REVIEW
Sentinel lymph node mapping for metastasis detection in colorectal cancer:
a systematic review and meta-analysis
Likui Qiao
Department of Pathology. Tianjin fourth Center Hospital . Tianjin, China
Received: 10/12/2019 · Accepted: 11/03/2020
Correspndence: Likui Qiao. Department of Pathology. Tianjin fourth Center Hospital. No. 1 Zhongshan Road. Hebei
District. Tianjin 300000, China. e-mail: likuiqiao19@163.com
ABSTRACT
Introduction: controversy exists on the diagnostic perfor-
mance of sentinel lymph node (SLN) mapping in colorectal
cancer. This study aimed to provide a more precise estima-
tion of its clinical significance.
Materials and methods: a systematic search of electronic
databases was conducted to retrieve all relevant studies up
to August 31st, 2019. Detection rate, sensitivity, and upstag-
ing rate were pooled together, and a subgroup analysis
was performed to identify factors that affect diagnostic
performance. The prognostic value of upstaging was also
explored.
Results: sixty-eight studies were eligible and included.
The pooled SLN detection rate was 0.93 (95 % CI, 0.91-
0.94), with a significant higher rate in colon cancer or
in studies including more than 100 patients. The overall
sensitivity of the SLN procedure in colorectal cancer was
0.72 (95 % CI, 0.67-0.77). The tracers used were found
to influence sensitivity. A mean weighted upstaging of
0.22 (95 % CI, 0.18-0.25) was identified. True upstag-
ing, defined as micro-metastases, was 14 %. Upstaged
patients were associated with worse overall survival
(OS) when compared with node-negative patients (HR =
2.60, 95 % CI, 0.16-4.63). In addition, upstaged patients
had a lower 5-year disease-free survival (DFS) rate than
node-negative patients.
Conclusion: based on the results of the present meta-anal-
ysis, the SLN mapping procedure should focus on early
stage patients to refine staging, since upstaging appeared
to be a prognostic factor for DFS and OS. The SLN proce-
dure can be recommended for colorectal cancer patients in
addition to conventional resection.
Keywords: Sentinel lymph node. Metastases. Colon cancer.
Rectal cancer. Meta-analysis.
1130-0108/2020/112/9/722-730 • REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS
© Copyright 2020. SEPD y © ARÁN EDICIONES, S.L.
INTRODUCTION
Colorectal cancer is the third most common cancer world-
wide (1). The 5-year survival rate of colorectal cancer highly
depends on disease stage, and is 75-90 % for stage I and II
disease (2), and only 10 % for distant metastatic disease (3).
The assessment of lymph node (LN) status is still the most
effective way to predict patient prognosis and determine
the need for adjuvant therapeutic intervention. However,
tumor understaging owing to the inadequacy of the current
technique for NL evaluation is responsible for the dismal
prognosis of node-negative patients (stages I & II) with col-
orectal cancer.
Standard LN assessment involves hematoxylin and eosin
(H&E) staining of 1-2 sections of a LN. However, this tech-
nique may overlook occult nodal disease from isolated
tumor cells (ITCs) and micrometastases (MMs) in LNs (4).
Serial sectioning, immunohistochemistry, and reverse tran-
scriptase polymerase chain reaction (RT-PCR) can provide
a more accurate staging of LNs (5). Yet, these methods are
labor-intensive, time-consuming, expensive, and may not
be widely adopted. The sentinel lymph node (SLN) concept
might offer a solution.
Sentinel lymph node mapping was developed to identify
the first to fourth LN in a lymphatic pathway, which are
most likely to harbor micrometastases (6). Ultrastaging
techniques could be used for only this limited number of
LNs to improve cancer staging (7). Upstaging is defined as
Qiao L. Sentinel lymph node mapping for metastasis detection in colorectal
cancer: a systematic review and meta-analysis. Rev Esp Enferm Dig 2020;
112(9):722-730
DOI: 10.17235/reed.2020.6767/2019
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 Sentinel lymph node mapping for metastasis detection in colorectal cancer: a systematic review and meta-analysis
the identification of ITCs or MMs with ultrastaging tech-
niques in patients classified as node-negative with routine
histopathological examination, who could benefit from
adjuvant chemotherapy. However, the results achieved
with SLN mapping in colorectal cancer are variable and
controversial.
Thus, a meta-analysis was needed. By analyzing all studies in
which SLN mapping was employed in colorectal cancer, the
objective of the present study was to disclose the diagnostic
performance of SLNs, and to investigate any variation in the
results according to tumor location and SLN procedure. In
addition, the role of SLN mapping on survival was analyzed.
MATERIALS AND METHODS
Search strategy
