Predictors of Bilateral Sentinel Lymph Node Mapping Failure in Endometrial Cancer: A Systematic Review and Meta-Analysis

Abstract

Objective

To identify clinicopathological and procedural predictors of bilateral sentinel lymph node (SLN) mapping failure in patients with apparent early-stage endometrial cancer predominantly undergoing minimally invasive surgery with indocyanine green (ICG) fluorescence imaging.

Data Sources

A systematic literature search was performed in PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from database inception to March 2026. Reference lists of relevant studies were also manually screened.

Methods of Study Selection

Observational studies were included, as randomized trials in this field typically do not report sufficient data on predictors of SLN mapping failure. Eligible studies predominantly involved patients with apparent early-stage disease undergoing minimally invasive surgery with cervical ICG-based SLN mapping and reporting extractable effect estimates or sufficient data for analysis. Studies were excluded if they had overlapping cohorts, used exclusively noncervical injection techniques, or included fewer than 50 patients. Two reviewers independently screened studies and extracted data.

Tabulation, Integration, and Results

Sixteen studies comprising 6977 patients were included. Random-effects meta-analysis demonstrated that obesity (BMI ≥30 kg/m²), high tumor grade (G3), nonendometrioid histology, and lymph node involvement were significantly associated with an increased risk of bilateral SLN mapping failure. In contrast, age, prior pelvic surgery, tumor size, cervical involvement, FIGO stage, lymphovascular space invasion, and surgical approach were not significantly associated with mapping outcomes. Heterogeneity was assessed using the I² statistic, and sensitivity analyses confirmed the robustness of the findings.

Conclusion

Bilateral SLN mapping failure in endometrial cancer is primarily driven by patient- and tumor-related factors, whereas surgical approach was not significantly associated with mapping outcomes. Identification of high-risk patients may facilitate individualized surgical planning and intraoperative decision-making.