The cumulative results of these studies reported that

lymphadenectomy did not improve disease-free survival (pooled hazard ratio [HR], 1.23; 95% confidence interval [CI], 0.96–1.58) and overall survival (pooled HR, 1.07; 95% CI, 0.81–1.43).[6, 7] These findings should be interpreted with caution, however, because of several pitfalls in the study design of both trials. First, they included a large proportion of low-risk women, which diluted the possible therapeutic effects of lymphadenectomy. Given the low rate of lymphatic spread in the early stage of disease (9%–13%), it is not surprising that the two trials SB525334 mouse failed to find any therapeutic role for pelvic lymphadenectomy in the low-risk population. Second, no clear indication was given for postoperative adjuvant therapy. One of the

main goals of lymphadenectomy MAPK Inhibitor Library in vitro is to tailor adjuvant treatment to decrease radiation-related morbidity in patients with negative nodes. However, the adjuvant therapy administration rate was similar in both study arms; this result obviously influenced postoperative outcomes. Third, neither trial evaluated appropriately the role of para-aortic lymphadenectomy. In patients with lymphatic spread, para-aortic node involvement occurs in 60% of patients with endometrioid EC and 70% of those with non-endometrioid EC.[8] Therefore, the performance of pelvic lymphadenectomy alone represents an incomplete surgical effort because of the partial removal of metastatic nodes. Additionally, in the ASTEC trial,[7] the number of pelvic nodes yielded was low in many of the patients. The median

number of pelvic nodes harvested was 12 (range, 1–59); moreover, in the lymphadenectomy arm, 241 women (35%) had nine or fewer nodes and 72 women (12%) had four or fewer nodes. Recently, in response to the current evidence that pelvic lymphadenectomy alone did not provide any significant benefit on EC, Todo et al.[9] designed a retrospective cohort TCL analysis (the SEPAL study) aimed at assessing the role of para-aortic lymphadenectomy. The authors compared outcomes of patients undergoing systematic pelvic lymphadenectomy or combined pelvic and para-aortic lymphadenectomy in intermediate- and high-risk EC patients. The SEPAL study showed that high-risk patients who had pelvic and para-aortic lymph node dissection experienced a longer overall survival than patients who had pelvic lymphadenectomy alone (HR, 0.53; 95% CI, 0.38–0.76; P < 0.001).