Low risk group
The ESMO-ESGO-ESTRO 2016 recommendations state no therapeutic benefit of LND for low-risk EC patients (Table 3). These recommendations are based on a study by Benedetti et al.(34), which concluded that systematic pelvic LND did not improve 5 year disease free survival (DFS) or overall survival (OS). However, these recommendations are limited as this RCT did not risk stratify their patient cohort. The second RCT was the ASTEC trial(20). The “low-risk” group was defined as FIGO 1988 IA or IB and G1 and G2, which differs from the current ESMO-ESGO-ESTRO 2016 classification (Table 3). Results showed no survival benefit (OS and recurrence-free survival (RFS)) of pelvic LND in “low-risk” patients. In this trial, para-aortic node sampling was at the discretion of the surgeon, and in patients with anaesthetic concern or obesity, the surgeon may have omitted dissection of some LNs. A reduced number of lymph nodes dissected is a significant predictor of progression free survival (PFS) and OS(5,21). These significant limitations may have contributed to the lack of therapeutic benefit shown, mistakenly supporting ESMO-ESGO-ESTRO 2016 recommendations. Additionally, a meta-analysis of seven observational studies(21)showed limited survival benefit with LND in low risk patients.