Surgical Staging of Differentiated Endometrial Cancer: An Analysis of Postoperative Outcome in a Gynecological Cancer Center in Sri Lanka

Introduction: Even though surgico-pathological staging is recommended in poorly differentiated endometrial cancer, management of differentiated endometrial cancer is controversial. Preoperative pelvic and abdominal Magnetic Resonance Imaging (MRI) is recommended in well-differentiated endometrial cancer to identify patients with risk factors for regional metastasis. However, access to MRI is limited in Sri Lanka, and surgico-pathological staging is the primary staging method available for most patients with differentiated endometrial cancer. Our objective was to evaluate the outcome of surgical staging among differentiated endometrial cancer patients who underwent primary surgery at the gynecological cancer center of Apeksha Hospital Maharagama, Sri Lanka. Methods: A retrospective study was conducted using the ongoing electronic database at the gynecological cancer center of the National Cancer Institute (Apeksha Hospital) in Maharagama, Sri Lanka. Data from December 2019 to December 2020 were selected for analysis. Results: During the study period, 112 patients with endometrial cancer underwent hysterectomy. This study included 90 patients with differentiated endometrial cancer (International Federation of Gynecology and Obstetrics [FIGO] Grade 1 and Grade 2), out of which pelvic lymph node dissection was performed in 78 (86.7%) cases. Among the 90 patients, 54 (60%) had medical comorbidities. It was reported that 35% (n=32) of the patients had myometrial invasion of more than 50% thickness. Furthermore, 13.8% of patients with deep myometrial invasion had lymph node metastasis, while only one patient (2%) in the superficial or no myometrial invasion group had lymph node metastasis. Therefore, the absence of deep myometrial invasion has a negative predictive value of around 98% for excluding pelvic lymph node metastasis. Conclusion: Approximately one in seven patients with deeply infiltrating differentiated endometrial cancer had lymph node metastasis. In limited resource settings where preoperative pelvic MRI is not readily available, implementing a policy of routine surgical pelvic lymph node assessment would be beneficial. This approach would aid in detecting stage IIIc disease and also help avoid unnecessary pelvic irradiation.