2 2. Complete Surgical Staging: Role of Lymphadenectomy in Endometrial Cancer A complete surgical staging, including lymphadenectomy is the gold standard to evaluate lymph node involvement, the most common site of extrauterine spread of endometrial cancer. However, the exact role, indications, and extent of lymphadenectomy in endometrial cancer patients remain controversial [4, 6, 11–13]. A recent Cochrane protocol conﬁrmed the prognostic role of lymphadenectomy, while its therapeutic role, the advantages in terms of survival, and extent of anatomical standardization are under debate [4]. Lymph node metastasis has been described, as well as one of the strongest predictors of disease recurrence and as a guide for subsequent adjuvant therapy in patients with positive lymph nodes. Patients with stage I disease have more than 90% 5-year survival rate compared to those with nodal metastasis who have survival rates ranging from 38% to 75% [14]. In a retrospective study, Bernardini et al. veriﬁed that a substantial number of patients with grade 1 endometrial cancer, based on preoperative and intra operative assessment, had higher grade disease on ﬁnal pathology. Lymphadenec- tomy did not aﬀect survival in these patients; however, it could identify patients with advanced disease and assist in tailoring adjuvant therapy for those with adverse risk factors [15]. Nevertheless, the exact therapeutic beneﬁt in terms of survival associated with lymphadenectomy is diﬃcult to deﬁne, especially in early stages. Recently, a multicentric randomized controlled trial (ASTEC) demonstrated no evidence of beneﬁt for systematic lymphadenectomy in terms of overall, disease-speciﬁc, and recurrence-free survival in women with endometrial cancer. A total of 1408 women, with a preoperative diagnosis of endometrial cancer conﬁned to the corpus uteri were randomized to standard surgery or standard surgery plus pelvic lymphadenectomy. A similar proportion of women in both groups received postoperative radiotherapy. After a median follow up of 37 months, there was no diﬀerence in overall survival between two groups and the analysis of disease or treatment-related death was in favour of the standard surgery group. Moreover, there was a signiﬁcant beneﬁt in recurrence-free survival for the standard surgery group, and surgical complication rates were higher in the lymphadenectomy group [16]. The results of the ASTEC trial, however, have been widely discussed. One important concern to limit the generalization of these results is the low number of lymph nodes (median of 12 lymph nodes) removed in the lymphadenectomy group. In the literature, excision of higher number of nodes was proved to have an eﬀect on overall survival, especially in patients with high- risk and intermediate-risk endometrial cancer [13, 17–19]. In addition, the ASTEC study did not assess the paraaortic nodes, which can be involved in up to 67% of patients with pelvic lymph node metastasis as demonstrated by Mariani et al. [20]. Another issue to be considered is the high rate of low-risk patients (STAGE 1A-1B grade 1-2) included in lymphadenectomy group, and subsequently low rates of Obstetrics and Gynecology International pelvic node metastasis. Finally, the follow up duration was considered too short for a survival study of a malignant disease. Furthermore, complete staging was not found to improve overall survival and disease-free survival in another RCT that compared treatment of early stage endometrial carcinoma with and without systematic pelvic lymphadenectomy [21]. A retrospective database review considered 12,333 patients undergoing surgical staging by lymphadenectomy and stratiﬁed them in groups: a low-risk (Stage IA, all grades and Stage IB, grade 1 and 2) and a medium- to high-risk group (Stage IB, grade 3 and Stage IC-IV, all grades). In low-risk group, there was no signiﬁcant beneﬁt of nodal resection, while a multivariate analysis demonstrated that in the medium- to high-risk group a more extended nodal resection was associated with increased 5-year survival [13]. 3. Preoperative Evaluation: Predictors of Lymph Node Metastasis There is general agreement that deﬁnitive staging of endome- trial cancer is based on pathological examination, but an accurate preoperative risk stratiﬁcation guides to the appro- priate type of surgery, avoiding the morbidity associated with unnecessary procedures [2, 6]. Both histopathological and clinical risk factors have been identiﬁed as predictors of lymph node involvement: histological type, grade of tumour, myometrial invasion, and cervical inﬁltration [2–6, 14, 22, 23]. 3.1. Preoperative Endometrial Biopsy. Tumour histological grading remains the most important preoperative factor in identifying risk status. There is only poor correlation between histological grade of tumour based on endometrial biopsy or D&C and ﬁnal pathology. Histological upgrading was demonstrated in 18% of endometrial cancer patients after deﬁnitive histological examination [2, 24, 25]. On the other hand, the identiﬁcation of clear cell or papillary serous carcinoma was demonstrated to have increased risk of distant metastasis, even in case of endometrial conﬁned lesions [26]. 3.2. Imaging Modalities and Risk Stratiﬁcation. As regards preoperative clinical staging, several studies proposed that identiﬁcation of patients with deep myometrial invasions (more than 50%; FIGO stage IC) and preoperative knowl- edge of cervical stroma inﬁltration (FIGO stage IIb) are important determinants for surgical decision [27, 28]. Sev- eral techniques are used to evaluate the depth of myometrial invasion and cervical inﬁltration. In this context, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), and Transvaginal Sonography (TVS) are the main diag- nostic tools used. Comparing the diagnostic accuracy of these techniques, several studies demonstrated no signiﬁcant diﬀerences in performance for both myometrial extent and cervical invasion [29, 30]. A recent prospective study com- pared the high-frequency (5.0–9.0 MHz) TVS and contrast- enhanced MRI in preoperative staging of endometrial cancer. Authors concluded that, in expert hands, TVS seems to be a