Risk Stratification
This patient has low-risk, early-stage endometrial cancer based on the following pathologic features 1, 2:
- Stage IA (FIGO 2009): Less than half myometrial invasion with tumor confined to uterus 1
- Grade 1 endometrioid adenocarcinoma 1
- No lymphovascular invasion (LVI) 1
- Negative lymph nodes (0/9 nodes involved) 1
- Adequate surgical staging completed: TLH with BSO and bilateral pelvic lymph node dissection 2, 3
According to ESMO guidelines, patients with stage IA/IB, grade 1 or 2, endometrioid histology are classified as low-risk and require no adjuvant therapy after complete surgical staging 1, 2.
Why No Adjuvant Therapy?
The tumor size of 3.5 cm, while noted as a risk factor when >2 cm, does not override the favorable combination of grade 1 histology, minimal myometrial invasion, absence of LVI, and negative nodes in determining overall low-risk status 1. The ESMO low-risk category specifically includes stage IA/IB grade 1-2 endometrioid tumors, and adjuvant radiotherapy has been shown to reduce locoregional recurrence but provides no overall survival benefit in this population 1.
Surveillance Protocol
Follow-up schedule 3:
- Clinical examination every 3-6 months for the first 2 years
- Every 6-12 months for years 3-5
- Annual visits thereafter
Imaging is not routinely indicated for asymptomatic low-risk patients during surveillance 3. Order imaging only if symptoms develop (vaginal bleeding, pelvic pain, unexplained weight loss) or physical examination findings are concerning 3.
Critical Pitfalls to Avoid
Do not over-treat low-risk disease. Adjuvant pelvic radiotherapy in this population increases locoregional control but does not improve overall survival and adds unnecessary toxicity and cost 1. The intermediate-risk category requiring vaginal brachytherapy specifically includes patients ≥60 years with deeply invasive grade 1-2 tumors OR superficially invasive grade 3 tumors—neither applies here 1, 2.
Ensure complete pathologic review. Confirm that the final pathology definitively shows endometrioid histology (not serous, clear cell, or other high-risk subtypes) and that the grade is truly 1 (≤5% solid growth pattern) 1. Preoperative histology changes at final evaluation in up to 25% of cases 1.
Counsel the patient that her prognosis is excellent, with 5-year survival rates exceeding 90% for stage IA grade 1 disease 4, and that observation alone is the standard of care 1, 2.