Evolution of lymph node assessment in endometrial carcinoma: a cohort study within the 2025 European prognostic...

European guidelines for endometrial carcinoma have shifted from selective to routine surgical lymph node assessment. This study evaluated the 2025 prognostic classification for its potential to identify patient subsets who could safely omit surgical staging.

This retrospective cohort study included patients treated at a single tertiary center. The predictive model incorporated preoperative histology, molecular classification, and estrogen receptor expression, in line with the European guidelines.

A total of 1063 patients were included. Among those staged, the incidence of stage IIIC disease was 2.0% (6 out of 298) when the primary tumor met low-risk prognostic group criteria, accounting for 39.1% of all patients who underwent lymph node assessment (298 out of 762). The incidence of stage IIIC was 10.4% (19 out of 183) when intermediate-risk prognostic criteria were met and 12.2% (12 out of 98) when high-intermediate-risk prognostic criteria were met. Among staged patients, the incidence of stage IIIC disease was 7.9% in those who met the model-defined low-risk features for nodal involvement, and 266 out of 746 (35.7%) fulfilled these features (stage IV excluded). When pathologically assessed myometrial invasion was added as an additional parameter for no specific molecular profile carcinomas, the risk of stage IIIC disease was 3.3% among staged patients who met low-risk features for nodal involvement, and 181 out of 746 (24.3%) fulfilled these features (stage IV excluded). Stage IIIC1-2 accounted for 6.5% (6 out of 93) of all stage IIIC cases in the analysis.

Pathologic and molecular evaluation according to European guidelines lacks accuracy in predicting nodal involvement in endometrial carcinoma, favoring routine staging when used alone. The small risk of nodal metastasis in carcinomas with features suggestive of low risk, combined with their substantial proportion, supports pursuing algorithms for selective staging. Incorporating myometrial invasion may enable a selective approach.