A 58-year-old postmenopausal woman from Delhi presents with vaginal bleeding for 3 months. She is obese (BMI 34 kg/m²), hypertensive, and diabetic. On examination, the uterus is normal size and mobile. Transvaginal ultrasound shows an endometrial thickness of 18 mm with heterogeneous echotexture. Endometrial biopsy reveals grade 1 endometrioid adenocarcinoma confined to the inner half of the myometrium. Staging MRI shows no evidence of cervical stromal invasion or extrauterine disease. What is the most appropriate next step in management?

Explanation

## Clinical Assessment **Key Point:** This patient has early-stage endometrial cancer (grade 1 endometrioid, stage IB — myoinvasion <50%) with no evidence of extrauterine spread. Surgical staging is the gold standard for endometrial cancer management. ## Rationale for Correct Answer Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) and pelvic lymph node dissection is the standard of care for: - All apparent stage I endometrial cancers (regardless of grade or myoinvasion depth) - Comprehensive surgical staging to assess nodal involvement and guide adjuvant therapy - Removal of the primary tumor and ovaries (which are a source of estrogen in postmenopausal women) **High-Yield:** Even in low-risk, early-stage endometrial cancer, lymph node assessment is essential because occult nodal metastases occur in 5–10% of apparent stage I cases and significantly alter prognosis and adjuvant treatment decisions. **Clinical Pearl:** Grade 1 endometrioid tumors with <50% myoinvasion are considered "low-risk" histology, but this does NOT eliminate the need for surgical staging. Adjuvant therapy decisions (radiation vs. observation) depend on final pathology and nodal status. ## Why Surgery is Mandatory | Feature | Implication | |---------|-------------| | Grade 1 endometrioid | Low-risk histology, but not curative without surgery | | Stage IB (inner half myoinvasion) | Still requires complete staging | | No imaging evidence of spread | Does not exclude microscopic nodal disease | | Postmenopausal status | Ovaries should be removed (no fertility preservation needed) | ## Staging Procedure Details 1. **Hysterectomy** — removes primary tumor and allows pathologic assessment of myoinvasion depth 2. **Bilateral salpingo-oophorectomy** — standard in postmenopausal women; removes hormonally active tissue 3. **Pelvic lymph node dissection** — assesses nodal involvement; findings determine adjuvant therapy 4. **Optional para-aortic lymph node assessment** — considered in intermediate/high-risk cases **Mnemonic:** **TAHBSO** = Total Abdominal Hysterectomy + Bilateral Salpingo-Oophorectomy (the surgical backbone of endometrial cancer treatment). ## Why Other Options Are Incorrect - **Radiation alone** — does not remove the primary tumor; inadequate for curative intent - **Chemotherapy first** — not indicated without prior surgical staging; upfront chemo is reserved for advanced/metastatic disease - **Endometrial ablation** — destroys the endometrium but does not remove the tumor; risks incomplete treatment and loss of surveillance capability