Patient BMI 43 but generally healthy. Presented after intermittent vaginal spotting for years. Pelvic US and endometrial biopsy c/w atypical endometrial hyperplasia. Underwent TLH BSO, LN grossly normal during surgery and were not resected. Final pathology with 2cm FIGO Grade 1 endometrioid adenocarcinoma with tumor invading > 50% of myometrial depth. Cervical stromal invasion and extensive (>3 vessel) lymphovascular invasion were seen. Negative margins. pT2Nx FIGO stage II. Molecular markers with pMMR, wild type p53, POLE testing pending, ER 91-100%, PR 71-80%, HER2 0+. Would you consider completion lymphadenectomy for this patient or move on to adjuvant EBRT as outlined in the PORTEC study (with possible PET/CT to r/o obvious LN involvement)?

Gynecologic Cancer Specialist

These cases are always challenging.  On one hand she requires additional therapy regardless of repeat operation but on the hand your option for treatment (chemo vs EBRT alone) would differ based off stage.I would perform imaging for sure - CT or PET to assess lymph nodes and any other concerns. If imaging is negative I might lean towards EBRT alone based on her molecular profile and PORTEC.  I would discuss surgical staging as I think it’s definitely something that should be considered… and if she would like a more definitive answer understanding she still needs additional therapy I would support that shared decision. So in summary Imaging for sure - PET or CT, Discuss need for additional therapy, Offer surgery then therapy, Go right to EBRT if scans look good. I don’t think my recommendation would change based on POLE status off of trial at this time.