Management of T1a M0 Grade 2 Endometrial Carcinoma
For T1a (tumor limited to endometrium) grade 2 endometrial cancer, perform total hysterectomy with bilateral salpingo-oophorectomy plus comprehensive surgical staging, followed by observation alone without adjuvant therapy. 1
Primary Surgical Treatment
The cornerstone of management is comprehensive surgical staging that must include the following components 1:
- Total hysterectomy with bilateral salpingo-oophorectomy 1
- Peritoneal fluid or washings for cytology 1
- Thorough exploration of the abdominal cavity and pelvic and para-aortic nodal areas 1
- Pelvic lymphadenectomy for complete surgical staging 1
- Para-aortic lymph node assessment, particularly if pelvic nodes appear suspicious 1
The pathologic evaluation must document depth of myometrial invasion, cervical involvement, tumor size and location, lymphovascular space invasion, and nodal status when resected 2.
Post-Surgical Management Based on Final Pathology
If Final Pathology Confirms Stage IA Grade 2
Follow-up alone is standard—no adjuvant therapy is required 1. This patient falls into the low-risk category (stage IA, grade 2, endometrioid histology) 3.
If Upstaged to Stage IB Grade 2
Options include vaginal brachytherapy or follow-up alone 1. Note that adjuvant pelvic radiotherapy significantly reduces the risk of pelvic/vaginal relapses but has no impact on overall survival 1.
If Higher-Risk Features Are Found
- Intermediate-risk disease (age ≥60 years, deeper myometrial invasion, or lymphovascular space invasion): vaginal brachytherapy alone is the preferred adjuvant treatment 2
- Stage II or higher disease: management escalates to include external beam radiotherapy with or without brachytherapy, and potentially chemotherapy depending on final stage 1
Critical Prognostic Factors to Document
The following independent prognostic factors must be assessed from the surgical specimen 3:
- Depth of myometrial invasion
- Histological type (endometrioid vs. non-endometrioid)
- Lymph-vascular space invasion
- Endocervical involvement
- Age
- Nodal status
Common Pitfalls to Avoid
Do not skip comprehensive surgical staging. While T1a grade 2 appears low-risk, approximately 10-15% of apparent early-stage patients are upstaged after complete surgical evaluation, which fundamentally changes management 4, 5.
Do not perform radical hysterectomy. Extensive surgery beyond total hysterectomy with bilateral salpingo-oophorectomy and lymphadenectomy does not improve outcomes and increases morbidity 6.
Do not routinely administer adjuvant radiotherapy for confirmed stage IA grade 2 disease. While radiotherapy reduces local recurrence, it does not improve overall survival and adds unnecessary toxicity 1.
Surveillance After Treatment
For confirmed stage IA grade 2 disease, surveillance should include 7:
- Physical examination every 3-6 months for the first 2 years, then every 6 months through year 5, and annually thereafter 7
- Vaginal cytology every 6 months for the first 2 years, and annually thereafter 7
- Do not routinely order CT scans, chest X-rays, PET scans, or CA-125 levels in asymptomatic patients, as these have poor detection rates and do not improve survival 7
Educate patients to immediately report symptoms such as vaginal bleeding, abdominal or pelvic pain, unexplained weight loss, and persistent cough or headaches, as 41-83% of recurrences are detected symptomatically rather than by surveillance testing 7.
Prognosis
Stage IA grade 2 endometrioid endometrial carcinoma has an excellent prognosis with a 5-year disease-free survival of approximately 94% and a recurrence rate of only 2-10% 7.