Sentinel Node Detection in Clinical Early Stage Ovarian Cancer
Phase: NA
Conditions: Ovarian Cancer, Sentinel Node
Sponsor: Maastricht University Medical Center

Sentinel node in ovarian cancer 
 
The SONAR study 
 
 
(Sentinel nOde iN ovArian canceR) 
 
 
 
 
 
 
 
 
M. Kleppe1, T. Van Gorp1,2, B.F.M. Slangen1,2, A.J. Kruse1,2, B. Brans3, R.F.P.M. 
Kruitwagen1,2 
 
1.  
Maastricht University Medical Centre, Department of Obstetrics and Gynecology, 
Maastricht, The Netherlands  
2.  
GROW, School for Oncology and Developmental Biology, Maastricht, The 
Netherlands 
3. 
 Maastricht University Medical Centre, Department of Nuclear Medicine, Maastricht, 
The Netherlands 
 
 
 
 
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S   NAR

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PROTOCOL TITLE Sentinel node in ovarian cancer 
 
Protocol ID 
NL40323.068.12 
Short title 
SONAR 
Version 
5 
Date 
May 2013 
Coordinating investigator/project 
leader 
 
R.F.P.M. Kruitwagen 
MaastrichtUniversityMedicalCentre, PO Box 5800, 6202 AZ 
Maastricht, The Netherlands.  
Fax: +31 43 3874765.   
E-mail address: r.kruitwagen@mumc.nl 
Principal investigator(s) (in 
Dutch: 
hoofdonderzoeker/uitvoerder) 
Multicenter research: per site 
M. Kleppe 
marjoleinkleppe@hotmail.com 
 
 
Sponsor (in Dutch: 
verrichter/opdrachtgever) 
Not applicable 
 
 
Independent physician(s) 
L. Lutgens (radiotherapy oncologist) 
l.lutgens@mumc.nl 
 
 
 
 
Nuclear medicine 
B. Brans 
b.brans@mumc.nl 
 
 
 
 
Pharmacy <if applicable> 
Not applicable 
 
 
 
 
 
 
 

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PROTOCOL SIGNATURE SHEET 
 
Name 
Signature 
Date 
Sponsor or legal representative: 
NA 
 
For non-commercial research, 
Head of Department: 
J.G. Nijhuis 
MaastrichtUniversityMedicalCentre, PO Box 5800, 
6202 AZ Maastricht, The Netherlands.  
Fax: +31 43 3874765.   
E-mail address: jg.nijhuis@mumc.nl 
 
 
 
Coordinating Investigator/Project 
leader/Principal Investigator: 
R.F.P.M. Kruitwagen 
MaastrichtUniversityMedicalCentre, PO Box 5800, 
6202 AZ Maastricht, The Netherlands.  
Fax: +31 43 3874764. 
E-mail address: r.kruitwagen@mumc.nl 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Table of contents 
1. INTRODUCTION AND RATIONALE .......................................................................................................... 8 
EPIDEMIOLOGY ................................................................................................................................................. 8 
BACKGROUND .................................................................................................................................................... 8 
STAGING ............................................................................................................................................................. 8 
THE CLINICAL SIGNIFICANCE OF STAGING ....................................................................................................... 9 
METHODS FOR IDENTIFICATION OF LYMPH NODE METASTASES ..................................................................... 9 
CONCLUSION .................................................................................................................................................... 11 
2. OBJECTIVES ................................................................................................................................................. 11 
PRIMARY OBJECTIVE .......................................................................................................................................... 11 
SECONDARY OBJECTIVE(S) ............................................................................................................................. 12 
3. STUDY DESIGN ............................................................................................................................................. 12 
4. STUDY POPULATION .................................................................................................................................. 12 
POPULATION (BASE) ........................................................................................................................................ 12 
INCLUSION CRITERIA ....................................................................................................................................... 12 
EXCLUSION CRITERIA ...................................................................................................................................... 13 
SAMPLE SIZE CALCULATION ........................................................................................................................... 13 
5. METHODS ...................................................................................................................................................... 13 
MAIN STUDY PARAMETER ............................................................................................................................... 13 
SECONDARY STUDY PARAMETERS ................................................................................................................... 14 
STUDY PROCEDURES ........................................................................................................................................ 15 
WITHDRAWAL OF INDIVIDUAL SUBJECTS AND REPLACEMENT ...................................................................... 19 
FOLLOW-UP OF SUBJECTS WITHDRAWN FROM TREATMENT ......................................................................... 19 
PREMATURE TERMINATION OF THE STUDY .................................................................................................... 19 
6. SAFETY REPORTING .................................................................................................................................. 21 
SECTION 10 WMO EVENT ............................................................................................................................... 21 
ADVERSE AND SERIOUS ADVERSE EVENTS ...................................................................................................... 21 
FOLLOW-UP OF ADVERSE EVENTS ................................................................................................................... 22 
DATA SAFETY MONITORING BOARD (DSMB) ................................................................................................ 22 
7. STATISTICAL ANALYSIS ........................................................................................................................... 22 
DESCRIPTIVE STATISTICS ................................................................................................................................ 22 
INTERIM ANALYSIS. ......................................................................................................................................... 23 
8. ETHICAL CONSIDERATIONS ................................................................................................................... 23 
REGULATION STATEMENT ............................................................................................................................... 23 
RECRUITMENT AND CONSENT ......................................................................................................................... 23 
OBJECTION BY MINORS OR INCAPACITATED SUBJECTS (IF APPLICABLE) ..................................................... 23 
BENEFITS AND RISKS ASSESSMENT, GROUP RELATEDNESS ............................................................................ 23 
COMPENSATION FOR INJURY........................................................................................................................... 24 
9. ADMINISTRATIVE ASPECTS AND PUBLICATION ............................................................................. 24 
HANDLING AND STORAGE OF DATA AND DOCUMENTS.................................................................................... 24 
ANNUAL PROGRESS REPORT ............................................................................................................................ 24 
END OF STUDY REPORT .................................................................................................................................... 25 
PUBLIC DISCLOSURE AND PUBLICATION POLICY ............................................................................................ 25 
10. REFERENCES .............................................................................................................................................. 25 
 
