A 62-year-old woman from Mumbai undergoes hysteroscopy and endometrial biopsy for postmenopausal bleeding. Histopathology confirms Grade 2 endometrioid adenocarcinoma, confined to the inner half of the myometrium. MRI shows no extension beyond the uterus. What is the most appropriate next step in management?

## Clinical Context Grade 2 endometrioid adenocarcinoma with superficial myometrial invasion (inner half) is FIGO Stage IB. This is an early-stage, intermediate-risk endometrial cancer. ## FIGO Staging of Endometrial Carcinoma | Stage | Definition | |-------|------------| | IA | Tumor confined to corpus uteri, no or <50% myometrial invasion | | IB | Invasion ≥50% of myometrium | | II | Cervical stromal invasion, no beyond uterus | | III | Local and/or regional spread | | IV | Tumor invades bladder/bowel mucosa or distant metastases | ## Management Algorithm for Early-Stage Endometrial Cancer ```mermaid flowchart TD A[Endometrial cancer diagnosed]:::outcome --> B{Stage?}:::decision B -->|Stage IA-IB| C{Grade and risk?}:::decision C -->|Low-risk| D[TAH-BSO alone]:::action C -->|Intermediate-risk| E[TAH-BSO ± adjuvant RT]:::action C -->|High-risk| F[TAH-BSO + adjuvant RT/CT]:::action B -->|Stage II-IV| G[TAH-BSO + staging + adjuvant therapy]:::action ``` ## Key Point: **Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) is the primary surgical treatment** for all stages of endometrial cancer. This is the definitive and curative approach for early-stage disease. ## High-Yield: - **Stage IB, Grade 2 = intermediate-risk endometrial cancer** - Surgical staging (TAH-BSO) is mandatory; it is both therapeutic and prognostic - Adjuvant radiation (vaginal brachytherapy ± external beam) may be added based on risk factors - Chemotherapy is reserved for high-risk (Grade 3, deep invasion, non-endometrioid histology) or advanced-stage disease - Observation alone is inadequate for confirmed malignancy ## Clinical Pearl: The presence of Grade 2 histology and myometrial invasion places this patient in the intermediate-risk category. While TAH-BSO is the definitive surgical treatment, adjuvant radiation may be considered depending on additional risk factors (age, lymphovascular invasion). However, surgery MUST be performed first. ## Mnemonic: **TAHBSO** = Total Abdominal Hysterectomy + Bilateral Salpingo-Oophorectomy — the cornerstone of endometrial cancer management. ## Warning: **Chemotherapy alone or radiation alone without surgery is NOT appropriate for resectable early-stage endometrial cancer.** Surgery must be the primary intervention. Chemotherapy is added only in high-risk or advanced cases. [cite:Robbins 10e Ch 22]