What is the standard treatment for stage I endometrial adenocarcinoma in a 49-year-old postmenopausal woman?

Treatment of Stage I Endometrial Adenocarcinoma in a 49-Year-Old Postmenopausal Woman

The standard treatment is total hysterectomy with bilateral salpingo-oophorectomy (TH/BSO), with adjuvant therapy decisions based on surgical-pathologic risk factors including tumor grade, depth of myometrial invasion, and presence of lymphovascular space invasion. 1

Primary Surgical Management

All patients with stage I endometrial adenocarcinoma should undergo TH/BSO as the cornerstone of treatment. 1, 2 This can be performed via open or laparoscopic approach. 1

Surgical Staging Components

The comprehensive surgical procedure must include: 1, 2

• Total hysterectomy with bilateral salpingo-oophorectomy
• Peritoneal washings for cytology
• Thorough inspection and palpation of abdominal organs (liver, diaphragm, omentum, peritoneal surfaces)
• Assessment of pelvic and para-aortic lymph nodes (though routine therapeutic lymphadenectomy remains controversial)

Pelvic lymphadenectomy does not improve overall survival or recurrence-free survival in early endometrial cancer and cannot be recommended as a routine therapeutic procedure, though surgical staging may inform adjuvant treatment decisions. 1

Critical Pathologic Assessment

The pathology report must document: 1, 2

• Depth of myometrial invasion (ratio of invasion to total myometrial thickness)
• Tumor grade (1,2, or 3)
• Cervical involvement (glandular or stromal)
• Lymphovascular space invasion (LVSI)
• Tumor size and location
• Nodal status if lymph nodes were resected

Risk-Stratified Adjuvant Treatment Algorithm

Stage IA, Grade 1-2 Disease

For stage IA (no or <50% myometrial invasion), grade 1-2 tumors, observation alone is the standard approach. 1, 2

However, vaginal brachytherapy should be strongly considered for patients ≥60 years of age or those with LVSI present. 1

Stage IA, Grade 3 Disease

Vaginal brachytherapy is the preferred adjuvant treatment for stage IA, grade 3 tumors, particularly in surgically staged patients. 1

Observation can be considered only if there is absolutely no myometrial invasion. 1

External beam radiotherapy (EBRT) should be considered as a category 2B option if the patient is ≥70 years or has LVSI. 1

Stage IB (≥50% myometrial invasion), Grade 1-2 Disease

Vaginal brachytherapy is the preferred adjuvant treatment. 1

Observation can be considered only if no adverse risk factors are present (age <60 years, no LVSI). 1

EBRT should be considered for grade 2 tumors if additional risk factors are present such as age ≥60 years and/or LVSI. 1

Stage IB, Grade 3 Disease

For stage IB, grade 3 disease with adverse risk factors, systemic chemotherapy is added as a category 2B option in addition to EBRT and/or vaginal brachytherapy. 1

Treatment Outcomes and Salvage Therapy

The 5-year disease-free survival for surgically staged stage I patients managed conservatively is 93%, with 5-year overall survival of 98%. 3

Importantly, 81% of isolated vaginal recurrences can be successfully salvaged with radiation therapy, which argues against routine adjuvant therapy for all low-risk patients. 4 The majority of local recurrences (75-100%) are salvageable with whole pelvic radiation and brachytherapy. 4, 3

Special Considerations for Medically Inoperable Patients

For patients with severe medical comorbidities (obesity, cardiac disease, diabetes) who cannot undergo surgery, definitive radiotherapy with external beam radiation and/or brachytherapy is an effective alternative. 1

The 5-year disease-free survival with definitive radiotherapy alone is 88.7%, with excellent pelvic control rates. 5 This approach achieves 5-year disease-free survival of 94.3%, 92.3%, and 78.0% for grades 1,2, and 3 respectively. 5

Critical Pitfalls to Avoid

Do not perform routine therapeutic pelvic lymphadenectomy for the sole purpose of improving survival, as randomized trials show no benefit on overall or recurrence-free survival, while increasing risk of lymphoedema. 1

Do not administer adjuvant radiation to all stage I patients, as the majority have excellent outcomes with surgery alone, and most recurrences can be salvaged. 4, 3

Do not use preoperative radiotherapy for stage I disease, as it cannot be tailored to specific histoprognostic factors and constitutes overtreatment. 1

Ensure vaginal brachytherapy is initiated as soon as the vaginal cuff has healed, but no later than 12 weeks after surgery when indicated. 1