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Case history

image A 79-year-old woman presented with a 2 month history of intermittent postmenopausal vaginal bleeding. She initially tried topical vaginal oestrogen cream, thinking she had atrophic vaginitis, but there was no improvement. She had no pain, vaginal discharge or weight loss. Her GP referred her urgently for a transvaginal ultrasound scan, which identified endometrial thickening of 9 mm. An endometrial biopsy confirmed a grade 2 endometrioid adenocarcinoma. She had an MRI scan of the abdomen and pelvis, which demonstrated deep myometrial invasion >50%, but no obvious pelvic or para-aortic lymph node involvement. Her chest x-ray was normal.

Her medical history included peripheral vascular disease (PVD) and obesity. Her BP was 168/102 mmHg and her BMI was 34 kg/m2. She was able to walk 80 m before developing claudication. She became short of breath ascending one flight of stairs. She was taking aspirin and simvastatin. Her performance status was 2. She had had two children, both with normal vaginal deliveries. She lived alone and had weekly visits from relatives.

Her case was discussed in the gynaecological cancers multidisciplinary team (MDT) meeting. Her cancer was assessed as stage IB (i.e. >50% myometrial invasion) according to the classification of the International Federation of Gynecology and Obstetrics (FIGO) (Table 18.1).1 It was recommended that she have a laparoscopic hysterectomy and bilateral salpingo-oophorectomy plus pelvic lymph node sampling. The MDT recommended a review by a care of the elderly physician, optimization of medical comorbidities and an assessment in the surgical clinic regarding her suitability for surgery and anaesthetic risk.

What are the goals of treatment for this patient?

What can be done preoperatively to optimize her for surgery?

How is obesity relevant to her management?

What can be done to improve her postoperative recovery?

What adjuvant treatment might be recommended?

If the risk of surgery was deemed to be too high, what alternative treatment could be recommended?

Table 18.1FIGO staging of endometrial cancer (2009).

What are the goals of treatment for this patient?

For early-stage endometrial cancer, patients should be offered treatment with curative intent. This usually involves primary surgery followed by an evaluation of the potential benefits of adjuvant radiotherapy (external beam radiation therapy [EBRT] or brachytherapy) and adjuvant chemotherapy. There must be a compelling reason ...

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