A 58-year-old postmenopausal woman from Delhi presents with vaginal bleeding for 3 months. She has a BMI of 34 kg/m², history of type 2 diabetes (HbA1c 8.2%), and hypertension. On examination, the uterus is normal size and non-tender. Pap smear is normal. Transvaginal ultrasound shows an endometrial thickness of 18 mm with heterogeneous echotexture. Endometrial biopsy reveals a grade 2 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 Context This patient presents with postmenopausal bleeding and biopsy-proven grade 2 endometrioid adenocarcinoma with myometrial invasion limited to the inner half (stage IB). She has metabolic risk factors (obesity, diabetes, hypertension) that are associated with endometrial cancer. ## Staging and Prognostic Factors | Feature | Finding | Significance | |---------|---------|---------------| | Grade | 2 (moderate) | Intermediate risk | | Myometrial invasion | Inner half | Stage IB | | Histology | Endometrioid | Favorable | | Cervical stromal invasion | Absent | No stage IIA | | Extrauterine disease | None on MRI | No stage III/IV | **Key Point:** Stage IB endometrial cancer (myometrial invasion ≤50%) with endometrioid histology is an intermediate-risk disease requiring comprehensive surgical staging. ## Surgical Management Algorithm ```mermaid flowchart TD A[Endometrial cancer diagnosed on biopsy]:::outcome --> B{Medically fit for surgery?}:::decision B -->|Yes| C[Comprehensive surgical staging]:::action C --> D[TAH-BSO + pelvic/para-aortic lymphadenectomy]:::action D --> E[Pathological staging]:::outcome E --> F{Risk stratification}:::decision F -->|Low risk| G[Observation]:::action F -->|Intermediate risk| H[Vaginal brachytherapy ± chemotherapy]:::action F -->|High risk| I[Chemotherapy + radiation]:::action B -->|No| J[Radiation therapy alone]:::action ``` **High-Yield:** Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) and pelvic lymph node dissection is the gold standard surgical approach for stage I endometrial cancer. Para-aortic lymphadenectomy should be considered in intermediate- and high-risk cases. **Clinical Pearl:** Endometrial cancer staging is **surgical-pathological**, not clinical. MRI findings guide but do not replace the need for comprehensive intraoperative assessment and lymph node sampling. ## Why This Patient Needs Full Staging 1. Grade 2 histology with myometrial invasion = intermediate-risk disease 2. Lymph node metastases occur in ~10–15% of stage IB cases and significantly alter adjuvant therapy 3. Vaginal hysterectomy alone is inadequate because it does not permit pelvic/para-aortic lymph node assessment 4. Postoperative risk stratification depends on final pathological stage **Mnemonic:** **TAHBSO** = Total Abdominal Hysterectomy, Bilateral Salpingo-Oophorectomy (the surgical backbone of endometrial cancer treatment). [cite:Park 26e Ch 16]