 

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List of abbreviations and relevant definitions 
EOC  
Epithelial ovarian cancer 
FIGO   
International Federation of Gynecology and Obstetrics 
SAE 
 
Serious adverse event 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Summary 
 
Rationale: 
As most cancers, ovarian cancer also spreads to regional lymph nodes. The concept of 
sentinel lymph node surgery is to see whether the cancer has spread to the very first lymph 
node or sentinel node. If the sentinel node does not contain cancer, then there is a high 
likelihood that the cancer has not spread to other lymph nodes. This means that, at least 
theoretically, a radical lymphadenectomy could be omitted and thus the associated morbidity. 
The sentinel node technique has been proven to be effective in other cancers such as breast 
cancer and malignant melanoma. In the gynaecological field it has been shown to be effective 
in vulvar cancer. Currently sentinel node studies are done for cervix and uterine cancer.  
Objective:  
1) To determine whether or not a sentinel node procedure in patients with ovarian cancer 
is feasible when the tracers are injected in the ovarian ligaments. 
2) To determine the anatomical localisations of the sentinel nodes. 
3) To determine the incidence of false negative sentinel nodes. 
Study design: phase I feasibility study. 
Study population: the following patients will be included: 
-  Patients with a high suspicion of an ovarian malignancy in whom a median laparotomy and 
a frozen section analysis is planned. 
- Patients with endometrial cancer in whom a staging laparotomy is planned.  
Intervention (if applicable): After opening the abdomen, before starting the surgical staging 
procedure, blue dye and the radioactive-colloid will be injected in the ligamentum ovarium 
proprium and the ligamentum infundibulo-pelvicum. This will be done on the ovary with 
suspicion of malignancy (patients with an ovarian tumour) or one of the normal ovaries 
(patients with endometrial cancer).  
Main study parameters: percentage of patients in whom it is feasible to identify sentinel 
nodes. Other study parameters are the anatomical localisation of the sentinel node(s) and the 
incidence of false negative lymph nodes.  
Nature and extent of the burden and risks associated with participation, benefit and 
group relatedness: the surgery is prolonged with 20-25 minutes due to the required 
incubation time after injection of the blue dye and radioactive isotope. A scintigram will be 
performed 24 hours after the surgery to determine whether residual radioactive lymph nodes 

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can be detected. The scintigram will only be performed if the patient is capable to be 
transported to the nuclear department. No extra blood samples will be taken, no extra visits, 
physical examinations or other tests are necessary. There is no risk of tumour dissemination 
by injecting the tracers in the ovarian ligaments. There is a 0,07 to 2,7% risk of an allergic 
reaction to the blue dye. The dose of radioactive isotope given does not give adverse side 
effects, either to the patients or the personnel present in the operating theatre. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1. Introduction and rationale 
 
Epidemiology 
Epithelial ovarian cancer (EOC) remains the tumour with the most unfavourable prognosis 
within the field of the gynaecological oncology. The incidence of ovarian cancer in the 
Netherlands in 2008 was 14.5 per 100.000, with 12.3 deaths per 100.000 [1]. In the US in 
2007 the incidence was 13.0 per 100.000 and there were 8.2 deaths per 100.000 [2]. The high 
mortality rate is partially due to the fact that approximately 75% of patients is diagnosed with 
advanced stage EOC. 
 
