Pre-surgical staging in endometrial cancer: An opportunity for risk stratification and triage?

backgroundEndometrial cancer (EC) is treated by comprehensive surgical staging that includes a systematic lymphadenectomy. The low rates of lymph node metastasis (LNM) in early stages question the benefit of routine lymphadenectomy in low-risk disease, but the absence of a reliable method to identify these patients in whom lymphadenectomy could be omitted makes complete staging the standard of care. This study evaluated a method of preoperative staging in EC to identify patients at low risk of LNM and adjuvant treatment.

methodsThis prospective observational study compared the presurgical staging and risk triage based on endometrial biopsy (EB) and imaging (magnetic resonance imaging [MRI], Positron Emission Tomography [PET] scan) in 94 cases of EC with the final surgicopathological staging and evaluated the role of each modality in presurgical evaluation and triage.

resultsNinety-four cases were triaged into 42 low-risk and 52 non-low-risk cases preoperatively. EB showed a sensitivity, specificity, and accuracy of 51.55%, 89.83%, and 75.53%, respectively, in identifying high-risk grade and histology. MRI was effective for local staging and identified tumor size, myometrial invasion, and cervical involvement with accuracy ranging from 82.20% to 97.78% for these parameters. MRI detected LNM with an accuracy of 85.11%, whereas PET exhibited an accuracy of 86.17%. The combined presurgical staging could identify low-risk disease with a sensitivity, specificity, and accuracy of 85.37%, 86.79%, and 86.17%, respectively.

conclusionPreoperative staging may triage patients into low-risk and non-low-risk cases, thereby facilitating a conscious decision to omit lymphadenectomy in low-risk cases, thus avoiding unnecessary morbidity without compromising oncological safety.