What is the treatment and prognosis for a 73-year-old woman with Endometrial carcinoma, FIGO (International Federation of Gynecology and Obstetrics) stage-1A, presenting with sudden vaginal bleeding (per vaginam)?

Treatment and Prognosis for a 73-year-old Woman with FIGO Stage-1A Endometrial Carcinoma

For a 73-year-old woman with FIGO stage-1A endometrial carcinoma presenting with sudden vaginal bleeding, the primary treatment is total hysterectomy with bilateral salpingo-oophorectomy without adjuvant therapy, and the prognosis is excellent with a 5-year survival rate exceeding 90%. 1, 2

Surgical Management

The cornerstone of treatment for stage-1A endometrial carcinoma involves:

1. Total hysterectomy with bilateral salpingo-oophorectomy (TH-BSO) 1

   • Complete surgical staging should include:
     • Peritoneal fluid collection/washings
     • Thorough exploration of abdominal cavity
     • Assessment of pelvic and para-aortic lymph nodes

2. Lymph node assessment

   • Sentinel lymph node biopsy is preferred in current practice 2
   • This helps determine if there is occult nodal disease that would upstage the cancer

Risk Stratification

Before determining the need for adjuvant therapy, risk stratification is essential:

• Low risk: Stage-1A, grade 1-2, endometrioid histology 1
• Intermediate risk: Stage-1A, grade 3 endometrioid histology 1
• High risk: Stage-1A with serous, clear cell, small cell or undifferentiated histology 1

For this 73-year-old patient, the risk category depends on the tumor grade and histology, which should be determined from the surgical specimen.

Adjuvant Therapy

Based on ESMO guidelines:

• Low-risk group (Stage-1A, grade 1-2, endometrioid): No adjuvant therapy required 1
• Intermediate-risk group: Consider adjuvant radiotherapy, especially if the patient has additional risk factors:
  • Age ≥60 years (applies to this patient)
  • Grade 3 tumors
  • Lymphovascular space invasion 1

Special Considerations for Elderly Patients

For a 73-year-old woman:

• Age is an independent risk factor that may influence treatment decisions 1, 2
• If surgery is contraindicated due to comorbidities, definitive radiotherapy could be considered
• For recurrent or metastatic disease that develops later, medroxyprogesterone acetate (200 mg daily) may be used, particularly in hormone receptor-positive tumors 1, 3

Follow-Up Protocol

After treatment, a structured follow-up is recommended:

• Clinical and gynecological examinations every 3-4 months for the first 3 years 1
• Every 6 months during the fourth and fifth years
• Annually thereafter
• Focus on early detection of vaginal or pelvic recurrences, which are potentially curable 1

Prognosis

The prognosis for FIGO stage-1A endometrial carcinoma is generally favorable:

• 5-year disease-free survival exceeds 90% 4
• 5-year overall survival approaches 98% for surgically staged patients 4

Potential Pitfalls to Avoid

1. Inadequate surgical staging: Ensure comprehensive surgical staging to accurately determine the extent of disease 2

2. Overlooking histological type: Serous and clear cell histologies have worse prognosis than endometrioid type, even in early stages 2

3. Not considering age as a risk factor: At 73 years, the patient's age itself is a risk factor that may influence treatment decisions 1

4. Insufficient follow-up: Most recurrences occur within the first 3 years, making regular follow-up crucial during this period 1

This patient's sudden vaginal bleeding is the classic presentation of endometrial carcinoma, and with proper surgical management and appropriate follow-up, she has an excellent chance of cure given the early stage of disease.