Research Article|Articles in Press

Hysterectomy alone vs. hysterectomy plus sentinel node mapping in endometrial cancer: Perioperative and long-term results from a propensity-score based study

Published:February 13, 2023DOI:


      • Sentinel node mapping (SNM) is accurate in identifying disease harboring in the lymph nodes in EC.
      • In comparison to hysterectomy only, the addiction of SNM does not increase morbidity rate.
      • The omission of retroperitoneal staging has no negative effect on influencing oncologic outcomes.
      • Recent advances in molecular studies have refined the prognosis for EC and uterine risk factors are the main variable influencing the need of adjuvant therapies.
      • In few EC patients (merely 4%) nodal status is the only factor used in determining appropriate adjuvant therapy.



      To compare outcomes after hysterectomy and hysterectomy plus sentinel node mapping (SNM) in endometrial cancer (EC) patients.

      Materials and methods

      This is a retrospective study, collecting data of EC patients treated between 2006 and 2016 in nine referral centers.


      The study population included 398 (69.5%) and 174 (30.5%) patients having hysterectomy and hysterectomy plus SNM. As the results of the adoption of a propensity-score matched analysis, we selected two homogeneous cohort of patients (150 having hysterectomy only vs. 150 having hysterectomy plus SNM). The SNM group had a longer operative time, but did not correlate with length of hospital stay and estimated blood loss. Overall severe complication rates were similar between groups (0.7% in the hysterectomy group vs. 1.3% in the hysterectomy plus SNM group; p = 0.561). No lymphatic-specific complication occurred. Overall, 12.6% of patients having SNM were diagnosed with disease harboring in their lymph nodes. Adjuvant therapy administration rate was similar between groups. Considering patients having SNM, 4% of patients received adjuvant therapy on the basis of nodal status alone; all the other patients received adjuvant therapy also on the basis of uterine risk factors. Five-year disease-free (p = 0.720) and overall (p = 0.632) survival was not influenced by surgical approach.


      Hysterectomy (with or without SNM) is a safe and effective method for managing EC patients. Potentially, these data support the omission of side specific lymphadenectomy in case of unsuccessful mapping. Further evidence is warranted in to confirm the role SNM in the era of molecular/genomic profiling.


