No survival benefit is associated with pelvic and para-aortic lymphadenectomy in lymph node–negative early-stage endometrioid endometrial cancer

OBJECTIVE: The therapeutic role of lymphadenectomy in endometrial cancer remains controversial. Although systematic pelvic and para-aortic lymphadenectomy (PPLND) has been suggested to improve survival in certain patients, randomized trials have failed to demonstrate a definitive benefit. This study aimed to evaluate the therapeutic value of lymphadenectomy according to risk groups in patients with early-stage, node-negative endometrioid endometrial cancer. METHODS: A retrospective review was conducted of 654 lymph node–negative patients with FIGO 2009 stage I–II endometrioid endometrial carcinoma who underwent primary surgical treatment at Bursa Uludağ University between 2000 and 2025. Patients were categorized into three surgical groups: no lymphadenectomy (n = 139), pelvic lymphadenectomy (PLND, n = 119), and combined pelvic plus para-aortic lymphadenectomy (PPLND, n = 396). Clinicopathological features, recurrence patterns, disease-free survival (DFS), and overall survival (OS) were compared across groups. Subgroup analyses were performed for low-, intermediate-, and high–intermediate-risk categories. RESULTS: Adverse pathological features including stage IB–II disease, higher grade, deep myometrial invasion, and LVSI were more frequent in the PPLND group (all p < 0.001). Recurrence rates were 9.4% (13/139) in the no-lymphadenectomy group, 5.9% (7/119) after PLND, and 8.3% (33/396) after PPLND, with no significant difference between groups (p = 0.575). However, local recurrences predominated in the no-lymphadenectomy group, whereas distant relapses were more common after PPLND (p = 0.016). In univariate analysis, FIGO stage, LVSI, deep myometrial invasion, and adjuvant chemoradiotherapy were associated with poorer DFS; in multivariate analysis, only chemoradiotherapy remained an independent adverse factor (HR 2.30, 95% CI 1.04–5.10, p = 0.041). For OS, age was the sole independent prognostic factor (HR 1.09, 95% CI 1.07–1.11, p < 0.001). Kaplan–Meier analysis by risk group showed no significant survival differences: in the low-risk group, PPLND patients displayed more favorable DFS/OS curves without statistical significance (DFS p = 0.340; OS p = 0.278). No survival benefit was observed in intermediate (DFS p = 0.725; OS p = 0.935) or high–intermediate-risk groups (DFS p = 0.449; OS p = 0.543). CONCLUSIONS: Systematic lymphadenectomy does not provide a therapeutic survival benefit in early-stage, node-negative endometrioid endometrial cancer, irrespective of risk stratification. The principal value of nodal assessment lies in accurate staging and guiding adjuvant therapy.