Cancer arising from the lining of the womb, known as endometrial carcinoma, is now the most common gynaecological cancer in western Europe and North America. Most women (75%) still have their tumour confined to the body of the womb at diagnosis and three-quarters of women with endometrial cancer will survive for five years after diagnosis. Lymph node metastases can be found in approximately 10% of women, who clinically have cancer confined to the womb at diagnosis, and removal of all pelvic and para-aortic lymph nodes is widely advocated, even for women with presumed early stage cancer. Lymph node removal is part in the international staging sytem (FIGO) for endometrial cancer. This recommendation is based on non-randomised studies that suggested improvement in survival following removal of pelvic and para-aortic lymph nodes. However, treatment of pelvic lymph nodes may not be directly therapeutic and may just indicate that a woman has a more aggressive cancer and therefore a poorer prognosis. Results of a systematic review and meta-analysis of RCTs of routine radiotherapy to treat possible lymph node metastases in women with early-stage endometrial cancer, did not improve survival, which was contrary to previously recommended treatment, based on evidence from non-randomised studies. Hence, more treatment to lymph nodes might not necessarily be better treatment, especially as surgical removal of pelvic and para-aortic lymph nodes has serious potential short and long-term harmful effects and most women will not have positive lymph nodes.
We found only two trials that compared lymphadenectomy with no lymphadenectomy in women with endometrial cancer. These two trials enrolled 1945 women. When we combined the findings from these two trials, we found that there was no evidence that women who received lymphadenectomy were less likely or more likely to die or have a relapse of their cancer. There were a considerable number of deaths and disease recurrences in the trials. Kitchener 2009 reported 191 deaths and 173 disease recurrences; Panici 2008 reported 53 deaths and 78 disease recurrences, so the estimates are likely to be accurate. The uncertainty of whether lymphadenectomy or no lymphadenectomy is best probably reflects the fact that there is no benefit in undertaking lymphadenectomy, rather than a lack of statistical power to detect a difference. More women experienced severe adverse events as a consequence of lymphadenectomy than those having no lymphadenectomy. The main limitations of the review were that we did not find any trials that evaluated either pelvic lymph node sampling, pelvic and para-aortic lymphadenectomy or the removal of bulky pelvic lymph nodes and the fact that quality of life (QOL) was not reported in either trial. The QOL for women following treatment is especially important for a condition that has relatively good survival rates.