title: Surgical treatment of endometrial cancer in developing countries: reasons to consider systematic two-step surgical treatment.
abstract: OBJECTIVE
  The aim of this study was to determine the lymph node status in a large cohort of women with endometrial cancer from the public health system who were referred to an oncology reference center in Brazil to identify candidates for the omission of lymphadenectomy based on clinicopathological parameters.
  
  
  METHODS
  We retrospectively analyzed a cohort of 310 women with endometrial cancer (255 endometrioid, 40 serous, and 15 clear cell tumors) treated between 2009 and 2014. We evaluated the histological type, grade (low vs. high), tumor size (cm), depth of myometrial invasion (≤50%, >50%) and lymphovascular space invasion to determine which factors were correlated with the presence of lymph node metastasis.
  
  
  RESULTS
  The factors related to lymph node involvement were tumor size (p=0.03), myometrial invasion (p<0.01), tumor grade (p<0.01), and lymphovascular space invasion (p<0.01). The histological type was not associated with the nodal status (p=0.52). Only twelve of 176 patients (6.8%) had low-grade endometrioid carcinoma, tumor size ≤2 cm and <50% myometrial infiltration.
  
  
  CONCLUSIONS
  The omission of lymphadenectomy based on the histological type, grade, tumor size and depth of myometrial invasion is not likely to have a large impact on the surgical treatment of endometrial cancer in our population because most patients present with large and advanced tumors. New strategies are proposed that prioritize hysterectomy performed in a general hospital as soon as possible after diagnosis, followed by an evaluation of the need for lymph node dissection at a reference center.
authors.affiliation: Department of Obstetrics and Gynecology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
authors.forename: Cristina
authors.initials: C
authors.lastname: Anton
authors.affiliation: Department of Obstetrics and Gynecology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
authors.forename: Giovanni Mastrantonio
authors.initials: GM
authors.lastname: di Fávero
authors.affiliation: Department of Advanced Operative and Oncologic Gynecology, Asklepios Hospital Hamburg, Hamburg, Germany.
authors.forename: Christhardt
authors.initials: C
authors.lastname: Köhler
authors.affiliation: Department of Pathology, Instituto do Câncer do Estado de São Paulo - Octavio Frias de Oliveira (ICESP), São Paulo, SP, Brazil.
authors.forename: Filomena Marino
authors.initials: FM
authors.lastname: Carvalho
authors.affiliation: Department of Obstetrics and Gynecology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
authors.forename: Edmund Chada
authors.initials: EC
authors.lastname: Baracat
authors.affiliation: Department of Obstetrics and Gynecology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
authors.forename: Jesus Paula
authors.initials: JP
authors.lastname: Carvalho
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001938:Brazil; D016889:Endometrial Neoplasms / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007044:Hysterectomy; D008197:Lymph Node Excision / Q000379:methods*; D008198:Lymph Nodes / Q000473:pathology; D008875:Middle Aged; D012189:Retrospective Studies