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Metastatic Sites and Spread Patterns of Endometrial Cancer

Primary Lymphatic Metastatic Routes

Endometrial cancer spreads primarily through lymphatic channels, with the external iliac and obturator lymph nodes representing the most common initial sites of metastasis, followed by internal iliac, common iliac, and para-aortic nodes in a predictable anatomical sequence. 1, 2

Pelvic Lymph Node Involvement

  • External iliac nodes are the single most frequently involved pelvic lymph node site in endometrial cancer, regardless of whether tumor is confined to the corpus or has invaded the cervix. 1

  • Obturator nodes represent the second most common site of isolated pelvic metastasis when tumor is confined to the uterine corpus, and serve as a key pathway to para-aortic spread. 1, 2

  • Internal iliac nodes are frequently involved and represent a major route of lymphatic spread, particularly in the primary drainage pathway from the uterus. 2

  • Common iliac nodes are involved significantly more often when cervical invasion is present—67% of patients with cervical involvement versus only 30% with corpus-confined disease (P < 0.01). 1

Para-aortic Lymph Node Spread

  • Para-aortic node metastasis occurs in 64% of patients with positive obturator nodes compared to only 23% with negative obturator nodes (P = 0.01), indicating the obturator-to-para-aortic pathway is the dominant route when disease is corpus-confined. 1

  • When cervical invasion is present, para-aortic spread occurs via the common iliac nodes—all patients with cervical invasion and positive para-aortic nodes had positive common iliac nodes. 1

  • When tumor is limited to the corpus, only 27% of patients with positive para-aortic nodes had common iliac involvement, confirming a direct obturator/external iliac-to-para-aortic route. 1

Anatomical Spread Pattern by Tumor Location

Corpus-Confined Disease

  • The major lymphatic pathway follows: endometrium → obturator/external iliac nodes → para-aortic nodes, with or without parametrial involvement. 2

  • Isolated pelvic metastases occur most frequently in external iliac and obturator nodes. 1

Disease with Cervical Invasion

  • The pathway shifts to: cervix → external iliac/common iliac nodes → para-aortic nodes. 1

  • Common iliac node involvement becomes significantly more frequent, serving as the gateway to para-aortic spread. 1

  • Isolated pelvic metastases occur most commonly in external iliac and common iliac nodes. 1

Direct Extension and Distant Metastases

Local Extension (Stage III Disease)

  • Serosal and/or adnexal involvement defines Stage IIIA disease. 3

  • Vaginal involvement defines Stage IIIB disease. 3

  • Parametrial metastasis occurs in approximately 23 of 52 node-positive patients, with 16 of 23 (70%) also showing retroperitoneal lymph node involvement. 2

Distant Metastases (Stage IVB)

  • Bladder and/or bowel mucosal invasion defines Stage IVA disease. 3

  • Distant metastases including intra-abdominal or inguinal nodes define Stage IVB disease. 3

  • Pre-operative imaging with chest/abdominal CT or FDG-PET-CT is recommended in high-risk patients to detect extrapelvic disease. 3

Rare Direct Para-aortic Pathway

  • A direct para-aortic spread pathway exists but is uncommon, accounting for only 6 of 52 (12%) node-positive cases with independent para-aortic metastasis without pelvic node involvement. 2

Clinical Implications for Staging

  • Lymph node assessment should prioritize obturator and external iliac nodes as sentinel sites, with systematic evaluation extending to internal iliac, common iliac, and para-aortic chains based on tumor location and cervical involvement. 1, 2

  • The presence of cervical stromal invasion (Stage II) fundamentally alters the metastatic pathway, shifting the dominant route toward common iliac nodes. 3, 1

  • Imaging modalities including transvaginal ultrasound, MRI, CT, and PET are used to detect lymph node metastases and distant spread, with diffusion-weighted MRI particularly useful for detecting small metastatic deposits. 4, 5

References

2
Research

Lymph node pathway in the spread of endometrial carcinoma.

European journal of gynaecological oncology, 2005

3
Guideline

FIGO Grading and Staging Guidelines for Endometrial Cancer

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Research

Endometrial cancer: an overview of novelties in treatment and related imaging keypoints for local staging.

Cancer imaging : the official publication of the International Cancer Imaging Society, 2018

5
Research

Role of imaging in the routine management of endometrial cancer.

International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 2018

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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