What is the primary treatment for a patient with uterine cancer classified as FIGO (International Federation of Gynecology and Obstetrics) stage 1c?

Primary Treatment for Uterine FIGO Stage 1C Cancer

The primary treatment for uterine cancer FIGO stage 1C consists of total hysterectomy with bilateral salpingo-oophorectomy (TH/BSO), surgical staging, and adjuvant chemotherapy. 1

Understanding FIGO Stage 1C

Stage 1C in the older FIGO staging system (which many of the guidelines reference) indicates:

• Cancer limited to the uterus
• Invasion to >50% of the myometrial thickness
• No cervical involvement

Note: In the updated 2009 FIGO staging, this would be classified as stage IB.

Surgical Management

Primary Surgery

• Total hysterectomy and bilateral salpingo-oophorectomy (TH/BSO) is the cornerstone of treatment 1
• Surgery should be performed by an appropriately trained surgeon with experience in gynecologic oncology 1
• Surgical approach may be via:
  • Laparotomy
  • Minimally invasive techniques (laparoscopy or robotic surgery)

Surgical Staging Components

• Visual evaluation of peritoneal, diaphragmatic, and serosal surfaces
• Peritoneal cytology collection (though it doesn't affect staging, it provides prognostic information)
• Pelvic lymph node dissection (PLND) 1, 2
• Para-aortic lymph node evaluation (especially for high-risk tumors) 1
• Omental biopsy (particularly for certain histologic subtypes)

Adjuvant Therapy

For FIGO stage 1C endometrial cancer, adjuvant therapy is strongly recommended due to the increased risk of recurrence:

• Adjuvant chemotherapy is recommended for stage 1C disease 1, 2

  • Options include carboplatin and paclitaxel regimens

• Adjuvant radiotherapy considerations:

  • Vaginal vault brachytherapy is effective in preventing locoregional recurrences 2
  • External beam radiation therapy may be considered for patients who did not undergo lymphadenectomy 2

Prognostic Factors and Risk Assessment

Several factors influence prognosis and treatment decisions:

• Histologic subtype and grade
• Lymphovascular space invasion
• Patient age and performance status
• Tumor size and location (fundus vs. lower uterine segment)

Special Considerations

Fertility Preservation

• Not typically an option for stage 1C disease due to deep myometrial invasion
• Standard treatment involves removal of the uterus and ovaries 1

Recurrence Risk

• Stage 1C has a higher risk of recurrence compared to stages 1A and 1B 3
• A study found 33% recurrence rate in stage 1C cases with high-grade histology, deep myometrial invasion, and tumor emboli when treated with TH/BSO alone 3
• This underscores the importance of adjuvant therapy in this stage

Follow-up Recommendations

• Regular surveillance every 3-6 months for the first 2-3 years
• Then every 6 months for years 3-5
• Annual follow-up thereafter
• Monitoring should include physical examination and consideration of imaging studies based on symptoms or findings

Common Pitfalls to Avoid

1. Inadequate surgical staging: Failure to perform comprehensive surgical staging can lead to undertreatment
2. Omitting lymph node assessment: Studies show that lymphadenectomy provides important prognostic information 2
3. Underestimating recurrence risk: Stage 1C has significant recurrence risk, particularly with high-grade histology
4. Delaying adjuvant therapy: Prompt initiation of adjuvant therapy is important for optimal outcomes

The evidence strongly supports that TH/BSO with surgical staging followed by adjuvant therapy provides the best outcomes for patients with stage 1C endometrial cancer, particularly in terms of reducing recurrence risk and improving survival.