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

Author(s): Mikel Gorostidi, MD, MSc, PhD, Marta Heras, MD, PhD, Mª Teresa Iglesias, PhD, Mar Rubio, MD, Nabil Manzour, MD, Rubén Ruiz Sautua, MD, Ibon Jaunarena, MD, Juan Céspedes, MD, Paloma Cobas, MD, Arantxa Lekuona, MD

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.