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 ag...

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 ...

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.