What is the initial treatment approach for a postmenopausal patient diagnosed with endometrial cancer?

Initial Treatment Approach for Postmenopausal Endometrial Cancer

The initial treatment for a postmenopausal patient with endometrial cancer is total hysterectomy with bilateral salpingo-oophorectomy (TH/BSO), preferably using a minimally invasive approach (laparoscopic or robotic), with lymph node evaluation tailored to risk factors identified during preoperative assessment and intraoperative findings. 1

Preoperative Workup

Before proceeding to surgery, complete the following assessment to optimize surgical planning:

• Endometrial tissue diagnosis via Pipelle biopsy or dilation and curettage (D&C) to confirm histologic type and grade 1
• Transvaginal ultrasound to assess endometrial thickness and myometrial invasion 1
• Pelvic MRI (most accurate imaging modality) to evaluate depth of myometrial invasion (98% accuracy) and cervical stromal invasion (90% accuracy) 1
• Complete blood count, liver and renal function profiles 1
• Clinical and gynecological examination 1
• Additional imaging (chest/abdominal CT or FDG-PET-CT) only if high risk of extrapelvic disease based on grade, histology, or deep myometrial invasion 1

Surgical Approach

Standard Surgical Procedure

Perform total hysterectomy with bilateral salpingo-oophorectomy as the cornerstone of treatment. 1

• Minimally invasive techniques (laparoscopic or robotic) are equivalent to laparotomy for prognosis and should be preferred, with robotic approach particularly beneficial in obese women 1
• Ovarian preservation is NOT appropriate in postmenopausal patients—bilateral salpingo-oophorectomy is mandatory 1
• Staging omentectomy should be added for serous carcinoma or carcinosarcoma histologies 1

Lymph Node Evaluation Strategy

The decision to perform lymph node assessment depends on preoperative and intraoperative risk stratification:

OMIT lymph node evaluation in:

• Endometrioid histology, FIGO stage IA, Grade 1-2 disease (lymph node metastasis risk <5%) 1

PERFORM lymph node evaluation in:

• Non-endometrioid histology (serous, clear cell, carcinosarcoma) 1
• FIGO stage IB disease (≥50% myometrial invasion) 1
• Grade 3 endometrioid tumors 1

Sentinel lymph node biopsy is an acceptable alternative to systematic lymphadenectomy for lymph node staging, with high sensitivity demonstrated in the FIRES trial, though long-term survival data from randomized trials are still pending 1

Special Circumstances

Medically Inoperable Patients

For postmenopausal patients with significant comorbidities (obesity, cardiac disease, diabetes) precluding surgery:

• External beam radiotherapy and/or brachytherapy as primary treatment 1
• This represents definitive treatment when surgery cannot be safely performed 1

High-Risk Histologies

For serous adenocarcinoma, clear cell carcinoma, or carcinosarcoma:

• More aggressive surgical staging including omentectomy 1
• Consider additional imaging (CT chest/abdomen/pelvis or PET-CT) preoperatively to detect extrapelvic disease 1
• These histologies behave more aggressively and warrant comprehensive staging 1

Critical Pitfalls to Avoid

• Do not preserve ovaries in postmenopausal women—this is only considered in premenopausal patients with stage IA Grade 1 disease 1
• Do not perform systematic pelvic lymphadenectomy in low-risk disease (stage IA Grade 1-2 endometrioid)—randomized trials show no survival benefit and increased morbidity (lymphedema) 1
• Do not skip preoperative imaging in patients with Grade 3 tumors or non-endometrioid histology—MRI accuracy for myometrial invasion guides the extent of lymph node dissection 1
• Do not assume all postmenopausal bleeding is cancer—but tissue diagnosis is mandatory before any intervention, as 90% of endometrial cancer patients present with abnormal bleeding 2, 3

Adjuvant Therapy Considerations

The need for postoperative adjuvant treatment (radiation, chemotherapy, or hormone therapy) depends on final surgical pathology including:

• FIGO stage (based on surgical findings) 1
• Histologic type and grade 1
• Depth of myometrial invasion 1
• Lymphovascular space invasion 1
• Lymph node status 1
• Molecular classification (p53, MMR proteins, POLE mutation status) 1

Most patients (75%) are diagnosed at stage I disease and have excellent prognosis with surgery alone, with 5-year survival rates of 93-96% for stage IA disease. 1, 2