The Molecular Subtypes That Now Decide Endometrial Cancer Treatment

Fertility-sparing treatment is done only if the lady desires fertility, the disease is early, confined to one single ovary, with no peritoneal deposits and no malignant cells in the ascites. Even at stage 1B we'd do a diagnostic laparoscopy to check the other ovary, because imaging might miss small deposits. For germ cell tumours we always do fertility-sparing surgery because they're highly chemosensitive; for other tumours the decision has to be tailor-made.

If it's an advanced stage, stage 3 or 4, treatment is usually chemotherapy with radiation therapy. Squamous cell carcinomas are radiosensitive, and chemotherapy is given as a radiosensitiser to get a better response. If there's stage 4 disease with distant metastasis, systemic therapy is needed. Even after this, if there's residual disease and the patient's performance status is good, we'd still go back and remove the residual disease.

We use ICG dye and do the procedure robotically or laparoscopically with a 4K camera using the Firefly technique. We always open the retroperitoneal spaces first and get everything ready before injecting, because if there's bleeding during dissection after injecting, you won't be able to locate the sentinel node properly. If you're implementing this for the first time, do a pilot study of at least 25 cases each for endometrial and cervical cancer before using it as your standard method.

The most common complication is urinary issues, in about one or two out of every hundred patients we operate on, because we try carefully to identify and spare the inferior hypogastric nerve. Unlike axillary lymph node dissection, we don't see lymphoedema with the same frequency after pelvic lymph node dissection. We also follow the ERAS protocol, enhanced recovery after surgery, ambulating the patient the same day and starting oral intake within hours.

PCOS is a lifestyle disease. If you correct the lifestyle, your hormones should be under control. We explain to patients what's causing the imbalance rather than putting them on hormonal pills upfront, and give them 3 to 4 months to work on diet, exercise, stress management and sleep, alongside antioxidant medications. 60 to 70 percent of our patients come back at the end of 3 months saying they're having regular cycles.

Every endometrial cancer patient is now categorised into one of four molecular subtypes, and that categorisation, more than grade alone, shapes the treatment plan.

A POLE-mutated tumour carries a good prognosis even when high-grade, which means surgery combined with radiation is often sufficient, without escalating to the aggressive chemotherapy a high-grade diagnosis would otherwise suggest.

A p53-mutant tumour carries the least favourable prognosis of the four subtypes, so all six planned chemotherapy doses need to be delivered on schedule, with radiation added as an adjuvant to reduce recurrence and improve overall survival.

Targeted therapies are reserved mainly for recurrent or unusual cases, used as maintenance treatment where a centre has the facilities to monitor patients closely and catch a recurrence early.