Introduction
Uterine endometrial carcinoma (EC) is the most common malignancy of the female reproductive tract in developed countries(1), with approximately 380,000 new cases worldwide in 2018(2).
Most patients present with early-stage (stage I/II)(3)endometrioid EC(4). In contrast, advanced cancer (stage III/IV)(5) accounts for more than 50% of uterine-related deaths(6). In order to guide management, a preoperative assessment is mandatory. This includes a full clinical history, pelvic examination, ultrasonography and endometrial biopsy or curettage to determine histotype and grade. Additionally, advanced imaging is recommended to assess myometrial invasion(5).
Lymph node (LN) metastasis is the most common site of extrauterine spread in EC(7) and contributes to a worse survival outcome. LN involvement is the most important prognostic factor in EC, especially for early clinical stages(8). Due to their high specificities(9), specialised imaging techniques such as pelvic CT, MRI and PET scan are recommended to determine LN status(5). However, detection rates of node positive disease and availability to provide imaging to all early-stage EC patients remains variable between centres(10). Hence, imaging alone is not sufficient for the surgical staging process(11).
The standard treatment of EC is total hysterectomy, bilateral salpingo-oophorectomy and in some cases systematic lymph node dissection (LND). LND is the surgical removal of lymph nodes(12). Complete surgical staging, including LND is considered the gold standard method of evaluating lymph node status(7,13,14). This can be used to assess patient prognosis and guide treatment decisions. LND has been demonstrated to have a possible diagnostic, prognostic and therapeutic benefit in patients with EC(12). However, LND is associated with surgically related morbidity(12), leading to studies considering whether LND is required.
It is evident from the breadth of the literature that clinicians worldwide must balance the benefits and harms of LND. Therefore, we aim to conduct a scoping review evaluating the roles of LND in all stages of EC particularly addressing the key controversies.