A 55-year-old woman with a history of type 2 diabetes and obesity (BMI 32 kg/m²) presents with postmenopausal bleeding. Transvaginal ultrasound shows an endometrial thickness of 18 mm with heterogeneous echotexture. Endometrial biopsy reveals endometrioid adenocarcinoma, FIGO grade 1. Staging workup including CT abdomen-pelvis and chest X-ray shows no evidence of distant metastasis. Pelvic MRI demonstrates tumor confined to the endometrium with intact junctional zone. Which of the following is the most appropriate management for this patient?

Explanation

## Endometrial Cancer Stage IA, Grade 1 Management **Clinical Context:** This patient has FIGO stage IA endometrial cancer (tumor confined to endometrium, grade 1). The key prognostic factors are: - **Low-grade histology** (grade 1) - **No myometrial invasion** (intact junctional zone on MRI) - **No lymphovascular space invasion** (assumed, not mentioned as present) - **Early stage** (IA) **Standard of Care (FIGO 2009 & GOG-99 trial):** For stage IA, grade 1–2 endometrial cancer **without adverse risk factors**, the recommended treatment is: - **Total abdominal or laparoscopic hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO)** - **Pelvic lymph node dissection is NOT routinely indicated** in low-risk early-stage disease **Rationale for Option 1 (Correct):** TAH-BSO without systematic pelvic lymphadenectomy is standard because: 1. **GOG-99 trial** demonstrated that lymphadenectomy does not improve survival in stage IA–IB, grade 1–2 cancers 2. **Low recurrence risk** (~5–10%) in this subset does not justify morbidity of lymphadenectomy 3. **Ovarian conservation** may be considered in premenopausal women, but this patient is 55 years old (postmenopausal); BSO is standard 4. Adjuvant therapy (vaginal brachytherapy or observation) is determined by final pathology **High-Yield:** Lymphadenectomy is reserved for **grade 3, stage IB, or presence of LVSI** (adverse risk factors). This patient lacks these features. ## Why Option 2 is Correct (Clarification): Option 1 states "pelvic lymph node dissection" — this is the trap. The correct answer is **Option 1** because it includes the standard components (TAH-BSO), and the question tests whether the candidate knows that **lymphadenectomy is NOT indicated** in low-risk stage IA disease. On re-reading, Option 1 includes lymphadenectomy, which is INCORRECT. **Option 2 (TAH-BSO alone, without lymphadenectomy) is the correct answer.**