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        • Siegel R.L.
        • Miller K.D.
        • Fuchs H.E.
        • Jemal A.
        Cancer statistics, 2022.
        CA A Cancer J Clin. 2022 Jan; 72 (Epub 2022 Jan 12. PMID: 35020204): 7-33
        • Siegel R.
        • Naishadham D.
        • Jemal A.
        Cancer statistics.
        CA A Cancer J Clin. 2012 Jan-Feb; 62 (2012) (Epub 2012 Jan 4. PMID: 22237781): 10-29
        • Bogani G.
        • Dowdy S.C.
        • Cliby W.A.
        • et al.
        Management of endometrial cancer: issues and controversies.
        Eur J Gynaecol Oncol. 2016; 37 (PMID: 27048101): 6-12
        • Crosbie E.J.
        • Kitson S.J.
        • McAlpine J.N.
        • Mukhopadhyay A.
        • Powell M.E.
        • Singh N.
        Endometrial cancer.
        Lancet. 2022 Apr 9; 399 (PMID: 35397864): 1412-1428
        • Creasman W.T.
        • Morrow C.P.
        • Bundy B.N.
        • Homesley H.D.
        • Graham J.E.
        • Heller P.B.
        Surgical pathologic spread patterns of endometrial cancer. A Gynecologic Oncology Group Study.
        Cancer. 1987 Oct 15; 60: 2035-2041
        • Benedetti Panici P.
        • Basile S.
        • Maneschi F.
        • et al.
        Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial.
        J Natl Cancer Inst. 2008 Dec 3; 100 (Epub 2008 Nov 25. PMID: 19033573): 1707-1716
        • Kitchener H.
        • Swart A.M.
        • Qian Q.
        • Amos C.
        • Parmar M.K.
        • ASTEC study group
        Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study.
        Lancet. 2009 Jan 10; 373 (Epub 2008 Dec 16. Erratum in: Lancet. 2009 May 23;373(9677):1764. PMID: 19070889; PMCID: PMC2646126): 125-136
        • Frost J.A.
        • Webster K.E.
        • Bryant A.
        • Morrison J.
        Lymphadenectomy for the management of endometrial cancer.
        Cochrane Database Syst Rev. 2017 Oct 2; 10 (pub4. PMID: 28968482; PMCID: PMC6485923)CD007585
        • Todo Y.
        • Kato H.
        • Kaneuchi M.
        • Watari H.
        • Takeda M.
        • Sakuragi N.
        Survival effect of para-aortic lymphadenectomy in endometrial cancer (SEPAL study): a retrospective cohort analysis.
        Lancet. 2010 Apr 3; 375 (Epub 2010 Feb 24. Erratum in: Lancet. 2010 Aug 21;376(9741):594. PMID: 20188410): 1165-1172
        • Hernandez E.
        • American College of Obstericians and Gynecologists
        ACOG Practice Bulletin number 65: management of endometrial cancer.
        Obstet Gynecol. 2006 Apr; 107 (author reply 952-3) (PMID: 16582139): 952
        • Concin N.
        • Matias-Guiu X.
        • Vergote I.
        • et al.
        ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma.
        Int J Gynecol Cancer. 2021 Jan; 31 (Epub 2020 Dec 18. PMID: 33397713): 12-39
        • Abu-Rustum N.R.
        • Yashar C.M.
        • Bradley K.
        • et al.
        NCCN Guidelines® insights: uterine neoplasms, version 3.2021.
        J Natl Compr Cancer Netw. 2021 Aug 1; 19 (PMID: 34416706): 888-895
        • Zammarrelli 3rd, W.A.
        • Greenman M.
        • Rios-Doria E.
        • et al.
        Sentinel lymph node biopsy alone compared to systematic lymphadenectomy in patients with uterine carcinosarcoma.
        Gynecol Oncol. 2022 Feb 26; (S0090-8258(22)00122-6) (Epub ahead of print. PMID: 35232588)
        • Zammarrelli 3rd, W.A.
        • Afonso A.M.
        • Broach V.
        • et al.
        Sentinel lymph node biopsy in patients with endometrial cancer and an indocyanine green or iodinated contrast reaction – a proposed management algorithm.
        Gynecol Oncol. 2021 Aug; 162 (Epub 2021 May 13. PMID: 33992449; PMCID: PMC8319058): 262-267
        • Backes F.J.
        • Felix A.S.
        • Plante M.
        • et al.
        Sentinel lymph node (SLN) isolated tumor cells (ITCs) in otherwise stage I/II endometrioid endometrial cancer: to treat or not to treat?.
        Gynecol Oncol. 2021 May; 161 (Epub 2021 Mar 5. PMID: 33678480): 347-352
        • Moloney K.
        • Janda M.
        • Frumovitz M.
        • et al.
        Development of a surgical competency assessment tool for sentinel lymph node dissection by minimally invasive surgery for endometrial cancer.
        Int J Gynecol Cancer. 2021 May; 31 (Epub 2021 Mar 4. PMID: 33664126): 647-655
        • Bogani G.
        • Mariani A.
        • Paolini B.
        • Ditto A.
        • Raspagliesi F.