Background 
EOC can metastasize through three different ways [3,4]: intraperitoneal (in the abdominal 
cavity), lymphogenous and haematogenous. Concerning the lymphogenous spread, it is clear 
that lymphatic metastases of EOC mainly occur in the para-aortic lymph nodes [5]. It is 
believed that the tumour cells follow the lymph vessels that accompany the ovarian artery and 
vein in the infundibulopelvic ligament up to the high para-aortic region and renal vein. 
Nevertheless, pelvic lymph node metastases are also frequently found [6-16]. These tumour 
cells probably follow a different route, following the para-uterine vessels in the broad 
ligament towards the uterine artery and vein and further on to the iliac vessels. In some case 
reports isolated inguinal node metastases are also described [17-20]. The exact mechanism of 
this route of metastasis is still unclear, but the metastatic cells might follow the course of the 
round ligament towards the inguinal lymph nodes, or might follow the iliac vessels towards 
the femoral vessels. The incidence of lymph node metastasis in clinical stage I-II ovarian 
carcinoma is 14.2% [21].  
 
Staging 
In case of a clinical early stage ovarian cancer, the Dutch guideline [1] recommends a staging 
laparotomy with adequate lymph node sampling, with an absolute minimum of ten lymph 
nodes removed. In the same guideline, a footnote is made stating that a larger number of 
removed lymph nodes will increase the chance of finding metastases. These lymph nodes also 
need to be sampled from different anatomical regions, of which the most important are the 

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para-aortic and paracaval region between the renal vein and inferior mesenteric artery, the 
common, internal and external iliac vessels and the obturator fossa.  
 
The clinical significance of staging 
According to the International Federation of Gynecology and Obstetrics (FIGO), EOC with 
lymph node metastases is classified as FIGO stage IIIC disease, even in the absence of 
peritoneal metastases [22]. In contrast to patients with FIGO stage I ovarian cancer after a 
comprehensive staging procedure, patients with a FIGO stage III ovarian cancer obtain 
adjuvant chemotherapy. Therefore, the recognition of lymph node metastases is of utmost 
importance.  
Surgical staging of EOC and the extent of lymph node dissection differs greatly from centre to 
centre [23].  
A review published in 2011 showed an incidence of 14.2% for lymphnode metastasis in early 
EOC [21]. The incidence is higher in the grade 3 tumours (20.0%) and the serous histological 
subtype (23.3%). Whereas in grade 1 and mucinous tumours this is respectively 4.0% and 
2.6%. 
 
Methods for identification of lymph node metastases 
Radiological imaging 
The assessment through radiological techniques (CT scan, MRI, PET) alone is not feasible. 
The sensitivity and specificity for detection of lymph node metastases in ovarian cancer of a 
PET scan are 73.2% and 96.7% respectively, of a CT scan 42.6% and 95.0%, and of a MRI 
54.7% and 88.3%. [25]. 
 
During surgery 
Removal of lymph nodes: 
• systematic lymphadenectomy / lymph node sampling 
Approaches range from taking some lymph nodes only (lymph node sampling) to systematic 
lymphadenectomy [22]. A systematic lymphadenectomy can be seen as the golden standard. 
However, such a radical procedure gives more late morbidity than lymph node sampling. 
These include the formation of lymphocyst (up to 13.5%), nerve and vessel injury (up to 4%) 
and increased blood loss and operating time [26, 27]. 
• removal of sentinel node(s) 

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Through a sentinel node procedure the first node that receives primary lymphatic flow can be 
identified (the so called sentinel node). The pathological examination is an indication of the 
nodal status of the remaining nodes. If the sentinel node is negative, the patient may be spared 
a radical lymphadenectomy and thus the morbidity that can be caused by it [28].  
The sentinel node technique has been proven effective in other cancers such as breast cancer 
and malignant melanoma. In the gynaecological field it has been shown to be effective in 
vulvar cancer. Currently sentinel node studies are done for cervix en uterine cancer. Studies 
done for sentinel node in ovarian cancer are very limited. One article that describes the role of 
sentinel lymph node sampling in gynaecological cancers, only briefly mentions ovarian 
cancer. The authors state that the procedure is difficult due to the often bulky mass ovarian 
tumours. Furthermore, with injecting in the ovary there is a possible risk of tumour 
dissemination [28]. 
Nyberg et al. have done a study in 16 patients with high-risk uterine cancer in which 
technetium and blue dye were injected in the right or left ovary [29]. They used an incubation 
time of 15 minutes. In this study patients were included with a high-risk uterine carcinoma 
because these patients obtain the same operation as patients with clinical early stage ovarian 
cancer: a total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) 
and a pelvic and para-aortic lymphadenectomy or lymph node sampling. In 15 out of 16 
patients the sentinel node was detected. Another study used activated charcoal solution to 
identify ovarian lymphatics in 11 patients. The charcoal was injected in the cortex of the 
ovary. The charcoal was deposited in the lymph nodes of all patients [12].   
These studies all inject in the ovary, which gives a risk of tumour dissemination. In our 
feasibility study we are planning to inject in the ligaments of the ovary, not in the cortex itself. 
Therefore, besides patients with high risk endometrial cancer, we also can include patients 
with en enlarged ovary without risk of tumour dissemination.  
 
