Would you change your approach to adjuvant radiation for an incompletely staged, at least IB, grade 1 endometrial cancer, if a uterine perforation occurred at time of surgery?

Similarly to the above authors, I agree with offering this patient vaginal brachytherapy.

Though she does not definitively meet GOG99 criteria, given the situation with deep myometrial invasion and perforation, this is a reasonable and low-risk treatment opportunity to decrease local recurrence.

There are several options for further evaluation of metastatic disease in this case of incompletely staged grade 1 endometrial cancer: 1) offer the patient a second surgery for complete surgical staging, as some centers would perform a full lymphadenectomy with >50% myometrial invasion, 2) CT abdomen/pelvis to rule out metastatic disease, 3) no further evaluation of the lymph nodes based on ASTEC trial. As long as the patient is thoroughly counseled...

Agree with @Dr. First Last RE vaginal brachytherapy.

Our cancer patients are managed with SLNB for nodal evaluation, unless the initial pre-operative diagnosis is hyperplasia - then we discuss SLNB at the time of hysterectomy or use Mayo Criteria to guide surgical LN staging.

There is no robust data to indicate cancer outcomes are altered in uterine perforation situation (please post if you other readers have some!).

This is an uncommon occurrence but probably most likely when the uterine manipulator is introduced for cancer surgery. Here is a study (retrospective) that suggests a manipulator is associated with worse oncologic outcomes. This by itself is thought-provoking.

Padilla-Iserte et al., PMID 32693096

This other study suggests, perforat...

Agree with the above comments. I do not think there is any evidence of uterine perforation and increased risk of local recurrence. Peritoneal cytology is no longer in the FIGO staging, and if anything this would be a chemotherapy-related issue, which this patient does not require. I would feel comfortable offering VBT alone.

There are 2 parts to this question:

First, is the incomplete surgical staging (by which I assume you mean no pathological lymph node assessment) problematic? The MRC ASTEC trial did not identify a benefit to lymphadenectomy in clinical stage I patients, so it would be reasonable to omit surgical lymph node staging (although some centers would have performed SLNB as part of the initial surgery). It would still be reasonable to get a CT scan of the abdomen/pelvis, if the patient has not already done so, to rule out gross nodal disease by imaging (though reactive nodes can be non-specifically, mildly prominent in the immediate postoperative period). This is consistent with NCCN guidelines, which say to "Consider imaging" for patients with incom...

I ask myself and the patient, "What if we were here before the hysterectomy? Would we recommend surgical staging? If the answer is yes, then why not now, assuming you heal and have no major contra-indications?"

GOG 33 reported 11% pelvic node metastasis and 6% para-aortic metastasis for outer third grade 1 disease. This IB patient could be middle third, but assuming a 2 cm or greater lesion approaching or exceeding 2/3 invasion, especially if LVSI, I would first evaluate with CT scan and consider a secondary staging procedure 6 to 8 weeks postoperatively with robotic-assisted laparoscopy. I inject the vaginal cuff with ICG and perform sentinel mapping, but liberally remove any slightly suspicious nodes on the medial aspect of internal iliac ...