A systematic search was conducted using Pubmed, Sci-
enceDirect, and Web of Science for all relevant studies
until August 31st, 2019. The search terms used were: “sen-
tinel node”, “mapping”, “colon cancer”, “rectal cancer”,
and “colorectal cancer”. Additional searches were done
by manually cross-checking the reference lists of eligible
studies and relevant reviews. Articles were systematical-
ly screened by titles and abstracts, and potentially eligible
studies were further examined in full-text mode.
Study selection
Studies that assessed the diagnostic performance of
SLN mapping in colorectal cancer were deemed eligible.
Besides, the following criteria had to be satisfied: prospec-
tive study design, sufficient data for extraction or calcula-
tion of true positives (TPs), true negatives (TNs) and false
negative (FNs), and a specific SLN mapping and histo-
pathological analysis procedure. Otherwise, studies were
excluded. In case of duplicate publications with overlapping
patient data, only the one with the largest sample size or
the most complete outcome data was included.
Quality assessment
The quality and validity of the included studies was
assessed using an evidence-based tool for the assessment
of the quality of diagnostic studies (QUADAS) (8). The fol-
lowing items were assessed and ranked yes, no, or unclear
based on the information provided in the text: consecutive
patients, specific inclusion and exclusion criteria, prospec-
tive study design, valid reference test (histology); SLN crite-
ria, detection procedures (detailed description of reference
standard to permit replication), in vivo or ex vivo method,
ultrastaging method, separated index tests were provided
according to disease stage and location.
Data extraction
The extraction of data from each included study was per-
formed using a standardized form. Extracted information
included:
1. First author, publication year, study design.
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723
2. Patient demographics: total sample size, number of
patients with colon or rectal cancer, TNM stage, age,
gender.
3. SLN procedure: tracer, concentration and dose, injection
time and site, in vivo or ex vivo evaluation, definition
of SLN.
4. Histopathological technique used for SLNs and non-
SLNs.
5. Outcome data: total number of harvested LNs or SLNs,
number of successful SLNs procedures, adverse events,
number of TPs, TNs, and FPs.
6. Survival outcome: overall survival (OS) and disease-free
survival (DFS).
Index test and reference standard
For each study, 2 x 2 contingency tables were developed.
The term false positive (FP) was not suitable for SLN
mapping because patients with only positive SLNs were
also defined as node-positive. Thus, FP was set as zero
in the whole study. The detection rate was calculated as
the number of successful procedures divided by the total
number of SLN procedure undertaken. All positive SLNs
identified with or without ultrastaging techniques were
defined as TP. FN was defined as any tumor-negative SLN
in the presence of a tumor-positive LN. The sensitivity
rate of the SLN procedure was calculated as TP/(TP + FN).
Patients with positive SLNs (ITC or MM) identified with
ultrastaging techniques only, and in the absence of posi-
tive LNs assessed with single-section H&E, were defined
as upstaged. The upstaging rate was calculated as the
number of patients with ITCs or MMs divided by the num-
ber of patients classified as N0 with routine histopatho-
logical examination.
Statistical analysis
As FPs were not applicable under this circumstance, spec-
ificity was set at 100 %. Thus, sensitivity was pooled with
a random effect model, without taking specificity into
account. Other diagnostic parameters that correlated to
specificity were not calculated.
The hazard ratio (HR) and 95 % confidence intervals (CIs)
were used to assess the association of node-positive (N+),
node-negative (N0), and upstage patients with OS and
DFS. The 3- and 5-year OS and DFS rates were compared
between N+, N0, and upstage patients, and were expressed
as odd ratio (OR) with 95 % CI.
The heterogeneity of the included studies was tested using
the chi-squared test and I2. An I2 > 50 % confirmed the exis-
tence of significant heterogeneity. Then, logistic regres-
sion and subgroup analyses were performed to evaluate
if a certain variance could affect heterogeneity and overall
diagnostic effect. Tumor location, detection method, type of
tracer, dose of dye, and average number of identified SLNs
were used as stratifying variables.
The statistical analysis was performed using the Stata ver-
sion 15.0 (Stata Corporation, College Station, TX, USA) and
R-2.15.2 (the Comprehensive R Archive Network) software
packages. A p-value < 0.05 was considered statistically sig-
724 L. Qiao

