Nodal assessment represents a crucial point in the management of endometrial cancer. Node negative uterine-confined endometrioid endometrial cancer patients experience excellent survival outcomes, being overall survival more than 80–90% at 5 years. In node positive disease, survival decreased to 60–70% at 5 years [Citation1]. Although randomized trials failed to demonstrate a possible therapeutic role of lymphadenectomy in endometrial cancer, nodal assessment represent an integral part of staging surgery in uterine neoplasm [Citation1]. Nodal assessment has important prognostic implication and might help to plan postoperative treatment, thus having an indirect therapeutic role [Citation1].
Recently, sentinel node mapping replaced systematic lymphadenectomy during staging surgery for endometrial cancer [Citation2–4]. Sentinel node mapping is associated with lower morbidity than lymphadenectomy. Moreover, sentinel node mapping is not inferior to systematic lymphadenectomy in term of detection rate. Accumulating data suggested that sentinel node mapping improves detection rate of positive nodes in comparison to lymphadenectomy, thanks to the application of ultrastaging on sentinel nodes harvested. It is estimated that the adoption of sentinel node mapping (and ultrastaging) increase positive node detection rate of more than 30%, being ultrastaging able to detect low volume disease not detectable with conventional histological examination [Citation5].
In the present paper, the Authors investigated the role of preoperative workup in endometrial cancer patients [Citation6]. The authors observed that PET/CT scan shows high sensitivity but moderate specificity for nodal involvement and might help in avoiding unnecessary extensive nodal dissection in patients with sentinel node mapping failure [Citation6].Considering the growing adoption of sentinel node mapping, PET/CT might help in formulating preoperative and operative plans. However, we have to take in account that almost all scientific societies suggested to avoid the use of complex preoperative workup in endometrial cancer patients [Citation7,Citation8]. The American Congress of Obstetricians of Gynecologists (ACOG) recommends that “only a physical examination and a chest radiograph are required for preoperative staging of the usual (type I endometrioid grade 1) histology, clinical stage I patient” [Citation7,Citation8]. Similarly, the Society of Gynecology Oncology (SGO) and the European Society for Medical Oncology (ESMO), the European Society for Radiotherapy and Oncology (ESTRO), and the European Society of Gynaecological Oncology (ESGO) consensus conference do not recommend preoperative imaging assessment, suggesting the option of imaging only for patients with clinically advanced or metastatic endometrial cancer [Citation8]. The role of adopting PET/CT and its cost-effectiveness in the context of sentinel node mapping have to be further validated into prospective trials. We can expected that costs utility of PET/CT is depending on the class of risk of endometrial cancer. As observed for CT scan [Citation8], in high-risk patients PET/CT would be useful in identify gross intra-abdominal disease and suspected nodes, thus tailoring surgical plans. We have to point out that in the era of the molecular/genomic characterization, tumor profiling would overcome imaging, surgical and pathological findings, allowing to identify the most accurate and effective treatment modality for endometrial cancer patients. Further evidence is needed to investigate the incorporation of molecular/genetic data and the potential implication of combining these data with preoperative imaging results. Additionally, the growing adoption of radiomics would be useful in predicting behavior and prognosis of various endometrial cancers [Citation9], thus potentially providing valuable information for personalized therapies.
Disclosure statement
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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