We read with great interest the recent analysis of systematic lymphadenectomy in endometrial cancer (EC) that was reported by Bendifallah et al. This study suggests that omission of systematic pelvic lymphadenectomy in women undergoing primary surgery for presumed stage I with grade I or II EC has no impact on disease outcome and overall survival.

However, intraoperative identification of lymph node involvement and precise disease stage in patients with EC is somewhat problematic. In a retrospective analysis of 128 patients with EC, we observed only a fair agreement between preoperative and postoperative evaluation of myometrial invasion (quadratic-weighted Cohen kappa, 0.30; 95% confidence interval, 0.12–0.48; P = .0006). The sensitivity, specificity, and positive and negative predictive values of intraoperative frozen section for the detection of ≥50% myometrial invasion were 76.3%, 96.4%, 95.7%, and 79.1%, respectively. This, in turn, can be translated as almost 20% of patients assumed to have early disease stage actually have advanced disease with possible pelvic/paraaortic lymph node involvement. Skip metastasis is also another concern in the staging and decision of systematic lymphadenectomy in these patients. Of patients, 16% have only isolated paraaortic lymph node involvement.

Preoperative tumor grading with intraoperative assessment of depth of myometrial invasion and histologic subtype has been reported to correlate poorly with final pathologic grade. A higher grade on final pathologic assessment will be diagnosed in 25% of patients with preoperative grade 1 disease and 3% will be diagnosed as nonendometrioid or grade III disease. The risk of underestimating the grade during intraoperative assessment in patients with grade 2 disease has been reported as approximately 29%, as well. Clinically relevant upstaging occurs in 18% of patients.

In contrast to the authors’ conclusion, we think that decision-making on systematic lymphadenectomy in patients with EC according to preoperative grade and intraoperative myometrial invasion may put a considerable number of patients with presumed early-stage disease at risk of incomplete surgery and adjuvant therapy.