nificant. Publication bias was analyzed using Deeks’ funnel
plot and an asymmetry test. The presence of publication
bias was defined as p < 0.05.
RESULTS
and ex vivo methods. Single-section H&E staining was
applied as reference standard for all the studies included.
In a majority of studies (45), serial sectioning and immuno-
histochemistry or RT-PCR were utilized for SLNs only, while
14 studies used them for both SLN and non-SLN evaluation.
In 9 studies no ultrastaging method was applied.

Literature evaluation
The titles or abstracts of 2,907 publications were screened to
locate the relevant studies. Then, 86 articles were retrieved
and reviewed in full-text mode. Out of these, 72 studies
were eligible for inclusion. After a more careful review,
three more studies were excluded because of overlapping
study patients. Eventually, 68 studies were included in the
analysis (5,9-67). Figure 1 demonstrates the flow chart of
the literature selection process.
Quality assessment
All included studies had a prospective study design, applied
a valid reference test (histology), and specified the in vivo
and ex vivo method. Twenty-seven articles reported con-
secutive patient inclusion. Fifty-three studies described
selection criteria. Thirty-nine of the 68 eligible studies met
7 of the 9 criteria.

Study characteristics
The studies selected contained a total of 5,205 patients,
with 5,326 SLN procedures performed. A total of 4,363
colon cancers and 917 rectal cancers were included. The
tracers used were patent blue, isosulfan blue, methylene
blue, indocyanine green (ICG), and radiocolloid. The in vivo
method was applied in 26 investigations, the ex vivo meth-
od in 24 studies; the remaining 18 reports used both in vivo
Identification
Detection rate
The pooled outcomes of 67 studies resulted in a detection
rate of 0.93 (95 % CI, 0.91-0.94) (Table 1). The detection rate
in patients with colon cancer was significantly higher than
in patients with rectum cancer (0.96 [95 % CI, 0.95-0.97]
vs 0.88 [95 % CI, 0.82-0.93], p = 0.007). Studies including
more than 100 patients showed significantly higher detec-
tion rates than smaller studies (0.96 [95 % CI, 0.94-0.98]
vs 0.91 [95 % CI, 0.89-0.94], p = 0.009). Overall, detection

Records identified through Additional records identified

database searching through other sources
(n = 2892) (n = 15)

Records after duplicates removed

(n = 2193)
Screening

Records screened Records excluded

(n = 2193) (n = 2107)

Full-text articles excluded,

Full-text articles assessed for with reasons (n = 18)
eligibility Overlapping population
(n = 3)
Eligibility

(n = 86)
Sample size < 10 (n = 6)
No quantitative data (n = 9)

Studies included in qualitative

synthesis
(n = 68)
Included

Studies included in qualitative

synthesis (meta-analysis)
(n = 68)

Fig. 1. Flow diagram of the literature search and study selection.

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 Sentinel lymph node mapping for metastasis detection in colorectal cancer: a systematic review and meta-analysis 725

Table 1. Detection rate results for sentinel lymph node mapping in colorectal cancer
Number of studies Sample size Detection rate 95 % CI p-value
Overall results 67 4653 0.93 0.91-0.94
Subgroup analysis
Location
Colon cancer 40 3040 0.96 0.95-0.97 0.007
Rectal cancer 12 459 0.88 0.82-0.93
Method
In vivo 27 2116 0.94 0.92-0.96 0.554
Ex vivo 30 1638 0.93 0.91-0.95
Colon cancer
In vivo 13 1471 0.94 0.91-0.95 0.493
Ex vivo 20 775 0.95 0.93-0.97
Rectal cancer
In vivo 4 165 0.89 0.82-0.98 0.537
Ex vivo 5 157 0.85 0.73-0.98
Tracers
Patent blue dye 27 2016 0.94 0.92-0.96 0.054
Isosulfan blue 14 1167 0.95 0.93-0.98
Methylene blue 7 377 0.83 0.76-0.90
Radiocolloid 3 81 0.95 0.90-1.00
Indocyanine green 5 217 0.94 0.88-1.00
Blue dye plus radiocolloid 7 458 0.96 0.93-0.99
Dosage
Fixed dose 10 591 0.97 0.95-0.99 0.063
Non-fixed dose 18 1394 0.93 0.91-0.96
Sample size
< 100 54 2366 0.91 0.89-0.94 0.009
≥ 100 13 2557 0.96 0.94-0.98

