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Surgical staging of endometrial cancer: does the patient benefit?

One decade ago, in part as a response to the then recent publications detailing the inaccuracy of clinical staging and the importance of extrauterine spread, FIGO designated endometrial cancer a surgically staged malignancy [1–4]. The initial FIGO clinical staging of endometrial cancer established 40 years earlier was based solely on operability and evidence of extrauterine spread. In 1961, the clinical staging schema was altered to include the potential adverse effect of cervical involvement and bladder or rectal extension. Ten years later, uterine size and tumor grade were incorporated into the clinical staging system. In 1998, FIGO adopted surgical staging, recognizing the importance of myoinvasion, depth of cervical invasion, site of metastasis, and results of peritoneal cytology. While surgical staging was not intended to predicate treatment, few can disagree that the collection of important pathologic information allows an increased understanding of biologic behavior, assists in the detection of extrauterine disease, potentially facilitates management decisions, and certainly improves communication regarding treatment results of patients within a specific surgical stage. These benefits should be welcome in the management of any malignant disease, particularly in one which has demonstrated a near twofold increase in mortality/incidence ratio during the past decade [5]. The adoption of surgical staging has created clinical anxieties as to who best directs management and has prompted questions as to actual patient benefit and necessary extent of procedure. Some argue that this is a “community” disease process and retroperitoneal evaluation is not the standard or even necessary. The importance or benefit of extensive surgical staging has been championed by a number of authors [6–9], questioned by some [10, 11], and denied by others [12]. In an effort to determine the potential patient benefit derived from surgical staging, a number of simple questions should be addressed.