0 cm) have less than 1% risk of lymphatic spread, while patients with tumor diameter greater than 2.0 cm or with preoperative diagnosis of endometrioid grade 3 or non-endometrioid EC had a substantial risk of lymphatic involvement greater than 10% (Fig. 2).[14] Other authors have used preoperative imaging and serum markers, suggesting that tumor volume (measured with magnetic resonance imaging), positron emission tomographic scan find more findings,[28] and preoperative cancer antigen 125 or human epididymis protein 4 levels may be useful

in tailoring the indications for lymphadenectomy.[20, 21, 29] Our experience suggests that frozen-section analysis may represent a safe and effective method to direct the operative plan in selected medical centers. However, if frozen-section analysis is not available or if it is not reliable, findings of preoperative endometrial sampling associated with intraoperative tumor size, imaging studies and serum markers are alternative methods to identify patients who may benefit from comprehensive surgical staging.

Traditional imaging, node palpation through the peritoneum and node sampling are inaccurate in predicting lymph BGB324 clinical trial node positivity.[5] In 2005, ACOG recommended that ‘retroperitoneal lymph node assessment is a critical component of surgical staging’ because it ‘is prognostic and facilitates targeted therapy to maximize survival and to minimize Ergoloid the effect of undertreatment and potential morbidity associated with overtreatment’.[5] Nevertheless, in clinical practice a high variation of procedures reflects the lack of standardization of lymphadenectomy: techniques vary from elective omission to simple lymph node sampling, to systematic pelvic lymphadenectomy with or without para-aortic lymphadenectomy. One investigation at Mayo

Clinic illustrated the prevalence and site of pelvic and para-aortic lymphatic metastases. We reported that, among patients with lymphatic spread, 84% and 62% had pelvic and para-aortic node metastases, respectively. In particular, 46%, 38% and 16% had involvement of both pelvic and aortic nodes, pelvic nodes only and aortic nodes only, respectively.[8] Para-aortic lymph nodes can be classified based on their location above and below the inferior mesenteric artery (IMA). At Mayo Clinic, we evaluated para-aortic metastatic site frequency relative to the IMA and found that aortic nodes above the IMA were involved in 77% of cases.[8, 30] Fotopoulou and coworkers[31] corroborated these results; they reported that metastatic disease above the IMA was recorded in 54% and 70% patients with stage IIIC and IIIC2 EC, respectively. Recently, a prospective study by our department suggested that, considering patients with aortic node involvement, high para-aortic lymph node metastases were detected in 88% of them, with no discernible difference between endometrioid (89%) and non-endometrioid (88%) histological subtypes.