rates did not differ significantly between the in vivo and ex
vivo methods. We further stratified studies according to
both cancer type and detection method. In both colon and
rectum cancer, the in vivo and ex vivo methods had similar
detection rates. No significant differences between tracers
were found. The volume of dye injection was not found to
affect detection rate (Table 1).
Diagnostic performance
The pooled sensitivity of the SLN procedure was 0.72 (95 %
CI, 0.67-0.77) (Fig. 2). No significant differences in sensitivity
were found between colon and rectum cancer (p = 0.34),
or the in vivo and ex vivo method (p = 0.89) (Table 2). The
sensitivity of the different types of tracer was also pooled;
they were, respectively: patent blue dye (0.75, 95 % CI, 0.68-
0.81), isofulfan blue (0.75, 95 % CI, 0.60-0.86), methylene
blue (0.64, 95 % CI, 0.47-0.79), ICG (0.34, 95 % CI, 0.13-0.64),
radiocolloid (0.43, 95 % CI, 0.33-0.54), and blue dye com-
bined with radiocolloid (0.78, 95 % CI, 0.63-0.88). ICG and
radiocolloid appeared to have a significantly lower sensi-
tivity as compared with blue dye (p < 0.0001). In studies
applying patent blue dye and isofulfan blue, a subgroup
analysis based on dosage was further conducted. However,
studies using a flexible dose (the amount of injected dye
was dependent on tumor size) did not show higher sensi-
tivity than studies employing a fixed dose. Also, none of
the following factors, namely number of SLNs identified
(< 4 vs ≥ 4), year of publication (< 2010 vs ≥ 2010), region
of experiment (America, Asia, or Europe), and sample size
(< 100 vs ≥ 100), had significant effects on SLN procedure
sensitivity (Table 2).
Upstaging
The pooled results of 47 studies revealed an upstaging
rate of 0.22 (95 % CI, 0.18-0.25). Thus, in around 22 % of
patients classified as N0 with conventional histopatholog-

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726
Fig. 2. Pooled sensitivity rate of sentinel lymph node
(SLN) mapping in colorectal cancer.
ical techniques, ultrastaging examination showed ITCs or
MMs. Fifteen studies provided separate data for MM and
ITC upstaging. The AJCC postulated that patients with MMs
should be upstaged from stage I or II to stage III. Thus, the
L. Qiao
true upstaging rate was 0.14 (95 % CI, 0.10-0.17) of stage I/
II patients becoming stage III.
Survival
The results from 4 studies revealed that upstaging patients
was associated with worse OS when compared to N0
patients, with a HR of 2.60 (95 % CI, 1.46-4.63) (Fig. 3).
No significant difference was found in 3-year DFS between
upstaged and N0 patients. However, 5-year DFS in upstaged
patients was significantly lower than in patients with N0
(OR = 0.31, 95 % CI, 0.14-0.69; p = 0.0004; I2 = 0 %) (Table 3).
In addition, upstaged patients showed a significantly lower
3-year (OR = 0.34, 95 % CI, 0.14-0.81; p = 0.02; I2 = 0 %) and
5-year OS (OR = 0.40, 95 % CI, 0.29-0.57; p = < 0.001; I2 = 0 %)
compared with N0 patients. The 3-year and 5-year OS rates
were similar between upstaged and N+ patients (Table 3).
Publication bias
A significant publication bias was found for detection rate
(p < 0.01) and upstage rate (p = 0.04).
DISCUSSION
The present study revealed an overall detection rate of 93 %
of the SLN mapping procedure for colorectal cancer. Apart
from cancer type and sample size, no other factors were
found to affect detection rate. Rectal cancer appeared to have
a significantly lower detection rate when compared with
colon cancer. The fat and bulky mesorectum might be one
of the reasons hampering SLN detection (61). In addition,
radiotherapy, an essential element for advanced rectal can-
cer, can alter lymphatic flow and induce fibrosis, resulting in
a significant decrease of LNs detected within the tumor-bear-
ing specimen (67). A learning curve of at least 10 cases has
been postulated by some authors (36,62). The existence of a
learning-curve effect was confirmed as a significantly higher
detection rate was seen in studies with more than 100 SLN
procedures. Evidence showed that accuracy and sensitivity
could reach 98 % and 96 %, respectively, when SLN mapping
was undertaken by skilled surgeons (55). Thus, SLN proce-
dures should be performed by surgeons with more expertise
and experience. Overall, a high pooled detection rate high-
lighted the technical feasibility of the SLN procedure.
This meta-analysis showed a sensitivity of 72 % of the SLN
procedure for colorectal cancer, which was relatively low
for a diagnostic procedure. It is suggested that the tech-
niques used for SLN assessment most probably influence
sensitivity. In our analysis, the tracer used for SLN detection
was found to be a significant factor affecting sensitivity. The
use of ICG resulted in a sensitivity of only 34 %. A previous
meta-analysis demonstrated that the sensitivity of ICG for
SLN detection had an extreme variation from 0 % to 100 %
(68). This was attributed to different doses, injection sites,
and times of injection. Also, ICG is quite a new tracer, and
its used has not been standardized yet. Based on the results
of this meta-analysis, patent blue dye remained the most
cost-effective tracer for the SLN procedure. Patent blue dye
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 Sentinel lymph node mapping for metastasis detection in colorectal cancer: a systematic review and meta-analysis 727

