Endometrial cancer is the most common gynecologic malignancy in the developed world. Most cases are diagnosed at an early stage and have low-grade histology, portending an overall excellent prognosis. There exists a subgroup of patients with early, high-risk disease, whose management remains controversial, as current data is clouded by inclusion of early stage tumors with different high-risk features for recurrence, unstandardized protocols for surgical staging, and an evolving staging system by which we are grouping these patients. Here, we present preoperative and intraoperative considerations that should be taken into account when planning surgical management for this population of patients. 1. Introduction Endometrial cancer is the most common gynecologic malignancy in the developed world. In 2013, it is estimated that over 49,000 new cases will be diagnosed and 4,000 deaths will be reported in the United States [1]. The overall prognosis is excellent for most patients diagnosed with early stage and low-grade disease. Recently, there has been a movement away from comprehensive surgical staging for women with endometrial cancer. This is driven, in part, by the lack of apparent benefit seen in a number of studies along with the presumed morbidity ascribed to lymphadenectomy. There are, however, well-established risk factors for patients with early stage disease which may confer a poorer survival advantage, including increasing age, grade 2-3 histology, positive lymphovascular space involvement, and outer 1/3 myometrial involvement [2]. This high-intermediate risk group of patients is defined by (1) any age with 3 of the above risk factors, (2) age ≥ 50 years with 2 of the above risk factors, and (3) age ≥ 70 years with at least one of the above risk factors [3]. The impact of surgical staging in the cohort of women with early stage disease with high to intermediate risk factors has not been investigated. Instead, these patients have been “lumped together” with women with low-risk disease, potentially obscuring any observable benefit. Further, in this subset of patients, adjuvant therapy may impact progression free and overall survival. The management of this subset of women is the focus of this paper. Management of patients with high to intermediate risk endometrial cancer is controversial. This is not surprising as the published literature that we may use to inform intraoperative and adjuvant treatment decisions is difficult to interpret. Studies sometimes include patients that have undergone comprehensive surgical staging that are incompletely
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