Perspective title Perspectives summary
The diagnostic role of lymph node dissection in early-stage endometrial cancer
LND should be used to guide adjuvant treatment(15) by stratifying patients by risk and not staging alone(16). LND shows varied use in guiding adjuvant treatment because pathological prognostic features differ between different risk stratification systems(12,17).
The prognostic role of lymph node dissection in early-stage endometrial cancer
Low risk group: LND is not warranted in EC staging based on the ESMO-ESGO-ESTRO 2016 as there is a very low risk of LN metastasis(18,19). LND may be warranted in EC staging to detect occult LN metastasis(20).
Intermediate and high-intermediate risk groups: LND is not warranted in EC staging as patients present with a low proportion of positive LNs(21) with unclear guidelines for adjuvant therapy(5). LND may be warranted in EC staging when adjuvant therapy is recommended(5).
High risk group: LND is warranted in EC staging based on the ESMO-ESGO-ESTRO 2016 due to high prevalence of lymph node involvement(22). Without LND, treatment would rely solely on radiation and chemotherapy(23).
The therapeutic role of lymph node dissection in early-stage endometrial cancer
Low risk group: There is no therapeutic benefit to LND based on the ESMO-ESGO-ESTRO 2016(20), although the evidence supporting these guidelines misclassify low risk patients(15,24).
Intermediate – high risk groups: While LND demonstrated improved survival in a large patient cohort(25,26), there is no therapeutic benefit to LND(15,24).
Role of lymph node dissection in advanced endometrial cancer
LND is beneficial in advanced EC based on ESMO-ESGO-ESTRO 2016. LND is effective at diagnosing advanced EC and tailoring adjuvant therapy(27). Patients benefited from undergoing LND, before debulking therapy(28). LND is used to calculate LN ratio, the strongest independent prognostic parameter in stage IIIC EC(29). LND is not beneficial in advanced EC. LND may be omitted for non-bulky advanced EC patients receiving appropriate adjuvant therapy(30). There is no consensus regarding the treatment of stage IVB EC(31).
What defines adequate lymph node dissection?
Lymph Node Counts: Improved survival is correlated with >10 LNs being removed by LND based on ESMO-ESGO-ESTRO 2016(5,24,27). Alternatively, improved survival is thought to correlate with >20 LNs being removed by LND(32). Lymph Node Targets: There is a need for pelvic and para-aortic LND(33) up to the renal vessels(34) based on ESMO-ESGO-ESTRO 2016. Special attention is needed for isolated positive para-aortic LNs(35). Surgical Method: Minimally invasive surgery (MIS) is preferred over laparotomy based on ESMO-ESGO-ESTRO 2016(5,36–38) while laparotomy is preferred for complex cases(39). Within MIS, robotic and laparoscopic LND shows similar adequacy(38–40) while robotic has certain advantages over laparoscopic surgery(38,41,42). Role of sentinel lymph node (SLN) dissection: ESMO-ESGO-ESTRO recognises SLN algorithms as a potential alternative to systematic LND in early stage EC(5,43) supported by recent studies(23,36,44).