An observational study reported a significant survival benefit of para-aortic lymphadenectomy in patients at intermediate or high risk of recurrence (based on presence of histologic grade 3 or deep myometrial invasion, or lymphovascular invasion, or evidence of spread outside of the uterine corpus), compared to patients who had hysterectomy with pelvic lymphadenectomy but without para-aortic dissection. This benefit was not observed in patients with low-risk endometrial cancer (143). In addition, the Postoperative Radiation Therapy in Endometrial Carcinoma (PORTEC) studies identified patients with stage IC, grade 3 endometrial carcinoma as being at high risk of early distant spread and death when treated with hysterectomy only (no staging), followed by pelvic external-beam radiation therapy. These patients had a 31% risk of distant recurrence (136). From the literature, it seems that the patients who have the potential to benefit from surgical staging are those with risk factors such as histologic grade 3, deep myometrial invasion, or lymphovascular invasion.
In summary, surgical staging should (i) identify patients with disseminated disease who are at high risk of recurrence; (ii) target postoperative treatment; (iii) reduce the number of patients potentially requiring postoperative treatment when the provided information is used appropriately (avoiding the risk of morbidity without reasonable benefit); and (iv) possibly eradicate lymphatic disease. In spite of these potential benefits in high-risk patients, prospective randomized data demonstrating a survival advantage or reduction in overall morbidity resulting from a potential reduction of adjuvant treatment still are not available.
The FIGO published the updated surgical staging system for endometrial cancer (Table 35.6) (144). In comparison with recommendations from 1988, the new system introduces the following
Table 35.6 Carcinoma of the Endometrium (2008)
Stage I∗ Tumor confined to the corpus uteri
IB∗ Invasion equal to or more than half of the myometrium
Stage II∗ Tumor invades cervical stroma, but does not extend beyond the uterus∗∗
Stage III∗ Local and/or regional spread of the tumor IIIA∗ Tumor invades the serosa of the corpus uteri and/or adnexae# IIIB∗ Vaginal and/or parametrial involvement# IIIC∗ Metastases to pelvic and/or para-aortic lymph nodes#
IIIC1∗ Positive pelvic nodes IIIC2∗ Positive para-aortic lymph nodes with or without positive pelvic lymph nodes
Stage IV∗ Tumor invades bladder and/or bowel mucosa, and/or distant metastases IVA∗ Tumor invasion of bladder and/or bowel mucosa IVB∗ Distant metastases, including intra-abdominal metastases and/or inguinal
FIGO Committee on Gynecologic Oncology. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynecol Obst 2009;105:103–104. ∗Either G1,G2,orG3. ∗∗Endocervical glandular involvement only should be considered as Stage I and no longer as Stage II. #Positive cytology has to be reported separately without changing the stage.
changes: (i) former stages IA and IB are combined; (ii) former stage IIA was eliminated so that only the presence of cervical stroma involvement is considered stage II disease; (iii) alone, peritoneal cytologic findings positive for endometrial cancer are no longer a criterion for disease upstaging (although FIGO still recommends the collection of peritoneal washing, recognizing the predictive value of positive cytologic findings when combined with other poor-prognosis factors); and (iv) stage IIIC was divided into IIIC1 and IIIC2 in accordance with the absence or presence of positive para-aortic nodes. The presence of parametrial disease is now formally recognized as stage IIIB disease.