Impact of cytoreductive surgery on survival in advanced endometrial cancer: a 20- year retrospective cohort study

Background The optimal extent of cytoreductive surgery in advanced-stage endometrial cancer remains controversial, and evidence is largely limited to small retrospective series with heterogeneous populations. This study aimed to evaluate the association between the extent of cytoreductive surgery and survival outcomes in a long-term single-center cohort of patients with advanced-stage EC. Methods Patients with FIGO stage IIIB–IV EC who underwent primary cytoreductive surgery between January 2000 and December 2020 were retrospectively analyzed. Cytoreductive status was classified as maximal (no macroscopic residual disease), optimal (≤ 1 cm residual disease), or suboptimal (> 1 cm residual disease). Overall survival (OS) and disease-free survival (DFS) were analyzed using the Kaplan–Meier method. Multivariable Cox proportional hazards regression was performed to identify independent prognostic factors. Results A total of 151 patients were included, of whom 57.0% achieved maximal cytoreduction, 35.8% optimal cytoreduction, and 7.3% suboptimal cytoreduction. The median OS for the entire cohort was 140.4 months (95% CI, 89.8–191.0), and the median DFS was 75.2 months (95% CI, 12.6–137.9). Median OS was not reached in the maximal cytoreduction group, whereas it was 50.2 months (95% CI, 11.0–89.4) and 10.2 months (95% CI, 3.7–16.6) in the optimal and suboptimal groups, respectively (log-rank p < 0.001). Median DFS was 188.5 months, 25.4 months, and 6.8 months, respectively (log-rank p < 0.001). In multivariable analysis, both optimal (HR 3.86, 95% CI 2.24–6.66) and suboptimal cytoreduction (HR 30.21, 95% CI 11.95–76.37) were independently associated with worse OS compared with maximal cytoreduction. Conclusion Maximal cytoreductive surgery was independently associated with improved overall and progression-free survival in patients with advanced-stage EC. These findings support maximal cytoreduction as a key surgical goal in appropriately selected patients managed by experienced multidisciplinary teams.