The lymphatic mapping can be done with blue dyes as well as radioactive isotopes; both can 
be injected in the ovarian ligaments which contain the main routes of lymph drainage. After 
the incubation time the sentinel nodes should be visualized by either colorization (blue lymph 
nodes can be identified) and / or by the radioactive tracer [29]. Although in breast cancer 
radioactive isotope compared to blue dye shows a higher detection rate of the sentinel node 
[30], it has been shown that the detection rate is the highest when both radioactive isotope and 
blue dye are combined, instead of using them alone [30, 34].  

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The blue dyes can cause an allergic reaction, which can present itself from hypotension with 
urticaria and erythema to severe cardiovascular collapse with bronchospasm [28]. However, 
the incidence of an allergic reaction from blue dye is very low and varies from 0.07 to 2.7% 
[31].  
The radioactive isotope is safe for the patient as well as the health care workers [35]. No 
allergic reactions are described due to the radio-active isotope. 
 
Conclusion 
This study is social relevant because in patients with clinical early stage ovarian cancer lymph 
node metastasis are found in 14.2%. A sentinel node procedure can prevent unnecessary 
radical lymph node dissection with it’s associated morbidity. If this procedure proves to be 
effective, it is also more accurate than the at random sampling which is currently done in the 
Netherlands.  
This study is scientific relevant since the research done for sentinel node procedure in ovarian 
cancer is very limited and so far limited to injection of tracers in the ovarian cortex with the 
possibility of tumour spread. Injection of tracer in the ovarian ligaments has, to our 
knowledge, never been published.  
 
 
2. OBJECTIVES 
 
Primary Objective 
To determine whether or not a sentinel node procedure in patients with ovarian cancer is 
feasible by injecting the tracers into the ovarian ligaments instead of into the ovary itself.  
 
In this feasibility study we will include both patients with (suspicion of) ovarian cancer as 
well as patients with a high-risk uterine carcinoma. The latter group of patients can also be 
included because these patients obtain the same surgical procedure; a total abdominal 
hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) and a pelvic and para-
aortic lymphadenectomy of lymph node sampling.  
 
 
 

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Secondary Objective(s)  
• The anatomical location(s) and number of the sentinel node(s): 
o visualized at surgery regarding blue dye 
o recorded by the gammaprobe at surgery radiocolloid 
o visualized at scintigraphy 24 hours after surgery regarding possibly remaining 
lymph nodes 
• Incidence of false negative lymph nodes. 
 
 
3. STUDY DESIGN 
 
Observational feasibility study to detect sentinel nodes: mapping the lymphatic drainage of 
the ovaries.  
The study will end after 20 patients, of which at least 10 patients with ovarian cancer, are 
included in which the complete sentinel node procedure has been performed. The expected 
inclusion period is estimated to be two years. If the detection rate of the sentinel node is less 
than 50%, or when less 5 patients are included in a year, the study will end prematurely.  
 
 
4. STUDY POPULATION 
 
Population (base)  
The study will be performed in the Maastricht University Medical Centre.  
1) Patients with a high suspicion of a malignant ovarian tumour planned for exploratory 
laparotomy will be asked to participate in the study. Only when a malignancy is confirmed by 
frozen section, the sentinel nodes will be removed prior to proceeding with a complete staging 
procedure. 
2) Patients with endometrial cancer in whom a staging laparotomy is planned. 
 
Inclusion criteria 
- 
Patients with a high suspicion of a malignant ovarian tumour planned for exploratory 
laparotomy. 
- 
Patients with high-risk endometrial cancer in whom a staging laparotomy is planned. 
- 
Age between 18 and 85 years. 

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Exclusion criteria 
- Previous surgery of both ovaries. 
- Previous vascular surgery of the aorta, caval vein, and/or iliac vessels. 
- Previous lymphadenectomy of lymph node sampling in the iliac or para-aortal region. 
- History of a malignant lymphoma. 
- History of a malignant tumour in the abdominal cavity. 
- Previous allergic reaction to blue dye. 
- Pregnant or lactating patients. 
- An allergy for human albumin. 
 
