I have a patient 73 year old female operated case of ca endometrium grade 1 all nodes negative myometrial invasion more than 50%,tumor size 4×4 cm, lower uterine segment involved, pole negative,p53 wild type, mmr intact, suggest regarding adjuvant treatmentI have a patient 73 year old female operated case of ca endometrium grade 1 all nodes negative myometrial invasion more than 50%,tumor size 4×4 cm, lower uterine segment involved, pole negative,p53 wild type, mmr intact,lvi negative suggest regarding adjuvant treatment
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"endometrial cancer" AND "adjuvant" AND "intermediate risk"
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ESGO ESTRO ESAP 2023 endometrial cancer adjuvant treatment high intermediate risk guidelines brachytherapy
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"endometrial cancer" AND "FIGO 2023" AND "adjuvant" AND "molecular classification"
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endometrial cancer high intermediate risk adjuvant treatment MMR intact p53 wild type myometrial invasion grade 1
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FIGO 2023 stage IB grade 1 endometrial cancer NSMP MMR intact p53 wild adjuvant treatment high intermediate risk
I now have comprehensive data from the ESGO/ESTRO/ESP 2025 guidelines and relevant literature to give a precise, evidence-based answer. Let me synthesize this carefully.
Adjuvant Treatment Recommendation - Ca Endometrium
Patient Summary / Risk Stratification
| Feature | Value |
|---|---|
| Age | 73 years |
| Histology | Endometrioid adenocarcinoma, Grade 1 |
| Myometrial invasion | >50% (deep myometrial invasion) |
| Tumor size | 4x4 cm |
| Lower uterine segment involvement | Yes |
| Vaginal pole / surgical margins | Negative |
| Nodes | All negative (pN0) |
| LVSI | Negative |
| p53 | Wild type (not abnormal) |
| MMR | Intact (MMR-proficient / NSMP) |
Molecular Classification (ProMisE / TCGA)
With p53 wild-type and MMR intact, this tumor falls into the NSMP (No Specific Molecular Profile) category. Since it is Grade 1 (low-grade) and presumably ER-positive (as is typical for Grade 1 endometrioid), the relevant subtype is NSMP low-grade, ER-positive.
FIGO 2023 Stage
Under the 2023 FIGO staging system:
- Deep myometrial invasion (>50%) = Stage IB
- No cervical stromal invasion
- No nodal or distant disease
- No LVSI
- Lower uterine segment involvement alone does not upstage to Stage II under FIGO 2023 (which now requires cervical stromal invasion for Stage II)
FIGO 2023 Stage: IB (IIBm if molecular stage is incorporated for NSMP low-grade ER+)
Risk Group Classification (ESGO/ESTRO/ESP 2025 Guidelines)
Per the latest ESGO/ESTRO/ESP 2025 guidelines (Lancet Oncology, August 2025), the risk group allocation is:
| Category | Risk Level |
|---|---|
| Stage IB NSMP low-grade, ER-positive, LVSI negative, pN0 | Intermediate Risk |
| Stage IIBm NSMP low-grade ER+ (if molecular staging applied) | High-Intermediate Risk |
Without molecular upstaging applying here (Stage IB anatomically, LVSI negative, nodes negative), this patient most precisely falls into the Intermediate Risk group.
- The 5-year risk of recurrence in the intermediate-risk group is estimated at 8-14%
Adjuvant Treatment Recommendation
Primary Recommendation: Vaginal Brachytherapy (VBT)
This is the preferred adjuvant treatment for intermediate-risk endometrial cancer:
- VBT alone is recommended (Level I, Grade A) - based on the landmark PORTEC-2 trial, VBT provides equivalent vaginal control and survival to pelvic EBRT, with significantly better quality of life and fewer side effects
- VBT reduces vaginal vault recurrence (the predominant site of relapse in this risk group)
- In a 73-year-old woman, VBT is well tolerated and preferred over EBRT
Is EBRT needed?
No, EBRT is not indicated here because:
- LVSI is negative (negative LVSI is the key driver for EBRT in intermediate-risk disease)
- Nodes are all negative (pN0 - complete nodal staging done)
- There is no cervical stromal invasion
- EBRT would add bowel/bladder toxicity without meaningful benefit over VBT in this setting
Is chemotherapy needed?
No. Chemotherapy is reserved for:
- High-risk groups (p53 abnormal, serous, high-grade, nodal disease)
- This patient's p53 wild-type, Grade 1, NSMP profile does NOT warrant chemotherapy
Special Considerations
Lower Uterine Segment Involvement:
Under FIGO 2009, LUS involvement was considered a factor elevating risk. Under FIGO 2023, LUS involvement alone (without cervical stromal invasion) does not upstage the disease. However, clinically, some groups treat LUS involvement as a reason to favor VBT over observation.
Age Factor (73 years):
The ESGO/ESTRO/ESP 2025 guidelines specifically state that omission of adjuvant brachytherapy can be considered for patients younger than 60 years - this patient at 73 is above 60, which supports giving VBT rather than omitting it.
PORTEC-2 Supporting Evidence:
The PORTEC-2 trial (NEJM 2010) established VBT as equivalent to EBRT in intermediate-risk endometrial cancer with far less gastrointestinal toxicity. 5-year vaginal recurrence was 1.8% (VBT) vs 1.6% (EBRT), with overall survival identical.
Final Recommendation
Adjuvant vaginal vault brachytherapy (VBT) - this is appropriate, evidence-based, and well-tolerated in this 73-year-old with intermediate-risk (FIGO IB, Grade 1, NSMP, LVSI-negative, pN0) endometrial carcinoma.
No EBRT, no chemotherapy is warranted given:
- Negative LVI
- Negative nodes (pN0)
- Low-grade histology
- p53 wild type / NSMP profile
- No cervical stromal invasion
If molecular/ER status confirms ER-positive NSMP low-grade: VBT remains the recommendation, consistent with ESGO/ESTRO/ESP 2025 guidelines for this subgroup.
Based on: ESGO/ESTRO/ESP Guidelines for Endometrial Cancer (Lancet Oncology, August 2025); PORTEC-2 trial; Berek & Novak's Gynecology. Recent literature: PMID 40986254 (SEOM-GEICO 2025 guidelines), PMID 41653655 (molecular classification in EC management, 2026).
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