Table 2. Subgroup results for sentinel lymph node mapping sensitivity in colorectal cancer
Number of studies Sample size Sensitivity 95 % CI p-value
Location
Colon cancer 40 2959 0.73 0.66-0.80 0.35
Rectal cancer 10 351 0.79 0.67-0.88
Method
In vivo 31 2071 0.71 0.62-0.78 0.90
Ex vivo 26 1481 0.70 0.61-0.77
Tracers
Patent blue dye 29 2005 0.75 0.68-0.81 < 0.0001
Isosulfan blue 14 1094 0.75 0.60-0.86
Methylene blue 7 317 0.64 0.47-0.79
Radiocolloid 4 108 0.43 0.33-0.54
Indocyanine green 5 132 0.34 0.13-0.64
Blue dye plus radiocolloid 5 289 0.78 0.63-0.88
Dosage
Patent blue dye
Fixed dose 10 561 0.73 0.63-0.81 0.636
Non-fixed dose 19 1526 0.76 0.67-0.83
Isosulfan blue
Fixed dose 8 340 0.69 0.54-0.80 0.438
Non-fixed dose 6 754 0.80 0.51-0.94
Number of SLNs
<4 49 3111 0.71 0.65-0.77 0.607
≥4 10 964 0.75 0.62-0.85
Publication year
< 2010 45 2924 0.72 0.66-0.78 0.902
≥ 2010 23 1768 0.72 0.60-0.81
Study country
America 15 1512 0.74 0.64-0.82 0.471
Asia 10 370 0.69 0.51-0.83
Europe 41 2740 0.73 0.66-0.79
Sample size
< 100 55 2227 0.70 0.64-0.75 0.078
≥ 100 13 2465 0.79 0.70-0.86

is inexpensive, relatively easy to use, and provides a sensi-

tivity of about 75 %. Some suggested the use of combined
radioguidance and blue dye to improve sensitivity in SLN
mapping (69). The subgroup with blue dye combined with
radiocolloid did show a slight increase in sensitivity (78 %).
However, this increase was not significant when compared
to blue dye alone (75 %). Considering that the injection of
radiocolloid required supplementary equipment and an
additional colonoscopy, which may bring about additional
patient discomfort and increased costs, and the high level
of radioactivity at the injection site may interfere with radio-
activity at the SLN, making them more difficult to identify
(26), a return of only a slight increase in sensitivity might
not be worth it. However, both ICG and radiocolloid are
relatively new approaches in SLN procedures for colorectal
cancer. Further prospective trials with large sample sizes Fig. 3. Correlation between upstaged patients and N0
are needed to explore their merit. patients with OS.

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728 L. Qiao

Table 3. 3-year and 5-year disease-free survival and overall survival among N0, N+, and upstaged patients
Outcome Number of studies Sample size Odds ratio 95 % CI p-value I2
DFS
Upstaged vs N0
3-year 2 210 0.59 0.16-2.23 0.43 79%
5-year 4 290 0.31 0.14-0.69 0.004 0%
Upstaged vs N+
3-year 2 139 4.01 1.19-13.53 0.03 85%
5-year 4 206 2.24 1.10-4.56 0.03 0%
OS
Upstaged vs N0
3-year 3 284 0.34 0.14-0.81 0.02 0%
5-year 5 864 0.40 0.29-0.57 < 0.0001 0%
Upstaged vs N+
3-year 2 139 1.12 0.43-2.92 0.82 1%
5-year 4 206 1.42 0.73-2.77 0.30 0%
DFS: disease-free survival; OS: overall survival; N0: node-negative patients; N+: node-positive patients.

