The Role of Surgery in Management of Primary Metastatic Endometrial Cancer

For the majority of patients with endometrial cancer who are diagnosed at an early stage, high-quality evidence directs mainstay initial surgical treatment, which confers excellent long-term survival. Conversely, the 8%-15% of endometrial cancers diagnosed at a clinically advanced stage with primary metastatic disease have a significantly worse prognosis and a 5-year relative survival rate of 15%-20%. The management of primary advanced endometrial cancer is understudied with the majority of relevant evidence being retrospective, single institution, and in heterogenous populations (combined with management of recurrent endometrial cancer), and there are few prospective studies that focus solely on primary advanced disease. It appears that hysterectomy and surgical cytoreduction may improve long-term survival in metastatic endometrial cancer; however, it remains unclear which patients are most likely to benefit. Furthermore, the new integration of molecular classifications to the management of endometrial cancer has opened up new prognosis and treatment perspectives; however, the majority of current trials investigating new management paradigms based on molecular features exclude advanced-stage disease, so the implications for practice regarding this patient group are understudied. This review analyzes the current available evidence regarding surgical management of primary metastatic endometrial cancer, including current international guideline recommendations, evidence for primary cytoreductive surgery and neoadjuvant systemic treatment followed by surgery, surgical resection of distant metastases, and lymph node management.