Concurrent Cisplatin with Pelvic IMRT is NOT Appropriate for Stage IA Grade 2 Endometrioid Endometrial Carcinoma
Stage IA, grade 2 endometrioid endometrial carcinoma is classified as low-risk disease and requires no adjuvant therapy after surgical staging—neither chemotherapy nor radiotherapy is indicated. 1, 2
Risk Stratification
Stage IA (tumor limited to endometrium), grade 2, endometrioid histology definitively meets criteria for low-risk disease according to established FIGO staging and risk classification. 1, 2
The three risk categories for stage I endometrial cancer are:
- Low risk: Stage Ia/Ib, grade 1 or 2, endometrioid histology 1
- Intermediate risk: Requires two of three major risk factors (age ≥60 years, deeply invasive, or G3 tumors) 1
- High risk: Stage IC with grade 3, or other high-risk features 1, 3
Your patient's presentation falls squarely into the low-risk category.
Standard Treatment Approach
For low-risk endometrial adenocarcinoma, no adjuvant therapy is recommended after total hysterectomy with bilateral salpingo-oophorectomy. 2 The 5-year disease-free survival rate is approximately 93% for surgically staged patients with disease confined to the uterine corpus. 2
The surgical management should include:
- Total hysterectomy with bilateral salpingo-oophorectomy 2
- Peritoneal fluid or washings obtained during the procedure 2
- Thorough exploration of the abdominal cavity and pelvic areas 2
- Lymphadenectomy is NOT recommended for low-risk disease as it provides no survival benefit 2
Why Cisplatin Plus Radiotherapy is Inappropriate
The evidence base for concurrent chemoradiation is limited to specific high-risk scenarios that do not apply here:
Cisplatin-based chemotherapy is reserved for advanced disease (Stage III-IV), where cisplatin and doxorubicin combination significantly improves progression-free survival and overall survival in optimally debulked stage III and IV disease. 1
Pelvic radiotherapy in intermediate-risk stage I disease reduces pelvic/vaginal relapses but has no impact on overall survival. 1 Even in intermediate-risk patients, radiotherapy alone (without chemotherapy) is the standard when adjuvant treatment is indicated. 1
Recent high-quality evidence from a 2024 randomized trial demonstrated that adding cisplatin to radiation therapy for localized endometrial cancer recurrences actually worsened outcomes (median PFS not reached for RT alone vs. 73 months for chemoradiation, HR 1.25), with increased acute toxicity and no survival benefit. 4 This underscores that cisplatin should not be added to radiation in early-stage disease.
When Adjuvant Therapy IS Indicated
Adjuvant pelvic radiotherapy may be considered only in intermediate-risk patients who have two of three major risk factors: age ≥60 years, deeply invasive tumors, or G3 histology, where locoregional relapse rate exceeds 15%. 1
Combined chemoradiation is reserved for:
- High-risk stage I disease (Stage IC with deep myometrial invasion >50% and grade 3) 3, 5
- Stage III-IV disease where combined modality treatment reduces risk of relapse or death by 36% (HR 0.64) 3
Critical Pitfalls to Avoid
Overtreatment of low-risk disease causes unnecessary toxicity without survival benefit. The adjuvant administration of progestational agents in low-stage endometrial cancer does not increase survival and is not recommended. 1, 2
Studies attempting to add chemotherapy to radiotherapy in high-risk stage I disease have shown:
- No improvement in overall survival (84.7% vs. 82.1%, p=0.148) 6
- No reduction in recurrence rates 6
- Increased bowel complications (2.7% vs. 9.5%) 6
The proposed treatment of cisplatin plus pelvic IMRT would expose this low-risk patient to significant acute toxicity (nausea, leucopenia, infection risk) 5, 6 without any evidence of benefit and potential harm to progression-free survival. 4
Recommended Follow-Up
After surgery alone, follow-up should include:
- History, physical and gynecological examination every 3-4 months for the first 3 years 2
- Follow-up intervals of 6 months during years 4-5 2
- Annual visits thereafter 2
Most recurrences occur within the first 3 years, and early detection of isolated vaginal or pelvic relapses allows for potentially curative salvage treatment. 1, 2