Intermediate-high risk group
The pathological inclusion criteria used by Benedetti et al.(34) were FIGO 1988 Stage IB and G1, satisfying current intermediate and high-intermediate risk groups. They reported that pelvic LND did not improve 5-year DFS or OS. Para-aortic LND and the use of adjuvant therapies was left to the discretion of the clinician, both of which may have influenced metastasis and therefore survival. A recent matched-pair study that focussed specifically on intermediate risk patients supported the findings of Benedetti et al. with the addition that post-operative morbidity was similar in both groups(30). Although a risk stratification system similar to ESMO-ESGO-ESTRO 2016 was adopted, cervical involvement was considered as an additional defining feature(35).
Before ESMO-ESGO-ESTRO 2016, multiple studies like the previously discussed ASTEC 2009, combined both intermediate and high-risk groups(20,36). We have followed suit for the purposes of standardisation. The ASTEC trial showed no benefit of pelvic LND in terms of RFS and OS. Alternatively, surgical staging including LND demonstrated improved survival in a large patient cohort with intermediate-high risk EC(36). This study was limited by its retrospective nature and therefore could not account for confounding factors such as comorbidities. Similar findings were observed in a retrospective multicentre study with the new ESMO-ESGO-ESTRO 2016 high-intermediate risk group(37).