CHAPTER 1 18 Preoperative risk stratification model guiding primary surgical treatment of endometrial cancer Primary surgical treatment according the latest ESGO/ESTRO/ESP guideline is based on preoperative tumor grade, histology and, if indicated imaging. Besides hysterectomy and bilateral salpingo-oophorectomy, additional staging including lymph node surgery (i.e. sentinel lymph node (SLN), lymph node dissection (LND)) is recommended in patients at substantial risk of metastases.13, 71 Current models for preoperative prediction of LNM and survival in EC are not optimal.13, 72 Numerous studies proposed preoperative risk stratification models for LNM.73-77 However, preoperative risk models including IHC and/or molecular markers are only limited.46, 78, 79 Within our research group we developed a Bayesian network model, ENDORISK, by integrating easy accessible preoperative markers and patient characteristics showing improved preoperative risk classification in EC.46 ENDORISK includes preoperative markers like; thrombocytosis, Cancer Antigen 125 (CA125), tumor grade, lymphadenopathy on imaging, atypical endometrial cells in cervical cytology, and IHC expression of p53, L1CAM, ER and PR. It was established to predict preoperatively macro-LNM and outcome accurately.46 Postoperative risk stratification model guiding adjuvant treatment of endometrial cancer For postoperative adjuvant treatment different classifications are used in clinical practice: ESGO/ESTRO/ESP, Postoperative Radiation Therapy for Endometrial Carcinoma (PORTEC) and Gynecologic Oncology Group (GOG) criteria.13, 80, 81 According to the latest ESGO/ESTRO/ESP guideline, adjuvant treatment is based on risk classification groups incorporating FIGO stage, tumor grade and histology, lympho-vascular space invasion (LVSI), with or without molecular markers.13 With the integration of the TCGA-based molecular classification a postoperative risk stratification model appears promising for guidance of adjuvant treatment.82, 83 Adjuvant therapy tailored to the TCGA groups will be studied in the prospective randomized control RAINBO trial.83, 84
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