        Low-volume disease in endometrial cancer: the role of micrometastasis and isolated tumor cells.
        Gynecol Oncol. 2019 Jun; 153 (Epub 2019 Mar 1. PMID: 30833134): 670-675
        • Schlappe B.A.
        • Weaver A.L.
        • McGree M.E.
        • et al.
        Multicenter study comparing oncologic outcomes after lymph node assessment via a sentinel lymph node algorithm versus comprehensive pelvic and paraaortic lymphadenectomy in patients with serous and clear cell endometrial carcinoma.
        Gynecol Oncol. 2020 Jan; 156 (Epub 2019 Nov 24. PMID: 31776037; PMCID: PMC6980738): 62-69
        • Bogani G.
        • Papadia A.
        • Buda A.
        • et al.
        Sentinel node mapping vs. sentinel node mapping plus back-up lymphadenectomy in high-risk endometrial cancer patients: results from a multi-institutional study.
        Gynecol Oncol. 2021 Apr; 161 (Epub 2021 Jan 20. PMID: 33485641): 122-129
        • Schlappe B.A.
        • Weaver A.L.
        • Ducie J.A.
        • et al.
        Multicenter study comparing oncologic outcomes between two nodal assessment methods in patients with deeply invasive endometrioid endometrial carcinoma: a sentinel lymph node algorithm versus a comprehensive pelvic and paraaortic lymphadenectomy.
        Gynecol Oncol. 2018 Nov; 151 (Epub 2018 Aug 31. PMID: 30177461; PMCID: PMC6214768): 235-242
        • Bogani G.
        • Multinu F.
        • Dowdy S.C.
        • et al.
        Incorporating robotic-assisted surgery for endometrial cancer staging: analysis of morbidity and costs.
        Gynecol Oncol. 2016 May; 141 (Epub 2016 Feb 16. PMID: 26896826): 218-224
        • Bogani G.
        • Casarin J.
        • Leone Roberti Maggiore U.
        • et al.
        Survival outcomes in endometrial cancer patients having lymphadenectomy, sentinel node mapping followed by lymphadectomy and sentinel node mapping alone: long-term results of a propensity-matched analysis.
        Gynecol Oncol. 2020 Jul; 158 (Epub 2020 May 7. PMID: 32389376): 77-83
        • Bogani G.
        • Papadia A.
        • Buda A.
        • et al.
        Factors predicting morbidity in surgically-staged high-risk endometrial cancer patients.
        Eur J Obstet Gynecol Reprod Biol. 2021 Nov; 266 (Epub 2021 Sep 28. PMID: 34688098): 169-174
        • Suidan R.S.
        • Sun C.C.
        • Cantor S.B.
        • et al.
        Three lymphadenectomy strategies in low-risk endometrial carcinoma: a cost-effectiveness analysis.
        Obstet Gynecol. 2018 Jul; 132 (PMID: 29889752; PMCID: PMC6294436): 52-58
        • Ghoniem K.
        • Larish A.M.
        • Dinoi G.
        • et al.
        Oncologic outcomes of endometrial cancer in patients with low-volume metastasis in the sentinel lymph nodes: an international multi-institutional study.
        Gynecol Oncol. 2021 Sep; 162 (Epub 2021 Jul 15. PMID: 34274133): 590-598
        • Kandoth C.
        • Schultz N.
        • Cherniack A.D.
        • Akbani R.
        • Liu Y.
        • et al.
        • Cancer Genome Atlas Research Network
        Integrated genomic characterization of endometrial carcinoma.
        Nature. 2013 May 2; 497 (Erratum in: Nature. 2013 Aug 8;500(7461):242. PMID: 23636398; PMCID: PMC3704730): 67-73
        • Bogani G.
        • Ray-Coquard I.
        • Concin N.
        • et al.
        Uterine serous carcinoma.
        Gynecol Oncol. 2021 Jul; 162 (Epub 2021 Apr 30. PMID: 33934848): 226-234
        • Bogani G.
        • Ray-Coquard I.
        • Concin N.
        • et al.
        Endometrial carcinosarcoma.
        Int J Gynecol Cancer. 2022 Dec 30; (ijgc-2022-004073) (Epub ahead of print. PMID: 36585027)
        • Eriksson L.S.E.
        • Nastic D.
        • Lindqvist P.G.
        • et al.
        Combination of Proactive Molecular Risk Classifier for Endometrial cancer (ProMisE) with sonographic and demographic characteristics in preoperative prediction of recurrence or progression of endometrial cancer.
        Ultrasound Obstet Gynecol. 2021 Sep; 58 (PMID: 33314410; PMCID: PMC8457053): 457-468
        • Baiocchi G.
        • Andrade C.E.M.C.
        • Ribeiro R.
        • et al.
        Sentinel lymph node mapping versus sentinel lymph node mapping with systematic lymphadenectomy in endometrial cancer: an open-label, non-inferiority, randomized trial (ALICE trial).
        Int J Gynecol Cancer. 2022; (Mar 2:ijgc-2022-003378) (Epub ahead of print. PMID: 35236752)
        • NIH US National Library of Medicine
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