Approach to Endometrial Cancer

Initial Diagnostic Workup

The management of endometrial cancer begins with comprehensive surgical staging via total hysterectomy with bilateral salpingo-oophorectomy, preceded by thorough preoperative evaluation including endometrial biopsy, transvaginal ultrasound, pelvic MRI, and molecular classification of the tumor 1
Obtain tissue diagnosis through endometrial biopsy or dilation and curettage before any surgical intervention 1
Perform transvaginal ultrasound to assess endometrial thickness, myometrial invasion, and rule out ovarian involvement 1, 2
Order pelvic MRI with dynamic contrast enhancement - this is the most accurate imaging modality for assessing myometrial invasion and cervical stromal invasion 1
Complete laboratory workup: full blood count, liver function tests, renal function profiles 1, 2
Conduct clinical and gynecological examination to assess disease extent 1

Perform total hysterectomy with bilateral salpingo-oophorectomy as the cornerstone of treatment 1, 3
Minimally invasive surgery is preferred over laparotomy, providing equivalent oncologic outcomes with superior perioperative benefits 1, 3
Robotic approach offers particular benefit in obese patients, with significantly lower major complication rates compared to laparotomy 4, 3
Routine systematic pelvic lymphadenectomy does NOT improve overall survival or disease-free survival in stage I endometrial cancer 5, 2, 3
Lymphadenectomy provides critical prognostic information and guides adjuvant therapy decisions 4, 3
Recommend complete surgical staging for intermediate-to-high-risk disease 4, 3
Use preoperative risk stratification to determine which patients require lymphadenectomy 6

Stratify patients based on FIGO stage, histological type and grade, depth of myometrial invasion, lymphovascular space invasion, lymph node status, and molecular classification 1, 2

Surgery alone is adequate for low-risk disease, no adjuvant therapy required 3
Vaginal brachytherapy is recommended for intermediate-risk disease to maximize local control with minimal side effects and no impact on quality of life 3

External beam radiotherapy and/or brachytherapy are acceptable alternatives for patients with significant comorbidities precluding surgery 8

Never perform uterine morcellation without ruling out malignancy - this risks spreading cancerous tissue and compromises pathological assessment 6
Do not rely on clinical staging alone - it underestimates disease extent in some cases 6
Avoid incomplete surgery when cancer is suspected 6
Recognize discrepancies between preoperative and final pathology occur frequently - be prepared to adjust treatment plans 6