PET/CT-Detected Supradiaphragmatic Lymph Nodes Signal Tougher Road in Advanced Ovarian Cancer, study finds

When planning cytoreductive surgery for advanced ovarian cancer, clinicians often face uncertainty: Does supradiaphragmatic lymph node (SDLN) involvement seen on 18F-FDG PET/CT truly impact survival or surgical success? A systematic review and meta-analysis published in Archives of Gynecology and Obstetrics offers new clarity, synthesizing data from over 600 patients to answer this critical question.

Study Design and Methods

Systematic review and meta-analysis: Researchers followed PRISMA guidelines, searching multiple databases for studies evaluating the impact of SDLN positivity on 18F-FDG PET/CT in advanced epithelial ovarian cancer.

Five retrospective studies (total 605 patients) were included, all of whom underwent primary cytoreductive surgery.

Key outcomes measured: overall survival (OS), progression-free survival (PFS), and rates of complete cytoreduction (R0).

Key Findings

SDLN positivity on PET/CT was significantly associated with poorer outcomes:

Overall survival: Hazard ratio (HR) 1.60 (95% CI 1.19–2.25, p=0.002)—SDLN-positive patients faced a 37% higher risk of death.

Progression-free survival: HR 1.53 (95% CI 1.19–1.96, p=0.0009).

Complete cytoreduction rates: Odds ratio 0.32 (95% CI 0.15–0.68, p=0.003)—significantly lower chances of achieving R0 resection.

These results were consistent across studies, despite all being retrospective and lacking histologic confirmation of PET/CT-positive SDLNs.

Clinical Implications

SDLN positivity may reflect extensive peritoneal disease or metastatic spread and thus identify a subgroup of patients with inherently poorer prognosis.

While SDLN involvement on PET/CT is not yet enough to dictate treatment decisions, it may help select patients for referral to specialized centers with expertise in upper abdominal or extended cytoreductive surgery.

The findings reinforce the need for cautious interpretation of PET/CT results, avoiding deferral of surgery based solely on SDLN status without considering the broader clinical picture.

Limitations and Future Directions

All included studies were retrospective, with no histologic confirmation of SDLN involvement—raising the possibility of false positives due to non-malignant causes.

PET/CT findings were not systematically compared with CT-only imaging, so the added value of PET/CT over conventional CT remains uncertain.

Larger, prospective, multicenter studies with histologic verification of SDLN status are needed to definitively guide clinical practice.

Conclusion

SDLN positivity on 18F-FDG PET/CT is associated with worse survival and lower resectability in advanced ovarian cancer. While this marker shouldn’t be used in isolation for treatment decisions, it can help risk-stratify patients and inform multidisciplinary management, especially at high-volume centers.

Key Points

PET/CT-detected supradiaphragmatic lymph node involvement predicts poorer overall and progression-free survival in advanced ovarian cancer.

SDLN positivity is linked to lower rates of complete cytoreduction during primary surgery.

Findings should be interpreted with caution due to lack of histologic confirmation in current studies.

SDLN status may help guide referral to specialized surgical centers, but shouldn’t yet drive treatment changes on its own.

Prospective, histologically confirmed studies are needed to validate SDLN as a clinical biomarker.

Citation:

Braun C, Peikert J, Brambs C. Prognostic and predictive value of supradiaphragmatic lymph node involvement detected by 18F‑FDG PET/CT in advanced ovarian cancer: a systematic review and meta‑analysis. Archives of Gynecology and Obstetrics. 2025;312:1927–1935. doi:10.1007/s00404-025-08234-w