Sample size calculation 
Between 24 and 28 patients will be included in the study. 
The sample size calculation is based on the fact that:  
- 
with a group of 20 evaluable patients the study group is large enough to give an answer 
whether sentinel node(s) can be detected related to the ovarian lymphatic flow when the 
tracers are injected in the ovarian ligaments. For this purpose both patients with an ovarian 
and endometrial malignancy, planned for a staging laparotomy can and will be included.  
- 
patients with a benign result on frozen section of the suspicious ovary will be excluded 
from the study because no lymph node(s) will be resected in these patients. These patients 
will be documented and described in the report after the study.  
- 
based on retrospective data, in 60% of the patients with a suspicious ovary, frozen section 
will confirm a ovarian malignancy.  
- 
to calculate one of the secondary endpoints (incidence of false negative sentinel lymph 
node) at least 10 patients with ovarian cancer should be part of the 20 evaluable patients.  
 
5. METHODS 
 
Main study parameter 
To determine whether or not a sentinel node procedure in patients with ovarian cancer is 
feasible by injecting the tracers into the ovarian ligaments instead of into the ovary itself.  
 

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The lymphatic drainage of the ovary follows the lymph vessels that accompany the ovarian 
artery and vein in the infundibulopelvic ligament up to the high para-aortic region and renal 
vein. The exact mechanism of drainage to pelvic area is still unclear. It may follow the lymph 
vessels adjacent to the uterus towards the pelvic lymph nodes.  
Through a sentinel node procedure the first node(s) that receives primary lymphatic flow 
should be identified (the so-called sentinel node(s)). In case of lymphatic spread, this lymph 
node will be the first lymph node obtaining a metastasis.  
 
In this feasibility study we will include both patients with (suspicion of) ovarian cancer as 
well as patients with a high-risk uterine carcinoma. The latter group of patients can also be 
included because these patients obtain the same surgical procedure; a total abdominal 
hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) and a pelvic and para-
aortic lymphadenectomy of lymph node sampling.  
 
Secondary study parameters 
In order to test the reliability of the sentinel node detection by injection in the ovarian 
ligaments, some secondary study parameters are also important: 
 
- 
The anatomical location(s) and number of the sentinel node(s, visualized at surgery by 
either blue dye or the radioactive tracer 
 
- 
The incidence of false negative lymph nodes, i.e. in contrast to the sentinel lymph node, 
one of the resected non-sentinel lymph nodes contains tumor cells. To calculate the 
percentage of false negative lymph nodes: the number of patients with negative sentninel 
lymph node(s) AND positive non-sentinel lymph node(s) is the numerator, the true 
amount of negative lymph nodes is the denominator." 
 
The golden standard would be to perform a complete pelvic and para-aortic 
lymphadenectomy. However, the Dutch guideline advises a comprehensive lymph node 
sampling as standard treatment. We feel such a golden standard can be considered in 
subsequent study, when this study provides evidence that a sentinel node procedure in this 
way indeed is feasible. Nevertheless, a possible false negative result obtained in this study is 
important and therefore will be documented. 
 

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- 
The incidence of unrecognized sentinel nodes 
Recognition of sentinel nodes with blue dye and the gamma probe during surgery is less 
reliable than by making a scintigram. Therefore ideally, as in breast and vulvar cancer, a 
scintigram is made before surgery to recognize the sentinel nodes so that during surgery no 
sentinel nodes will be missed. However, this principle cannot be accomplished in patients 
with ovarian cancer, because the tracers cannot be injected at the appropriate sides without 
opening the abdomen. However, we expect that missing sentinel nodes in patients with 
ovarian cancer occurs less frequent because the area where the sentinel nodes can reside is 
restricted to well described areas. Nevertheless, by making a scintigram 24 hours after 
surgery, at least an impression is obtained on the incidence of unrecognized sentinel lymph 
nodes. 
 
Study procedures 
Informed consent procedure 
Eligible patients will be asked to take part in the study at the time the diagnosis and the 
suggested surgical therapy are discussed at the outpatient services (either high suspicion of a 
malignant ovarian tumour planned for exploratory laparotomy or high-risk endometrial cancer 
planned for staging laparotomy). The gynaecological oncologist will explain the outline of the 
study and gives the patient the information brochure. Of course it will be stressed that the 
patient remains free to withdraw at any time from protocol investigations without giving 
reasons and without prejudicing any further treatment. After admittance to the hospital (one 
day before surgery) the gynecologist who will perform the surgery, once more discusses the 
study and, when the patient agrees to take part in the study, obtain a written informed consent. 
 
