We would like to thank Drs Toptas and Simsek for their comments regarding our recent article. Analyzing a large population-based database of patients with endometrial cancer (EC), we found that omission of systematic lymphadenectomy in women with stage I grade I or II EC has no impact on survival.

The comments of Toptas and Simsek suggest that the proper question to ask is not whether lymphadenectomy has survival influence but rather how to improve prediction of lymph node (LN) involvement and evaluate the disease stage in patients with EC. We agree with this point of view. To date, the therapeutic value of systematic lymphadenectomy is still controversial, and guidelines regarding the type and extent of LN dissection are debated. In clinical practice the decision to perform systematic lymphadenectomy depends on both primary site tumor characteristics (ie, grade differentiation, histological subtype, deep myometrial invasion, lymphovascular space invasion, and cervical stromal involvement) and clinical parameters (ie, age and comorbidities). As underlined by Toptas and Simsek, identification of LN involvement and correct disease staging is essential to decide the best therapeutic approach. Clinical and pathological variables (eg, myometrial invasion, histological type, and grade) have been almost constantly reported to be associated with the risk of LN metastasis, but individually none of these characteristics can be used to identify a subset of patients for whom LN resection is unnecessary. As emphasized by Toptas and Simsek, nowadays the accuracy of preoperative evaluations of myometrial invasion, tumor grade, and primary tumor extension is unfortunately not adequate to determine whether lymphadenectomy is required or not. Moreover, the accuracy of frozen section has been demonstrated when the tumor diameter is <3 cm.

In this context, we have developed and validated a robust nomogram based on clinical and routinely definitive pathological characteristics of the hysterectomy specimen that is able to predict the risk of LN metastasis in patients with EC. By providing predictions that are both evidence based and individualized, these estimates have the potential to improve medical decision in management and to help inform the decision-making process of physicians.

In contrast to Toptas and Simsek comments, in cases of underestimation of the myometrial invasion or grade, it is possible to perform a secondary lymphadenectomy and to adapt the adjuvant therapy upon the definitive pathological findings. To conclude, our intention is not to undertreat patients but to promote individualized procedures to avoid unnecessary lymphadenectomy surgery.