A United Kingdom national survey of pre-operative imaging and lymph node staging practices in early-stage endometrioid endometrial carcinoma

Background: The molecular classification system for endometrial carcinoma has been recently introduced, offering a new framework for diagnosis and management. This study aims to evaluate variations in clinical practice concerning pre-operative imaging and determine whether the adoption of molecular classification has influenced surgical staging practices. Methods: A peer-reviewed online survey was distributed to members of the British Gynaecological Cancer Society (BGCS) using Microsoft Forms. The survey was conducted from 26 January 2024, to 02 August 2024. Data from the responses were analyzed using Microsoft Excel (Version 16.89.1, 2024). Results: The survey received 69 responses, representing 82% of cancer centres in the United Kingdom (UK). For grade 1 endometrial carcinomas, 68 out of 69 respondents (99%) reported performing pelvic imaging (ultrasound or magnetic resonance imaging (MRI)) for pre-operative staging, with 32 out of 69 (46%) performing pelvic imaging exclusively. Among cases of grade 2 carcinomas, 27 out of 69 respondents (39%) relied solely on pelvic imaging. For grade 3 endometrial carcinomas, 68 out of 69 respondents (99%) reported conducting chest, abdomen, and pelvis Computerised Tomography (CT) scans. Notable variations were observed in lymph node staging practices. The majority of centres do not perform lymph node excision for grade 1–2, stage 1A carcinomas. Sentinel lymph node biopsy is typically employed for grade 1–2, stage 1B or higher and for all grade 3 carcinomas. Conclusions: There is significant variability in the approaches to pre-operative imaging and lymph node staging for grade 1 and grade 2 endometrioid endometrial carcinomas across the UK. Enhancing adherence to guidelines could increase the use of pre-operative chest X-rays while reducing the frequency of CT scans, thereby minimising radiation exposure for patients with low-risk endometrial carcinomas. Expanding access to sentinel lymph node biopsies will have substantial implications for provision of services, particularly cancer units, in the UK.

Gynaecological cancer; Endometrial cancer; Pre-operative imaging; Lymph node staging; Molecular classification

[1] World Cancer Research Fund. Endometrial cancer statistics. 2025. Available at: https://www.wcrf.org/preventing-cancer/cancer-statistics/endometrial-cancer-statistics/ (Accessed: 30 November 2024).

[2] NHS England. Cancer registration statistics, England, 2022. 2024. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/cancer-registration-statistics/england-2022/incidence-by-main-cancer-group (Accessed: 30 November 2024).

[3] Nikolay Geshev, Dimitrov R, Kirkov V, Vodenicharova A, Yanakieva A, Slavov S. Preoperative ultrasound assessment of myometrial invasion in endometrial cancer and prediction of surgical stage. Biotechnology & Biotechnological Equipment. 2022; 36: 753–758.

[4] Maheshwari E, Nougaret S, Stein EB, Rauch GM, Hwang KP, Stafford RJ, et al. Update on MRI in evaluation and treatment of endometrial cancer. Radiographics. 2022; 42: 2112–2130.

[5] Morrison J, Balega J, Buckley L, Clamp A, Crosbie E, Drew Y, et al. British gynaecological cancer society (BGCS) uterine cancer guidelines: Recommendations for practice. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2022; 270: 50–89.

[6] Concin N, Matias-Guiu X, Vergote I, Cibula D, Mirza MR, Marnitz S, et al. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. International Journal of Gynecological Cancer. 2021; 31: 12–39.

[7] Haltia U-M, Bützow R, Leminen A, Loukovaara M. FIGO 1988 versus 2009 staging for endometrial carcinoma: a comparative study on prediction of survival and stage distribution according to histologic subtype. Journal of Gynaecologic Oncology. 2014; 25: 30–35.

[8] Berek JS, Matias-Guiu X, Creutzberg C, Fotopoulou C, Gaffney D, Kehoe S, et al.; Endometrial Cancer Staging Subcommittee, FIGO Women’s Cancer Committee. FIGO staging of endometrial cancer: 2023. International Journal of Gynaecology and Obstetrics. 2023; 162: 383–394.

