Nodal Regions to Include in Endometrial Cancer Treatment

Standard Nodal Regions for Surgical Staging

Pelvic lymph nodes from the external iliac, internal iliac, obturator, and common iliac regions should be routinely included in surgical staging for endometrial cancer, as recommended by the National Comprehensive Cancer Network 1
Para-aortic nodal evaluation from the inframesenteric and infrarenal regions should be included for high-risk tumors, such as deeply invasive lesions, high-grade histology, serous adenocarcinoma, clear cell adenocarcinoma, or carcinosarcoma, as recommended by the National Comprehensive Cancer Network 1
For comprehensive surgical staging, para-aortic lymph node dissection should extend up to the renal vessels, according to the Annals of Oncology guidelines 2

For low-risk disease, such as G1/2 and myometrial invasion <50%, sentinel lymph node dissection can be considered for staging, as suggested by the Annals of Oncology 2
Visual evaluation of peritoneal, diaphragmatic, and serosal surfaces with biopsy of suspicious lesions is important to exclude extrauterine disease, as recommended by the National Comprehensive Cancer Network 1

For intermediate risk and high-risk disease, lymphadenectomy is recommended to guide staging and adjuvant therapy, according to the Annals of Oncology guidelines 2
Excision of suspicious or enlarged lymph nodes in the pelvic or para-aortic regions is important to exclude nodal metastasis, as recommended by the National Comprehensive Cancer Network 1

Omental biopsy is commonly performed in tumors with serous adenocarcinoma, clear cell adenocarcinoma, or carcinosarcoma histology, as recommended by the National Comprehensive Cancer Network 1
For non-endometrioid histologies, such as serous, clear cell, undifferentiated carcinoma, or carcinosarcoma, more comprehensive nodal evaluation is warranted, according to the Annals of Oncology guidelines 3, 4

For patients with cervical stromal invasion, the presacral lymph node region should also be included in the clinical target volume, as recommended by the National Comprehensive Cancer Network 1

Failure to perform adequate para-aortic lymph node evaluation in high-risk cases may lead to understaging and inadequate treatment, as warned by the National Comprehensive Cancer Network and the Annals of Oncology 1, 4
Some patients may not be candidates for lymph node dissection due to medical comorbidities, and alternative treatment approaches should be considered, as recommended by the National Comprehensive Cancer Network 1