Surgery with or without lymph node sampling

Low risk: Well-differentiated or moderately differentiated tumor and/or depth of myometrial invasion is less than 50% and/or tumor is smaller than 2 cm.

High risk: Poorly differentiated tumor and/or depth of myometrial invasion is 50% or more and/or tumor is 2 cm or larger.

In two studies, patients with low-risk cancer had a sufficiently low risk of lymph node metastasis such that lymph node sampling could be omitted. For patients meeting high-risk criteria, a full pelvic and para-aortic lymph node dissection was suggested, given patterns of lymphatic spread.[16,17]

An alternative strategy is the use of sentinel lymph node dissection in patients with presumed stage I endometrial cancer.[18] Although this strategy has been widely adopted at various academic centers, a prospective multicenter trial to determine the false-negative rate for this protocol is lacking. For cases in which isolated tumor cells are identified using the sentinel lymph node approach, it is unclear whether treatment is necessary.

In patients with high-risk histology (serous, clear cell, carcinosarcoma, or undifferentiated tumors), hysterectomy and bilateral salpingo-oophorectomy with pelvic and para-aortic lymph node dissection is the standard approach.

Laparotomy has been the standard surgical approach. However, laparoscopy is now favored because of the improvement in patients' postoperative recovery without significant impact on outcomes.

For patients with early-stage endometrial cancer, several randomized trials have compared total laparoscopic hysterectomy (TLH) with the standard open procedure, total abdominal hysterectomy (TAH). Feasibility of the laparoscopic approach has been confirmed, but this approach is associated with a longer operative time.[15,19,20] TLH has an improved [15,19] or similar [20] adverse event profile and a shorter hospital stay [15,19,20] than does TAH.

For patients with early-stage endometrial cancer, several randomized trials have compared total laparoscopic hysterectomy (TLH) with the standard open procedure, total abdominal hysterectomy (TAH). Feasibility of the laparoscopic approach has been confirmed, but this approach is associated with a longer operative time.[15,19,20] TLH has an improved [15,19] or similar [20] adverse event profile and a shorter hospital stay [15,19,20] than does TAH.

TLH is associated with less pain and a quicker resumption of daily activities,[20,21] although one study found that most of the gains in quality of life favoring laparoscopy at the 6-week postsurgical period were no longer significant at 6 months.[20,21]

A GOG trial (GOG-LAP2) randomly assigned 2,616 patients with clinical stages I to IIA disease in a 2:1 ratio to comprehensive surgical staging via laparoscopy or laparotomy.[22][Level of evidence A1]Time to recurrence was the primary end point, with noninferiority defined as a difference in recurrence rate of less than 5.3% between the two groups at 3 years.

A GOG trial (GOG-LAP2) randomly assigned 2,616 patients with clinical stages I to IIA disease in a 2:1 ratio to comprehensive surgical staging via laparoscopy or laparotomy.[22][Level of evidence A1]Time to recurrence was the primary end point, with noninferiority defined as a difference in recurrence rate of less than 5.3% between the two groups at 3 years.

The recurrence rate at 3 years was 10.24% for patients in the laparotomy arm and 11.39% for patients in the laparoscopy arm, with an estimated difference between groups of 1.14% (90% lower bound, -1.278; 95% upper bound, 3.996).

A GOG trial (GOG-LAP2) randomly assigned 2,616 patients with clinical stages I to IIA disease in a 2:1 ratio to comprehensive surgical staging via laparoscopy or laparotomy.[22][Level of evidence A1]Time to recurrence was the primary end point, with noninferiority defined as a difference in recurrence rate of less than 5.3% between the two groups at 3 years. › The recurrence rate at 3 years was 10.24% for patients in the laparotomy arm and 11.39% for patients in the laparoscopy arm, with an estimated difference between groups of 1.14% (90% lower bound, -1.278; 95% upper bound, 3.996).

Although this difference was lower than the prespecified limit, the statistical requirements for noninferiority were not met because of fewer-than-expected recurrences in both groups.

A GOG trial (GOG-LAP2) randomly assigned 2,616 patients with clinical stages I to IIA disease in a 2:1 ratio to comprehensive surgical staging via laparoscopy or laparotomy.[22][Level of evidence A1]Time to recurrence was the primary end point, with noninferiority defined as a difference in recurrence rate of less than 5.3% between the two groups at 3 years.

The 5-year overall survival (OS) rate was 89.8% in both groups.

A Cochrane review of the use of laparoscopic staging included four randomized controlled trials that reported OS and progression-free survival (PFS). Ninety percent of the patients were from the GOG-LAP2 trial.[23][Level of evidence A1]

A Cochrane review of the use of laparoscopic staging included four randomized controlled trials that reported OS and progression-free survival (PFS). Ninety percent of the patients were from the GOG-LAP2 trial.[23][Level of evidence A1]

Overall, laparoscopy and laparotomy were associated with similar OS and PFS rates.