How would you manage a patient with FIGO 2018 IA G3 endometrioid adenocarcinoma with substantial LVSI, and was N- with adequate nodal staging?

I continue to treat based on the 2018 group staging system, although I acknowledge the valuable prognostic insights gained from histology and molecular features incorporated into the 2023 system.

When discussing treatment options with the patient, I avoid framing them as 'more aggressive' or 'less aggressive' unless there is reasonable assurance that the 'more aggressive' option actually improved outcomes. If it were my decision, I'd lean towards vaginal brachytherapy. However, it seems that in p...

The main (IMO) extensive LVSI literature and associated elevated risks of pelvic nodal recurrence (Bosse et al., PMID 26049688) are from a pooled analysis of the PORTEC-1 and PORTEC-2 trials.

Neither trial routinely did lymphadenectomy, just a biopsy of suspicious nodes. PORTEC-2 explicitly excluded patients who had a staging lymphadenectomy. So we have no idea if extensive LVSI really predicts for 'recurrence' or just a higher than normal rate of pelvic nodal involvement (similar to how we think...

I would favor pelvic IMRT (or proton therapy) with a vaginal cuff HDR boost. Based on considerable data, including the PORTEC studies, substantial lymphovascular invasion is an independent predictor of local-regional recurrence.

If p53 is aberrant, I tend to treat Grade 3 as I would uterine serous. That is, chemotherapy is likely the workhorse of the treatment regimen. In this case, given p53 wild type, I think vaginal brachytherapy is appropriate here.