[9] León-Castillo A, Boer SMd, Powell ME, Mileshkin LR, Mackay HJ, Leary A, et al. Molecular classification of the PORTEC-3 trial for high-risk endometrial cancer: impact on prognosis and benefit from adjuvant therapy. Journal of Clinical Oncology. 2020; 38: 3388–3397.

[10] Casanova J, Duarte GS, da Costa AG, Catarino A, Nave M, Antunes T, et al. Prognosis of polymerase epsilon (POLE) mutation in high-grade endometrioid endometrial cancer: systematic review and meta-analysis. Gynecologic Oncology. 2024; 182: 99–107.

[11] Gordon RE, Mettler Jr FA, Wicks JD, Bartow SA. Chest X-rays and full lung tomograms in gynecologic malignancy. Cancer. 1983; 52: 559–562.

[12] Hashimoto C, Shigeta S, Shimada M, Shibuya Y, Ishibashi M, Kageyama S, et al. Diagnostic performance of preoperative imaging in endometrial cancer. Current Oncology. 2023; 30: 8233–8244.

[13] Amkreutz LC, Mertens HJ, Nurseta T, Engelen MJ, Bergmans M, Nolting E, et al. The value of imaging of the lungs in the diagnostic workup of patients with endometrial cancer. Gynecologic Oncology. 2013; 131: 147–150.

[14] Creasman WT, Morrow CP, Bundy BN, Homesley HD, Graham JE, Heller PB. Surgical pathologic spread patterns of endometrial cancer: a gynecologic oncology group study. Cancer. 1987; 60: 2035–2041.

[15] Praiss AM, Huang Y, St Clair CM, Tergas AI, Melamed A, Khoury-Collado F, et al. A modern assessment of the surgical pathologic spread and nodal dissemination of endometrial cancer. Gynecologic Oncology. 2020; 157: 329–334.

[16] Milam MR, Java J, Walker JL, Metzinger DS, Parker LP, Coleman RL, et al. Nodal metastasis risk in endometrioid endometrial cancer. Obstetrics and Gynecology. 2012; 119: 286–292.

[17] Abdelrahman AE, Salem A, Al Attar AZ, Elsebai E, Samy W, Ibrahim MA, et al. p53, Pirh2, and L1CAM as promising prognostic biomarkers of endometrial carcinoma: an immunohistochemical and genetic study. Applied Immunohistochemistry & Molecular Morphology. 2022; 30: 713–725.

[18] Corr B, Cosgrove C, Spinosa D, Guntupalli S. Endometrial cancer: molecular classification and future treatments. BMJ Medicine. 2022; 1: e000152.

[19] George A, Herbertson RA, Stillie A, McCormack S, Drean AM, Wesselbaum A, et al. Current management practices for endometrial cancer (EC) in the UK: a national healthcare professional survey (KNOW-EC). Clinical Oncology. 2024; 36: e448–e455.

[20] Rossi EC, Kowalski LD, Scalici J, Cantrell L, Schuler K, Hanna RK, et al. A comparison of sentinel lymph node biopsy to lymphadenectomy for endometrial cancer staging (FIRES trial): a multicentre, prospective, cohort study. The Lancet. Oncology. 2017; 18: 384–392.

[21] Persson J, Salehi S, Bollino M, Lönnerfors C, Falconer H, Geppert B. Pelvic sentinel lymph node detection in high-risk endometrial cancer (SHREC-trial)-the final step towards a paradigm shift in surgical staging. European Journal of Cancer. 2019; 116: 77–85.

[22] Cusimano MC, Vicus D, Pulman K, Maganti M, Bernardini MQ, Bouchard-Fortier G, et al. Assessment of sentinel lymph node biopsy vs lymphadenectomy for intermediate- and high-grade endometrial cancer staging. JAMA Surgery. 2021; 56: 157–164.