Intermediate and high-intermediate risk groups
LND is vital to bridge the gap between pathological prognostic features such as lymphovascular space invasion (LVSI) and adjuvant therapy. ESMO-ESGO-ESTRO 2016 outlines adjuvant therapy recommendations in considerable detail for the latter two sub-groups of intermediate risk patients. LND could therefore be considered justified in this case. However, in the first sub-group (LVSI-positive, G1/2 and superficial myometrial invasion (<50%)), even if LND is commenced, guidelines for adjuvant therapy are not clear (Table 3).
A matched-pair retrospective study highlighted that a low proportion of intermediate-risk patients who underwent LND had positive LNs compared to unstaged patients(30). Furthermore, across all risk groups, surgery-related adverse effects of LND must not be ignored(29). Specifically in the intermediate risk group, postoperative complications such as lymphocyst formation and lower-limb lymphoedema were significantly higher in the LND group(30–32). Interestingly however, infection rates were higher in unstaged patients, perhaps because non-surgical infections were also included(30).
Ultimately, there is conflicting evidence comparing the benefit of knowing the LN status to the adverse effects of LND.