Although detection rates for rectal cancer were significantly
lower than for colon caner, sensitivity was similar between
groups, indicating the feasibility of SLN mapping in rectal
cancer; this overturned the conclusion of previous studies
that suggested that SLN detection in rectal carcinoma was
unreliable (13). The ex vivo method proved to be as effec-
tive as the in vivo method for SLN mapping in colorectal
cancer. With the ex vivo method, SLN mapping is avail-
able to all patients, as it can provide a safe and allergy-free
procedure. The ex vivo method is more patient-friendly. In
addition, the ex vivo technique allows a precise introduc-
tion of dye into the submucosa (70). It does not prolong the
procedure length and avoids intraoperative tumor manip-
ulation, which makes it a procedure that is much easier to
perform and requires a shorter learning curve in compar-
ison with the in vivo method (50). However, the ex vivo
method is less physiological than the in vivo technique,
with its inability to detect an aberrant lymphatic drainage
pattern. Seven of the studies included recorded an aberrant
lymphatic drainage, which accounted for 7 % of patients.
Thus, the selection of the in vivo or ex vivo method should
be based on operator experience and colorectal patient
characteristics. Patients with rectal cancer can benefit more
from an ex vivo procedure.
Nevertheless, SLN mapping, in addition to conventional
resection, should be recommended for patients diagnosed
with colon or rectal cancer without clinical evidence of LN
involvement or metastasis. Although a pooled false-nega-
tive rate of 26 % was detected, skip metastases in colorectal
cancer are deemed to be of no clinical significance. Unlike
breast cancer and melanoma, all draining lymph nodes at
the regional level are resected irrespective of SLN status
or technique failure. Pathologically, all harvested LNs are
examined by at least one conventional standard. Thus,
patients with skip metastases after the SLN procedure
would still receive appropriate systemic therapy. SLN map-
ping in colorectal cancer will not lead to underdiagnosis
or undertreatment of any patient in spite of having skip
metastases. The use of SLN mapping in colorectal cancer
should be focused on refining staging in order to identify
high-risk patients with early-stage cancer who could benefit
from adjuvant chemotherapy.
A mean upstaging rate of 22 % was found in the present
analysis. Our study also explored the prognostic value of
patient upstaging. Upstaged patients were found to be
associated with worse 5-year DFS and worse OS when com-
pared to node-negative patients. This finding suggested
that upstaged patients could potentially benefit from adju-
vant therapy. However, the studies included in the survival
analysis did not specify whether patients were upstaged
with ITCs or MMs. According to the tumor-node-metastasis
classification, ITCs histopathologically do not result in a
change of nodal status. Patients with ITCs are considered to
be cured after oncological resection, and no adjuvant che-
motherapy is recommended (53). A previous report found
similar survival rates between N0 patients with or without
ITCs, whereas patients with MM showed significantly lower
survival rates (71). Thus, whether ITCs or MMs contribute
to worse survival outcomes, and whether adjuvant chemo-
therapy will improve survival in these patients, remains to
be proven by large randomized trials.
A major limitation of the present meta-analysis was the
tremendous clinical diversity seen across studies regarding
patient selection, SLN mapping techniques, pathological
analysis, surgeon experience, and institutions. Although a
subgroup analysis was performed, heterogeneity could not
be completely eliminated. In addition, a significant publica-
tion bias was found for detection and upstage rate. Thus,
the findings of this study were not adequate enough to
establish a standardization of the SLN procedure, but may
provide guidance regarding the SLN technique.

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 Sentinel lymph node mapping for metastasis detection in colorectal cancer: a systematic review and meta-analysis
CONCLUSION
Overall, this meta-analysis demonstrated a sensitivity of
74 % for SLN mapping in patients with colorectal cancer,
and an upstage rate of 22 %. Upstaged patients showed sig-
nificantly lower DFS and OS when compared to N0 patients.
Hence, the SLN procedure should be focused on early-stage
patients to refine staging. SLN procedures are clinically
safe, and will not lead to understaged and undertreated
patients, hence may be recommended for colorectal cancer
patients in addition to conventional resection.
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