What is the recommended staging evaluation and treatment approach for a patient with endometrial carcinoma?

Endometrial Carcinoma Staging and Treatment

Staging System

Endometrial carcinoma is a surgically staged disease using the FIGO 2009 staging system, which requires total hysterectomy with bilateral salpingo-oophorectomy as the primary treatment, followed by risk-stratified adjuvant therapy based on surgical-pathologic findings. 1

The FIGO 2009 staging system classifies disease as follows:

• Stage IA: No myometrial invasion or invasion to less than half of the myometrium 2, 1
• Stage IB: Invasion equal to or more than half of the myometrium 2, 1
• Stage II: Cervical stromal invasion 2, 1
• Stage III: Local/regional spread including serosal invasion, adnexal involvement, vaginal/parametrial involvement, or lymph node metastases (IIIC1 for pelvic nodes, IIIC2 for para-aortic nodes) 2
• Stage IV: Bladder/bowel mucosal invasion (IVA) or distant metastases (IVB) 2

Preoperative Evaluation

Essential Imaging and Laboratory Studies

Contrast-enhanced dynamic MRI is the single best imaging modality to assess myometrial invasion depth and cervical stromal involvement preoperatively. 2, 1

Required preoperative workup includes:

• Endometrial biopsy for histologic confirmation 1, 3
• Transvaginal ultrasound to evaluate endometrial thickness and myometrial invasion 2, 1
• Contrast-enhanced dynamic MRI for assessing uterine and locoregional pelvic extension 2, 1
• Chest X-ray to screen for pulmonary metastases 2
• Complete blood count, liver and renal function profiles 2, 1
• CT scan of abdomen and retroperitoneal nodes to investigate extrapelvic disease in clinically advanced cases 2

Important caveat: Preoperative histologic diagnosis (type and grade) based on endometrial sampling is changed at final histological evaluation in up to 25% of cases, so imaging cannot fully replace surgical staging. 2

Surgical Treatment Approach

Standard Surgical Procedure

The minimal surgical procedure must include total hysterectomy with bilateral salpingo-oophorectomy, acquisition of peritoneal fluid or washings, thorough exploration of the abdominal cavity, and evaluation of pelvic and para-aortic nodal areas. 2, 1

Minimally invasive surgery (laparoscopic or robotic) should be performed rather than laparotomy whenever possible, as it provides equivalent oncologic outcomes with shorter hospital stay, less pain, lower complication rates, and improved quality of life. 2, 1

Lymphadenectomy Controversy

The role of systematic lymphadenectomy remains debated:

• Routine systematic pelvic lymphadenectomy does NOT improve disease-free survival or overall survival in stage I endometrial cancer based on two large randomized trials (Italian study and ASTEC trial). 2, 1
• However, lymphadenectomy is highly important for determining prognosis and tailoring adjuvant therapies, so many experts recommend complete surgical staging for intermediate-to-high-risk endometrioid cancer (stage IA G3 and IB). 2, 1
• For high-risk histologies (serous, clear cell, carcinosarcoma), omentectomy and retroperitoneal lymph node dissection are recommended, though their effect on survival remains unclear. 2, 1

Risk Stratification

Approximately 75% of patients present with stage I disease, which can be subdivided into three risk categories based on established prognostic factors (FIGO stage, histological grade, depth of myometrial invasion, histological type, age, lymphovascular space invasion, and endocervical involvement): 2, 1

Low-Risk Disease

• Stage IA, grade 1-2, endometrioid histology 2, 1
• Treatment: No adjuvant therapy required 2, 1

Intermediate-Risk Disease

• Stage IB, grade 1-2, endometrioid histology; OR stage IA, grade 3, endometrioid histology 2, 1
• Treatment: Adjuvant pelvic radiotherapy significantly reduces pelvic/vaginal relapses but has NO impact on overall survival 2, 1
• Within intermediate-risk patients aged ≥60 years with deeply invasive G1-G2 or superficially invasive G3 tumors, locoregional relapse rate exceeds 15%, and adjuvant radiotherapy is recommended 2, 1

High-Risk Disease

• Stage IB, grade 3, endometrioid histology; OR any stage with serous, clear cell, small cell, or undifferentiated histology 2, 1
• Treatment: Platinum-based chemotherapy provides significantly improved overall survival and progression-free survival compared with adjuvant radiotherapy alone 2, 1
• Pelvic radiotherapy is recommended to increase locoregional control 2, 1

Stage-Specific Treatment

Stage II Disease

• Stage IIa (endocervical glandular involvement only): Treated as stage I 2
• Stage IIb (cervical stromal invasion): Extended radical hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection 2
• Patients with high-risk features require adjuvant pelvic radiotherapy 2

Stage III-IV Disease

For optimally debulked stage III-IV disease, cisplatin and doxorubicin combination chemotherapy significantly improves progression-free survival and overall survival compared with whole abdominal radiation therapy with pelvic boost. 2

Because of toxicity considerations, carboplatin and paclitaxel combination is an acceptable alternative. 2, 1

For patients with residual disease after surgery, maximal surgical cytoreduction should be attempted in those with good performance status. 1

Medically Inoperable Patients

For the 5-10% of patients who are not surgical candidates, external radiation therapy with or without intracavitary brachytherapy is recommended. 1

Special Considerations

Progestational agents (e.g., medroxyprogesterone acetate 200 mg daily) are active in steroid receptor-positive tumors, mostly G1 and G2 lesions, and may be considered for select patients. 2

Common pitfall: Do not rely solely on preoperative imaging or frozen section for risk stratification, as these methods have up to 25% discordance with final pathology. 2 Final treatment decisions should be based on comprehensive surgical-pathologic staging.