Sentinel Lymph Node Biopsy Versus Systematic Lymphadenectomy in Endometrial Cancer: Real-World Evidence from a Propensity Score- Matched European Cohort

Abstract

Background:

Sentinel lymph node (SLN) biopsy has been proposed as a less invasive alternative to systematic lymphadenectomy (LND) in endometrial cancer staging. Robust real-world evidence comparing both approaches with adequate statistical adjustment remains limited.

Methods:

We conducted a retrospective cohort study of patients with histologically confirmed endometrial carcinoma who underwent primary surgical staging at Donostia University Hospital (2014–2023). Patients were classified according to nodal assessment strategy: SLN biopsy alone or SLN biopsy plus LND. Mapping was performed using dual indocyanine green injection and laparoscopic near-infrared detection. Propensity score matching (3:1 nearest neighbor) was applied using demographic, clinicopathological, and FIGO 2009 stage variables. Surgical, pathological, and oncologic outcomes were compared.

Results:

A total of 448 patients were included (116 SLN-alone, 332 SLN+LND). After Propensity Score- Matched (PSM), 439 patients were analyzed (112 vs 327). SLN biopsy alone was associated with shorter hospital stay (–1.05 days; p<0.001) and reduced lymphadenectomy rates (p<0.001), without differences in hemoglobin drop. Detection rates were comparable, with significantly higher three-zone detection in the SLN group (p=0.003). No significant differences were observed in progressionfree survival (HR 1.90, 95% CI 0.89–4.04) or overall survival (HR 1.50, 95% CI 0.57–4.11), including patients classified as preoperative high-risk.

Conclusion:

SLN biopsy provides comparable oncologic outcomes to systematic lymphadenectomy while significantly reducing surgical morbidity. These findings add large-scale European real-world evidence supporting SLN biopsy as a safe staging strategy in appropriately selected patients and may support future European guideline recommendations.