.initials: WB
authors.lastname: Veldhuis
authors.forename: A Peter M
authors.initials: AP
authors.lastname: Heintz
authors.forename: Willem PthM
authors.initials: WP
authors.lastname: Mali
authors.forename: Petra H M
authors.initials: PH
authors.lastname: Peeters
authors.forename: Karel G M
authors.initials: KG
authors.lastname: Moons
mesh_terms: D015986:Confounding Factors, Epidemiologic; D003287:Contrast Media; D005682:Gadolinium; D006801:Humans; D008198:Lymph Nodes / Q000473:pathology*; D008207:Lymphatic Metastasis / Q000175:diagnosis*; D008279:Magnetic Resonance Imaging / Q000379:methods; D016017:Odds Ratio; D012680:Sensitivity and Specificity
chemical_list: D003287:Contrast Media; D005682:Gadolinium