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Distribution of stage of endometrial cancer at presentation, USA 2004‐2010. Adapted from Siegel 2015.
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Figure 1

Distribution of stage of endometrial cancer at presentation, USA 2004‐2010. Adapted from Siegel 2015.

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Study flow diagram.
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Figure 2

Study flow diagram.

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Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
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Figure 3

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
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Figure 4

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Comparison 1 Survival, Outcome 1 Overall survival.
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Analysis 1.1

Comparison 1 Survival, Outcome 1 Overall survival.

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Comparison 1 Survival, Outcome 2 Recurrence‐free survival.
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Analysis 1.2

Comparison 1 Survival, Outcome 2 Recurrence‐free survival.

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Comparison 2 Adverse events, Outcome 1 Direct surgical morbidity.
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Analysis 2.1

Comparison 2 Adverse events, Outcome 1 Direct surgical morbidity.

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Comparison 2 Adverse events, Outcome 2 Lymphoedema or lymphocyst.
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Analysis 2.2

Comparison 2 Adverse events, Outcome 2 Lymphoedema or lymphocyst.

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Comparison 2 Adverse events, Outcome 3 Surgery‐related systemic morbidity.
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Analysis 2.3

Comparison 2 Adverse events, Outcome 3 Surgery‐related systemic morbidity.

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Summary of findings for the main comparison. Summary of findings table

Lymphadenectomy for the management of endometrial cancer

Patient or population: women with stage I endometrial cancer

Settings: inpatient or outpatient

Intervention: lymphadenectomy

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Lymphadenectomy

Overall survival
Follow‐up: median 37 to 49 monthsa

HR 1.07
(0.81 to 1.43)

1851
(2 studies)

⊕⊕⊕⊝
Moderateb

As a result of the way HRs are calculated, assumed and corresponding risks were not estimated

Recurrence‐free survival
Follow‐up: median 37 to 49 monthsa

HR 1.23
(0.96 to 1.58)

1851
(2 studies)

⊕⊕⊕⊝
Moderateb

As a result of the way HRs are calculated, assumed and corresponding risks were not estimated

Direct surgical morbidity

Study population

RR 1.93
(0.79 to 4.71)

1922
(2 studies)

⊕⊕⊕⊝
Moderateb

17 per 1000

33 per 1000
(13 to 80)

Moderate‐risk population

19 per 1000

37 per 1000
(15 to 89)

Surgery‐related systemic morbidity

Study population

RR 3.72
(1.04 to 13.27)

1922
(2 studies)

⊕⊕⊕⊝
Moderateb

3 per 1000

11 per 1000
(3 to 40)

Moderate‐risk population

5 per 1000

19 per 1000
(5 to 66)

Lymphoedema or lymphocyst

Study population

RR 8.39
(4.06 to 17.33)

1922
(2 studies)

⊕⊕⊕⊕
High

8 per 1000

67 per 1000
(32 to 139)

Moderate‐risk population

11 per 1000

92 per 1000
(45 to 191)

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; HR: Hazard ratio; RR: Risk ratio.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aMedian follow‐up was 37 months (interquartile range (IQR) 24 to 58 months) in the Kitchener trial and 49 months (IQR 27 to 79 months) in the trial of Panici.

bEstimate is imprecise, as a fair degree of uncertainty can be seen in the pooled estimate, as indicated by a 95% confidence interval.

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Summary of findings for the main comparison. Summary of findings table
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Table 1. Pre‐2009 FIGO staging

Stage

Extent of disease

I

Tumour limited to uterine body

IA

 Limited to endometrium

IB

< 1/2 myometrial depth invaded

 

IC 

> 1/2 myometrial depth invaded

II 

Tumour limited to uterine body and cervix

IIA

Endocervical invasion only

 

IIB

Invasion into cervical stroma

III 

 

Extension to uterine serosa, peritoneal cavity and/or lymph nodes

 

IIIA 

Extension to uterine serosa, adnexae or positive peritoneal fluid (ascites or washings)

 

IIIB 

Extension to vagina

 

IIIC

Pelvic or para‐aortic lymph nodes involved

IV

 

Extension beyond true pelvis and/or involvement of bladder/bowel mucosa

 

IVA 

Extension to adjacent organs

 

IVB

Distant metastases or positive inguinal lymph nodes
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Table 1. Pre‐2009 FIGO staging
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Table 2. FIGO staging (2009)

Stage

Extent of disease

1

Tumour confined to corpus uteri

IA

No or less than half myometrial invasion

IB

Invasion equal to or greater than half of the myometrium

II

Tumour invasion into cervical stroma but not extending beyond uterus

III

Local and/or regional spread of tumour

IIIA

Tumour invasion into serosa of corpus uteri and/or adnexae

IIIB

Vaginal and/or parametrial involvement

IIIC

Metastases to pelvic and/or para‐aortic lymph nodes

IIIC1

Positive pelvic nodes

IIIC2

Positive para‐aortic lymph nodes with or without positive pelvic lymph
nodes

Stage IV tumour invasion into bladder and/or bowel mucosa, and/or distant metastases

IVA

Tumour invasion into bladder and/or bowel mucosa

IVB

Distant metastases, including intra‐abdominal metastasis and/or inguinal nodes

Pelvic washings/cytology should be recorded separately and now does not change the stage.

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Table 2. FIGO staging (2009)
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Comparison 1. Survival

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Overall survival Show forest plot

2

1851

Hazard Ratio (Random, 95% CI)

1.07 [0.81, 1.43]

2 Recurrence‐free survival Show forest plot

2

1851

Hazard Ratio (Random, 95% CI)

1.23 [0.96, 1.58]
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Comparison 1. Survival
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Comparison 2. Adverse events

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Direct surgical morbidity Show forest plot

2

1922

Risk Ratio (IV, Random, 95% CI)

1.93 [0.79, 4.71]

2 Lymphoedema or lymphocyst Show forest plot

2

1922

Risk Ratio (IV, Random, 95% CI)

8.39 [4.06, 17.33]

3 Surgery‐related systemic morbidity Show forest plot

2

1922

Risk Ratio (IV, Random, 95% CI)

3.72 [1.04, 13.27]
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Comparison 2. Adverse events
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