Surgical procedures 
Patients with a high suspicion of a malignant ovarian tumour  
After making the median incision and opening the abdomen, before starting with removal of 
the enlarged and suspicious adnex, blue dye and the radioactive isotope will be injected in the 
ligamentum ovarii proprium (median side) and the ligamentum infundibulo-pelvicum (lateral 
side), close to the ovary and just below the peritoneum. Four syringes will be made containing 
0,2 ml patent blue and 0,15 ml (20-MBq) radioactive isotope (99mTc-nanocolloid or 
Nanocoll®, GE Healthcare, Eindhoven, The Netherlands, see appendix for information 
leaflet) will be given. Mixing patent blue and radioactive isotope does not affects the quality 
of the two substances, nor does it give extra or different side effects for the patient [36]. The 

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99mTc-nanocolloid is prepared by trained laboratory staff on the nuclear lab in a sterile ‘class 
A’ Laminar Air Flow (LAF) hood. Afterwards patent blue is added and the syringe is mixed. 
This is done 30 minutes before the start of the surgery. 
A 15-minute interval will be planned after injection. The exact time interval for detection of 
positive nodes is unclear. Common practice is to wait for 15 minutes, if in this time period the 
node is not detected, it is considered negative. In daily practice a wait of more than 15 
minutes during is surgery is not workable. At 5 and 10 minutes the radioactivity will be 
measured along the lymphatic tract to document whether or not perhaps sentinel node(s) can 
be identified at a shorter time-interval in future studies. A Geiger counter measures the 
radioactivity. The Geiger counter will be the same device in all surgeries.  
After the 15 minutes time-interval the adnex will be removed and admitted to the pathologist 
for a frozen section. If the result is benign, no further actions will be performed in these 
patients. If the result is malignant, the sentinel node(s) will be identified either (once more) by 
the radioactive tracer and / or visually (blue dye) after opening the retroperitoneal space.  
After removal of the sentinel node(s) a complete standard staging procedure will be 
performed including a comprehensive at random sampling of other lymph nodes at the 
different locations. 
 
Surgical steps related to the study (standard or extra): 
- 
Median laparotomy (standard care) 
- 
Injection of blue dye and radioactive isotope (extra for the study) 
- 
15 minute waiting time during the surgery (extra for the study) 
- 
Removal of the adnex and admittance to the pathologist for a frozen section analysis. 
(standard care) 
- 
If the result is benign, no further actions will be performed in these patients and the 
procedure ends at this time. (standard care)  
- 
If the result is malignant, the sentinel nodes will be identified either by the radioactive 
tracer and / or visually (blue dye). (extra for the study) 
- 
The sentinel nodes will be removed. (standard or extra for the study, depending on 
whether or not the lymph node(s) would have been removed as part of the standard lymph 
node sampling) 
- 
Subsequently a complete staging procedure will be performed. (standard care) 
 
Patients with endometrial cancer in whom a staging laparotomy is planned 

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After making the median incision and opening the abdomen, blue dye and the radioactive 
isotope will be injected in the ligamentum ovarii proprium (median side) and the ligamentum 
infundibulo-pelvicum (lateral side) of one of the ovaries, in the same manner as decribed 
above in patients with a high suspicion of an ovarian malignancy. The choice of the ovary 
(left or right side) will switch between left and right by each patient who is included in the 
study.  
 A 15-minute interval will be planned after injection. In this time period at 5 and 10 minutes 
the radioactivity will be measured along the lymphatic tract to document whether or not 
perhaps sentinel node(s) can be identified at a shorter time-interval in future studies. The 
radioactivity is measured by a Geiger counter. The Geiger counter will be the same device in 
all surgeries.  
After the 15 minutes time-interval the sentinel node(s) will be identified either (once more) by 
the radioactive tracer and / or visually (blue dye) after opening the retroperitoneal space.  
After removal of the sentinel node(s) a complete standard staging procedure will be 
performed including a comprehensive at random sampling of other lymph nodes at the 
different locations. 
 
Surgical steps related to the study (standard or extra): 
- 
Median laparotomy (standard care) 
- 
Injection of blue dye and radioactive isotope (extra for the study) 
- 
15 minute waiting time during the surgery (extra for the study) 
- 
The sentinel nodes will be identified either by the radioactive tracer and / or visually (blue 
dye) (extra for the study)  
- 
The sentinel nodes will be removed. (standard or extra for the study, depending on 
whether or not the lymph node(s) would have been removed as part of the standard lymph 
node sampling) 
- 
Subsequently a complete standard staging procedure will proceed as normal (standard 
care). 
 
After surgery 
One day after the surgery a scintigram will be taken if possible (depending on mobility of the 
patient) at the nuclear department to detect any remained radioactive hot spots. A scintigram 
is done in a similar way as a CT-scan. If there is any rest radioactivity this may indicate that 

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sentinel nodes have not been identified during surgery and therefore gives an indication of the 
reliability of identifying sentinel nodes during surgery. 
 
