How would you treat a high intermediate risk stage IA grade 2 endometrial ca?

If it is Stage IA, Grade 2 without additional risk factors, we recommend observation. It is not considered high intermediate risk.

If it is Stage IA, Grade 2 with additional risk factors such as LVI or age 60+, we recommend a referral to radiation oncology to discuss. Anecdotally, most patients will choose brachytherapy.

Our patients generally receive sentinel lymph node evaluation. If nodes are not surgically evaluated, pelvic radiation is considered if LVI (usually extensive LVI) is present.

Here are two excellent online calculators/nomograms:

Bayta Systems PORTEC/GOG Calculator This calculator is excellent and will give expected outcomes for observation, brachy, or EBRT.

OHSU PORTEC Loco-regional recurrence nomogram

This above patient would no...

In general, I would offer vaginal brachytherapy. I like to use the PORTEC-1&2 nomogram (Creutzberg et al., IJROBP 2015) when discussing treatment options with patients. For example, with a 60 year old with IA, grade 2 and LVI, the risk of LRR with observation would be ~ 12-13%; with vaginal brachytherapy it would be ~ 4%; and with pelvic RT it would be about 2%. Pelvic RT has maybe a 2-3% decrease in LRR at the cost of more treatments and bowel/bladder toxicity.

My recommendation would change based on patient-specific factors.

• Patients on PORTEC-1&2 had at least lymph node sampling and palpation. If the patient was obese and/or had comorbidities that precluded any lymph node evaluation, then I would make sure there was imaging of the pelvis ...

Brachytherapy alone unless has substantial LVSI or p53 mutation then would consider adding EBRT especially if nodes not sampled. Chemotherapy is for p53 mutation positive.
Concin et al., PMID 33397713