What is the treatment plan for a 37-year-old female with adenocarcinoma endometrioid type diagnosed via endometrial biopsy?

Treatment Plan for a 37-year-old Female with Endometrial Adenocarcinoma Endometrioid Type

The standard treatment for a 37-year-old female with endometrial adenocarcinoma endometrioid type is total hysterectomy with bilateral salpingo-oophorectomy and surgical staging, which includes pelvic and para-aortic lymph node assessment. 1

Initial Assessment

Before proceeding with treatment, proper assessment is essential:

1. Imaging studies:

   • Transvaginal ultrasound (TVUS) as initial imaging 2
   • Pelvic MRI to assess:
     • Depth of myometrial invasion (accuracy 88-89%)
     • Cervical involvement (accuracy 85-88%)
     • Adnexal involvement 2
   • CT abdomen/pelvis for high-grade tumors or suspected extrauterine disease 2

2. Pathologic review:

   • Confirmation of endometrioid adenocarcinoma type
   • Determination of grade (G1, G2, or G3)
   • Expert gynaecopathologist review 1

Treatment Options

Standard Approach

For most patients with endometrial adenocarcinoma:

• Total hysterectomy with bilateral salpingo-oophorectomy (TH/BSO) 1
• Surgical staging including:
  • Peritoneal fluid collection/washings
  • Thorough exploration of abdominal cavity
  • Pelvic and para-aortic lymph node assessment 1
  • Omentectomy in high-risk cases 1

Fertility-Preserving Option

Given the patient's young age (37), fertility preservation may be a consideration if:

• Well-differentiated (grade 1) endometrioid adenocarcinoma
• Disease limited to the endometrium (confirmed by MRI)
• No evidence of suspicious or metastatic disease
• Strong desire for future fertility 1

If these criteria are met:

1. Referral to a specialized center 1
2. Conservative management with progestins:
   • Medroxyprogesterone acetate (400-600 mg/day) or
   • Megestrol acetate (160-320 mg/day) 1
3. Close follow-up with endometrial sampling every 3-6 months
4. TH/BSO after childbearing is complete or if disease progresses 1

Adjuvant Therapy Based on Risk Stratification

After surgery, adjuvant therapy depends on final surgical staging and risk factors:

Low Risk (Stage IA, Grade 1-2)

• No adjuvant therapy needed 1

Intermediate Risk

• Consider adjuvant pelvic radiotherapy, which reduces local recurrence but has no impact on overall survival 1

High Risk (Stage IC, II, III, or Grade 3)

• Pelvic radiotherapy to increase locoregional control
• Consider adjuvant chemotherapy for stage III/IV disease 1

Important Considerations and Pitfalls

1. Preoperative grade may not match final grade:

   • Up to 30% of tumors initially diagnosed as grade 1 on biopsy are upgraded to grade 2 or 3 on final pathology 3
   • Approximately 12.6% of patients with preoperative grade 1 diagnosis have advanced stage (III-IV) disease 3

2. Age is not protective:

   • While endometrial cancer is less common in younger women, cases in premenopausal women can be aggressive 4
   • Do not delay appropriate treatment based solely on age

3. Genetic testing considerations:

   • Consider Lynch syndrome testing, especially in young patients
   • Universal testing of endometrial carcinomas for mismatch repair genes is recommended 1

4. Surgical approach:

   • Minimally invasive approach (laparoscopic or robotic) is preferred when feasible
   • Radical hysterectomy is generally not necessary for endometrial cancer unless there is cervical stromal involvement 5

The decision between standard surgical management and fertility-preserving therapy should be made after thorough discussion of risks and benefits, with the understanding that fertility preservation is not the standard of care and carries risks of disease progression.