Data collection 
Patient characteristics. The following information will recorded: 
- 
Record number 
- 
Age 
- 
Checked inclusion and exclusion criteria 
- 
Checked informed consent 
- 
Histology: tumour type (ovarian or endometrial), differentiation grade, numbers of lymph 
node removed including sentinel node(s) including histological results specified per 
sentinel node 
- 
FIGO stage 
 
- Surgical findings: tumour side, injections side, result frozen section, time between injection 
and detection, sentinel node positive or not, number of sentinel nodes, first sentinel node blue, 
first sentinel node gamma detection, amount of gamma counts, complications during surgery, 
side effects during surgery.  
- Postoperative scintigram, residual nodes, location of residual nodes. 
- Result pathology nodes removed: benign or malignant. 
The surgeon has to register the number and location of both sentinel nodes resected. For this 
purpose the surgeon has to draw the location of the lymph nodes in an anatomical drawing 
(see Figure 1 - page 20). Ten different locations will be used to report where the sentinel 
nodes were found:  
1. high para-aortic 
2. low para-aortic 
3. interaortic-caval 
4. para-caval 
5. iliaca communis left 
6. illaca communis right 
7. external iliaca left 
8. external iliaca right 
9. obturator left 
10. obturator right 

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The surgeon also has to register the location of the lymphatic tissue removed, related to the 
lymph node sampling following the removal of the sentinel node(s). 
 
Withdrawal of individual subjects and replacement 
Subjects can leave the study at any time for any reason if they wish to do so without any 
consequences. The investigator can decide to withdraw a subject from the study for urgent 
medical reasons. Also patients with an ovarian tumour and benign result at frozen section 
during surgery will be excluded from the study.  
These patients will be replaced by a new study subject until 20 completed sentinel node 
procedures are performed. 
 
Follow-up of subjects withdrawn from treatment 
The reasons why patients have left the study after initial inclusion will be documented in a 
anonymous way. 
 
Premature termination of the study 
- 
When after 1 year <5 patients have been included.  
- 
When in < 50% of patients the sentinel nodes are identified (interim analysis after 10 
procedures). 

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Figure 1: location of lymph nodes  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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6. SAFETY REPORTING 
 
Section 10 WMO event 
In accordance to section 10, subsection 1, of the WMO, the investigator will inform the 
subjects and the reviewing accredited METC if anything occurs, on the basis of which it 
appears that the disadvantages of participation may be significantly greater than was foreseen 
in the research proposal. The study will be suspended pending further review by the 
accredited METC, except insofar as suspension would jeopardise the subjects’ health. The 
investigator will take care that all subjects are kept informed.  
 
Adverse and serious adverse events 
Because both the blue dye and the radioactive tracer are injected outside the ovary, there is no 
risk of spread of tumour cells. 
An allergic reaction can occur due to the blue dye. The clinical presentation can range from 
urticaria, skin rash, blue hives, erythema, hypotensive episodes to an anaphylactic shock. For 
breast cancer minor reactions are reported in 0.9% of the sentinel node procedures. Severe 
allergic reactions, requiring administration of vasopressor occurred in 4 of 5853 procedures 
(0.07%). Anaphylactic shock after administration of blue dye is considered a medical 
emergency [30]. The anaesthesiologist is informed of the use of dye during the surgery, 
before the start of the surgery. Adequate fluid supply and if necessary resuscitation can be 
given in the setting of the surgery. Epinephrine injections can be given to treat hypotension, 
salbutamol spray for broncospasms [31]. 
 
All SAEs will be reported through the web portal ToetsingOnline to the accredited METC that 
approved the protocol, within 15 days after the sponsor has first knowledge of the serious 
adverse reactions. 
SAEs that result in death or are life threatening should be reported expedited. The expedited 
reporting will occur not later than 7 days after the responsible investigator has first knowledge 
of the adverse reaction. This is for a preliminary report with another 8 days for completion of 
the report.  
 

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Follow-up of adverse events 
All adverse events will be followed until they have abated, or until a stable situation has been 
reached. Depending on the event, follow up may require additional tests or medical 
procedures as indicated, and/or referral to the general physician or a medical specialist. 
 
Data safety Monitoring Board (DSMB) 
The principle of sentinel nodes is familiar for several malignancies, among others breast and 
vulvar cancer.  With respect to ovarian cancer the knowledge is limited and so far only 
studied by injecting the tracers in the ovarian cortex with the possible risk of tumour 
dissemination. The method described in this protocol (injection in the ovarian ligaments) has 
no risk of tumour dissemination. No new medicaments or substances are tested. Both the blue 
dyes as well as the radioactive tracers are known substances used for detecting sentinel nodes 
related to other malignancies. Therefore no DSMB is involved in this feasibility study. 
 
