Background Obesity is an important risk factor for the development of endometrial cancer and is associated with poor outcomes. However, the impact of body fat distribution on survival and surgical outcomes in endometrial cancer patients is unclear.

Methods This is a retrospective study in women diagnosed with primary endometrial cancer between February 2006 and August 2017 at the Royal Cornwall Hospital who had abdominal CT-scan as part of routine diagnostic work-up. Subcutaneous abdominal fat volumes and visceral abdominal fat volumes were quantified, and visceral fat percentage calculated.

Results A total of 302 patients with high grade endometrial cancer were included. The median age was 70 years and median Body Mass Index (BMI) was 29.7 kg/m2. The majority of patients (60%) had endometrioid type histology. High visceral fat percentage was associated with poor overall- and disease-free survival (p < 0.001 and p = 0.003 respectively), which remained significant when adjusting for age, FIGO stage, histological subtype, comorbidities and BMI. Postoperative complications were more frequent in patients with high visceral fat volume (p = 0.002) and multiple comorbidities were associated with high BMI (p < 0.001) and high visceral fat percentage (p < 0.001).

Conclusion Obesity with high visceral fat percentage is an independent negative prognostic factor in endometrial cancer and high visceral fat volumes are associated with increased postoperative complication rates. The additional association of high visceral fat with multiple comorbidities might be reflecting an unhealthy macroenvironment.