Editorial [Hot Topic: Surgical Treatment of Endometrial Cancer (Guest Editor: Maite Cusido Gimferrer)]

Endometrial adenocarcinoma is a high prevalence tumor in the industrialized world, and whose incidence is progressively increasing. Its association with obesity, diabetes and sedentary lifestyles explain the increase of cases in urban cultures and possibly it should be considered as an indicator of poor social health, in this case, secondary to the progress of an industrialized population. Globally analyzed, it can be considered a tumor of good prognosis. Survival rates are around 81% in industrialized countries. The reason for this may be its frequent early diagnosis due to symptoms appearing fairly soon. It is mainly detected in menopausal women by abnormal bleeding, generally at stage I; thus not requiring an expensive early diagnostic system. However, even though survival at stage I is about 97%, advanced stage cases or those with poor prognostic factors are also diagnosed, with a mortality rate that has been unchanged for ages despite the use of adjuvant techniques to surgery. Since Creasman's work in 1987 [1] myometrial invasion, tumor grading and nodal involvement have been considered the most important prognostic factors. Despite the development of current diagnostic techniques, the International Federation of Gynecology and Obstetrics (FIGO) calls for a surgical classification establishing the above mentioned prognostic factors. The disagreement on establishing the extent of the staging surgery causes great controversy. Since a hysterectomy is mandatory in the treatment, uterine prognostic factors will always be analyzed, but not usually with lymph nodes. There are supporters and detractors of performing a lymphadenectomy in endometrial adenocarcinoma. However, in 1988 the FIGO [2] stated that correct staging of endometrial cancer required both a pelvic and a para-aortic lymphadenectomy. Since then it has been proposed that radiotherapy is not necessary when the lymphadenectomy shows no node involvement. Nevertheless, there is little clinical evidence regarding the benefits of lymphadenectomy, a procedure that increases morbidity as well [3]. Although large series have reported an improvement in survival rates following a lymphadenectomy [4, 5], with some considering that its scope is a determining factor [6-10], the ASTEC study [11] found no impact on survival. The results of the ASTEC study are complemented by the findings of an Italian multicentre study [12] which randomized 500 patients and also reported no differences in survival rates between the groups. However, both these studies were criticized by Hockel and Dornhofer [13], who pointed out that the disease was only treated at the pelvic level. Another criticism of this study was that in the standard surgery group the surgeon could remove the pelvic nodes if s/he considered that this would benefit the woman. This concession contradicts the stated aim of the study. Moreover, the fact that 43% of patients included were low risk dilutes the possible therapeutic effect of lymphadenectomy [14, 15]. Just recently Todo et al. [16] from Japan have published a retrospective cohort study (SEPAL) in which they compare intermediate- and high- risk patients, who had been treated with pelvic lymphadenectomy or pelvic and para-aortic lymphadenectomy. They show that overall and disease-free survival is significantly improved in the pelvic and para-aortic lymphadenectomy group. They conclude that pelvic limphadenectomy alone might be an insufficient surgical procedure for endometrial cancer in patients at risk of limph node metastasis and also suggest that adjuvant chemotherapy could further improve survival of patients at high risk of limph node metastasis. Although this is a retrospective study, it confirms the clinical suspicion that para-aortic lymphadenectomy has a therapeutic benefit in intermediate- and high-risk patients but not in low-risk patients. Even though nodal status is controversial, the prognosis is significantly poorer when there is lymph node involvement. Lymphadenectomy varies depending on the medical centre where it is performed. It ranges from ignoring the nodal study, to selective biopsy of palpable nodes, to pelvic or pelvic-aortic lymphadenectomy. The particular uterine lymphatic drainage following two different paths, either the uterine artery or the utero-ovarian vessels, explains lymph node metastases in atypical areas. The progression from the pelvic to the para-aortic region is not as constant as to the cervix and even frequent involvement sites are not definable. Sentinel lymph node determination is considered a technique of better prospects to locate the area of higher involvement risk in each particular case, although experience in its application is still needed.....