 
7. STATISTICAL ANALYSIS 
 
Descriptive statistics 
Registered items: 
- 
Sentinel nodes 
o Number per patient 
o Location(s) per patient 
o Number(s) of sentinel nodes containing a metastasis per patient 
o Location of sentinel nodes containing a metastasis per patient 
- 
Non-sentinel lymph nodes removed during the subsequent staging procedure 
o Number per patient 
o Location(s) per patient 
o Number(s) containing a metastasis per patient 
o Location of non sentinel nodes containing a metastasis per patient 
Based on the above registered items the median and mean number of sentinel nodes and its 
main locations can be determined. By combining the data of the sentinel en non-sentinel 
nodes, cases in which de sentinel node is false negative can be identified 
 

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Interim analysis.  
For the surgeons there will be probably a learning curve for applying the injection and 
detecting the nodes, therefore initially the detecting rate of the sentinel node(s) in this pilot 
study should not be set to high. Nevertheless, an interim analysis will be done once we have 
included 10 patients in whom the sentinel node procedure could be performed. This will be 
done by one of the investigators. If less than 50% of the cases no sentinel node(s) could be 
detected the study will prematurely end.  
 
 
8. ETHICAL CONSIDERATIONS 
 
Regulation statement 
The study will be conducted according to the principles of the Declaration of Helsinki (see for 
the most recent version: www.wma.net) and in accordance with the Medical Research 
Involving Human Subjects Act (WMO). 
 
Recruitment and consent 
The recruitment will be done by the gynaecologic oncologists based in the Maastricht 
University Medical Centre. The patient will be informed by the doctor who sees her in the out 
patient clinic. This is not always the doctor who will do the surgery. A patient information 
letter will be given. The patient has at least three days to consider their decision. The patient 
information letter and the consent form are two separate documents. When the patient returns 
for a routine visit, the patient is asked whether or not she wants to participate in the study. 
 
Objection by minors or incapacitated subjects (if applicable) 
No minors or incapacitated subjects will be included in the study. 
 
Benefits and risks assessment, group relatedness 
The risk of the study are low, a small chance of 0.07-2.7% of an allergic reaction to the blue 
dye. The surgery will be prolonged with 20-25 minutes, which is without extra risk for the 
patient. 
 

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Compensation for injury 
The sponsor/investigator has a liability insurance which is in accordance with article 7, 
subsection 6 of the WMO. 
 
The sponsor has an insurance which is in accordance with the legal requirements in the 
Netherlands (Article 7 WMO and the Measure regarding Compulsory Insurance for Clinical 
Research in Humans of 23th June 2003). This insurance provides cover for damage to 
research subjects through injury or death caused by the study. 
1. € 450.000,-- (i.e. four hundred and fifty thousand Euro) for death or injury for each 
subject who participates in the Research; 
2. € 3.500.000,-- (i.e. three million five hundred thousand Euro) for death or injury 
for all subjects who participate in the Research;  
3. € 5.000.000,-- (i.e. five million Euro) for the total damage incurred by the 
organisation for all damage disclosed by scientific research for the Sponsor as 
‘verrichter’ in the meaning of said Act in each year of insurance coverage. 
 
The insurance applies to the damage that becomes apparent during the study or within 4 years 
after the end of the study. 
 
 
9. ADMINISTRATIVE ASPECTS AND PUBLICATION 
 
Handling and storage of data and documents 
Each patient will be given a unique identification number (= inclusion number) to ensure the 
privacy of the patient. Reference to the case will only be made by means of an identification 
number. The acquired data will be recorded anonymously in a Microsoft Access file. This file 
contains the patient characteristics and surgical findings (see Study Design – data collection) 
and will be saved for 15 years. The members of the study group have access to the data. In a 
separate file, owned by the principal investigator, the patient can be identified by correlating 
the inclusion number with the patient’s hospital number.  
 
Annual progress report 
The investigator will submit a summary of the progress of the trial to the accredited METC 
after one year. Information will be provided on the date of inclusion of the first subject, 

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numbers of subjects included and numbers of subjects that have completed the trial, serious 
adverse events/ serious adverse reactions, other problems, and amendments.  
 
End of study report 
The investigator will notify the accredited METC of the end of the study within a period of 8 
weeks. The end of the study is defined as the last patient’s last visit.  
In case the study is ended prematurely, the investigator will notify the accredited METC, 
including the reasons for the premature termination. 
Within one year after the end of the study, the investigator/sponsor will submit a final study 
report with the results of the study, including any publications/abstracts of the study, to the 
accredited METC.  
 
Public disclosure and publication policy 
At the end of the trial there a meeting will be planned to discuss the final data which will be 
published in a peer reviewed paper. At least submission of the manuscript will be done within 
6 months after the study has ended.  
 
 
 
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