Endometrial Cancer with Positive Peritoneal Washings: Stage I or III?
A 64-year-old woman with postmenopausal bleeding undergoes total hysterectomy, bilateral salpingo-oophorectomy, and pelvic washings. Final pathology: endometrioid adenocarcinoma, grade 2, invading 40% of the myometrium, no cervical stromal invasion, no adnexal involvement, and 0 of 18 pelvic nodes positive. Peritoneal washings are positive for malignant cells. The surgeon documents "stage I endometrial cancer" in the operative note. The abstractor must assign stage and reconcile the discrepancy.
1. How should positive peritoneal washings be handled in FIGO staging for endometrial cancer, and what stage should be assigned?
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The critical judgment is that positive peritoneal cytology is no longer a stage-defining finding in the current FIGO endometrial cancer staging. It was removed from the staging criteria and is now recorded as a separate prognostic/descriptive factor rather than upgrading the case to stage IIIA.
Reasoning:
- The tumor is confined to the uterus with <50% myometrial invasion, grade 2, no cervical stromal involvement, no adnexal spread, and negative nodes.
- Under current FIGO, this is stage IA (invasion <50% of myometrium).
- Positive washings should be documented in the abstract as a cytology finding and may be noted as a risk factor, but they do not change the stage assignment.
- The abstractor should not "correct" the stage upward based on washings; instead, record stage IA and note the positive cytology in the appropriate text/cytology field.
If the institution uses an older staging schema, the abstractor must follow the schema in force for the diagnosis date and document which schema was applied.
2. The operative note says "stage I" but the pathology report includes positive washings. How should the abstractor reconcile this and what should be documented?
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Reconciliation steps:
- Trust the pathology and staging rules over the operative note's free-text stage. Surgeon-documented stage is a clinical opinion; the registry assigns stage from the full record using the applicable FIGO/TNM rules.
- Confirm the schema: Identify the FIGO edition applicable to the diagnosis date (this determines whether cytology is stage-defining).
- Document the discrepancy: Note that the operative note recorded stage I while the pathology documented positive peritoneal cytology; explain that cytology is not stage-defining under the current schema and that stage IA was assigned.
- Capture all elements: myometrial invasion depth, grade, cervical status, adnexa, nodes, and cytology in their respective fields.
- Escalate if ambiguous: If the schema or institutional policy is unclear, flag for review rather than guessing; do not silently override without documentation.
3. What prognostic and follow-up implications does the positive cytology have even though it does not change stage?
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Although not stage-defining, positive cytology is associated with higher risk of peritoneal recurrence and worse outcomes in some series, so it should be captured for risk stratification.
Implications:
- Treatment planning: May influence decisions about adjuvant therapy (e.g., vaginal brachytherapy versus external beam, or systemic therapy) depending on other risk factors such as grade, LVSI, and depth of invasion.
- Surveillance: May prompt closer follow-up for peritoneal and distant recurrence.
- Reporting: Should be recorded as a discrete data element so that survival and recurrence analyses can stratify on it.
- Data quality: Ensures the registry can support studies on the prognostic significance of cytology without conflating it with stage.