title: The sentinel node procedure in early stage cervical cancer, taking the next step; a diagnostic review.
abstract: OBJECTIVE
  Recent reviews on the sentinel lymph node (SLN) procedure in cervical cancer have shown that bilateral SLN detection and ultra staging are safe and superior options compared to a unilateral detection, frozen section and H&E analysis. So far, nobody identified a subgroup of patients in whom a SLN procedure may replace pelvic lymph node dissection (PLND).
  
  
  METHODS
  We searched PubMed, Embase, CINAHL and Cochrane from inception up to November 26, 2014. Studies reporting SLN detection, and/or histological outcome of the SLN were included. Methodological quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool by two independent reviewers. Data to complete 2×2 contingency tables were obtained, and patient-, study- and technique characteristics were extracted. Results were pooled and plotted in forest plots.
  
  
  RESULTS
  Forty-seven studies (4130 patients) were analyzed. Pooled data of diagnostic accuracy on ultra staging (18 studies; 1275 patients) showed a sensitivity of 94% (95% CI 80-99%) and negative predictive values ranging between 91 and 100%. After ultra staging, 19 false negative results remained. Prerequisites such as early FIGO stage (IA2, IB1, IIA primary tumor size <40mm), no suspicious pre-, and per-operative lymph nodes, and bilateral negative SLNs after ultra staging resulted in 1 remaining false negative result among 1257 patients (0.08%). Pooled data on a combined tracer in early stage cervical cancer patients with primary tumor size <20mm (6 studies; 276 patients) resulted in 87% bilateral SLN detection.
  
  
  CONCLUSIONS
  Early stage cervical cancer patients (FIGO IA2, IB1, IIA primary tumor size <40mm) who have no suspicious pre-, and per-operative lymph nodes, and have bilateral negative SLNs after ultra staging, have a residual risk of 0.08% (1/1257) on occult metastases. On the basis of these results we recommend not to perform a full PLND in these patients.
authors.affiliation: Radboud University Medical Centre, Radboudumc Institute for Health Sciences, Department of Operating Rooms, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands. Electronic address: Casper.Tax@radboudumc.nl.
authors.forename: Casper
authors.initials: C
authors.lastname: Tax
authors.affiliation: Radboud University Medical Centre, Radboudumc Institute for Health Sciences, Department of Operating Rooms, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands; Radboud University Medical Centre, Radboudumc Institute for Health Sciences, Department of Health Evidence, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands.
authors.forename: Maroeska M
authors.initials: MM
authors.lastname: Rovers
authors.affiliation: Radboud University Medical Centre, Radboudumc Institute for Health Sciences, Department of Gynaecology, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands.
authors.forename: Corine
authors.initials: C
authors.lastname: de Graaf
authors.affiliation: Radboud University Medical Centre, Radboudumc Institute for Health Sciences, Department of Gynaecology, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands.
authors.forename: Petra L M
authors.initials: PL
authors.lastname: Zusterzeel
authors.affiliation: Radboud University Medical Centre, Radboudumc Institute for Health Sciences, Department of Gynaecology, P.O. Box 9101, 6500 HB Nijmegen, the Netherlands.
authors.forename: Ruud L M
authors.initials: RL
authors.lastname: Bekkers
mesh_terms: D005188:False Negative Reactions; D005260:Female; D006801:Humans; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology* / Q000601:surgery; D008207:Lymphatic Metastasis; D009367:Neoplasm Staging; D010388:Pelvis; D011237:Predictive Value of Tests; D021701:Sentinel Lymph Node Biopsy; D002583:Uterine Cervical Neoplasms / Q000473:pathology*
keywords: Cervical cancer; Diagnostic accuracy; Diagnostic review; Sentinel node; Systematic review