What is the recommended surgery for a 68-year-old woman with grade 2 endometrioid endometrial carcinoma limited to less than 50% myometrial invasion (stage IA)?

Surgical Management of Grade 2 Endometrioid Endometrial Cancer, Stage IA (< 50% Myometrial Invasion) in a 68-Year-Old Woman

Perform total hysterectomy with bilateral salpingo-oophorectomy as the primary surgical treatment; lymphadenectomy is optional and not required for this intermediate-risk patient, though sentinel lymph node mapping may be considered. 1

Primary Surgical Procedure

The cornerstone operation consists of:

• Total abdominal hysterectomy with bilateral salpingo-oophorectomy 1, 2
• Peritoneal washings for cytology at the start of surgery 1, 2
• Thorough exploration and palpation of the abdominal cavity, including inspection of the peritoneum, omentum, and lymph nodes 1, 2
• Minimally invasive approach (laparoscopic or robotic) is preferred over laparotomy when feasible, offering equivalent oncologic outcomes with reduced morbidity 1, 3

Lymph Node Assessment Decision Algorithm

For this 68-year-old patient with grade 2, stage IA endometrioid cancer:

• Systematic pelvic and para-aortic lymphadenectomy is NOT required because randomized trials demonstrate no survival benefit in early-stage disease 1, 3
• Sentinel lymph node biopsy is a reasonable option (category 2B) if the surgeon has expertise in the technique 1
• Full lymphadenectomy may be considered if intraoperative findings reveal unexpected high-risk features (deep invasion, cervical involvement, or extrauterine disease) 1
• The risk of lymph node metastasis in stage IA grade 2 disease with < 50% invasion is approximately 5-10%, making routine lymphadenectomy of uncertain benefit 1, 3

Critical Intraoperative Considerations

The surgeon must:

• Assess depth of myometrial invasion visually and by palpation 1
• Examine the cervix for gross involvement (which would upstage to stage II) 1
• Inspect the ovaries and fallopian tubes for synchronous tumors 1, 4
• Evaluate for any extrauterine disease that would change staging 1

Pathologic Evaluation Requirements

The final pathology report must document:

• Depth of myometrial invasion (confirm < 50%) 1
• Presence and extent of lymphovascular space invasion (LVSI) 1, 3
• Cervical stromal involvement 1
• Tumor size and location 1, 5
• Peritoneal cytology results 1
• Nodal status if lymph nodes were resected 1

Risk Stratification After Surgery

This patient falls into the intermediate-risk category (stage IA, grade 2, < 50% invasion) according to the 2016 ESMO-ESGO-ESTRO consensus classification 1, 3

Adjuvant therapy decisions depend on final pathology:

• If LVSI is negative: Vaginal brachytherapy is the preferred adjuvant treatment, though observation alone is acceptable for patients < 60 years 1, 3
• If LVSI is unequivocally positive: The patient is reclassified as high-intermediate risk and should receive vaginal brachytherapy or limited-field external beam radiotherapy 1, 3
• If depth of invasion is confirmed ≥ 50%: The patient becomes stage IB and requires adjuvant vaginal brachytherapy 1, 2

Age-Specific Considerations for This 68-Year-Old Patient

• At age 68, this patient is at higher risk for pelvic recurrence compared to younger women with identical pathology 1, 6
• Adjuvant radiotherapy reduces pelvic recurrence from approximately 27% to 3% in elderly patients with intermediate-risk disease 6
• Radiotherapy is well-tolerated in elderly patients, with only 1-3% experiencing significant late toxicity 6
• Given her age ≥ 60 years, vaginal brachytherapy should be strongly recommended even if other risk factors are minimal 1, 3

Common Pitfalls to Avoid

• Do not perform routine systematic lymphadenectomy in apparent stage IA grade 2 disease, as it does not improve survival and adds morbidity 1, 3
• Do not omit bilateral salpingo-oophorectomy in this postmenopausal patient; ovarian preservation is only considered in premenopausal women with grade 1 disease 3
• Do not rely on preoperative grade alone—up to 25% of cases are upgraded after final pathology, so intraoperative assessment must guide surgical extent 3
• Do not skip peritoneal washings, even though positive cytology no longer affects FIGO staging, as it may influence adjuvant therapy decisions 1