Grade 1 endometrioid endometrial cancer in an obese woman on apixaban

Risk stratification

• She has presumed stage IA, grade 1 endometrioid carcinoma with <50% myometrial invasion on MRI. This is the low-risk group: no nodal staging or, if the team performs it, sentinel node biopsy rather than full lymphadenectomy is sufficient. Cross-sectional imaging of chest and abdomen (CT) and PET-CT are not routinely required in this low-risk, asymptomatic picture; they are reserved for high-grade histology, deep invasion, cervical involvement or symptoms.
• Confirm the preoperative pathology with a second read if any doubt; check LVSI on the final specimen, since it upgrades risk postoperatively.
• Optimise comorbidity: repeat HbA1c in the month before surgery, control blood pressure, screen for anaemia and iron deficiency, arrange anaesthetic review for a BMI 38 patient with a potentially difficult airway and for positioning and pneumoperitoneum, and assess VTE and bleeding risk formally.
• Also consider whether she has any symptoms of ovarian pathology given incompletely visualised ovaries and organise a dedicated transvaginal/transabdominal ultrasound.

Apixaban

• Stop apixaban 48 hours before surgery (last dose two days preoperatively). Do not bridge with therapeutic heparin: for a non-valvular atrial fibrillation patient with a moderate stroke risk, bridging with DOACs increases bleeding without reducing thromboembolism.
• Restart after surgery when haemostasis is secure, typically 24–48 hours postoperatively for laparoscopic surgery, and use prophylactic low-molecular-weight heparin in the interim.

Thromboprophylaxis: BMI 38 plus cancer surgery is high risk - weight-adjusted prophylactic low-molecular-weight heparin (for example enoxaparin 40 mg twice daily or 60 mg daily), mechanical calf compression, and extended prophylaxis for 28 days after major pelvic cancer surgery.

Surgical approach

• The standard operation is total hysterectomy with bilateral salpingo-oophorectomy, with peritoneal washings if your unit does them, and the laparoscopic route is oncologically acceptable - the LACE trial randomised clinical stage I endometrial cancer to open versus laparoscopic surgery and found no difference in disease-free or overall survival, with shorter hospital stay and fewer complications in the laparoscopic arm.
• In a BMI 38 woman, laparoscopy has real advantages: less wound infection and dehiscence, less pain, faster mobilisation, lower VTE risk. The trade-offs are longer operative time, steep Trendelenburg positioning (ventilation and airway issues), risk of conversion (higher with obesity, adhesions, poor exposure), and trocar-related injury in a thick abdominal wall.
• She needs a surgeon and anaesthetist experienced with obese patients, appropriate instruments and table weight limits, and antibiotic prophylaxis. The district hospital is acceptable provided the accredited oncology team operates, frozen section and ultrastaging pathology are available, and there is an escalation plan to a comprehensive cancer centre if the operative findings are unexpected.

Nodes - what to tell her

• For low-risk disease (grade 1–2, <50% invasion, no LVSI) systematic lymphadenectomy is not required: it does not improve survival and increases lymphoedema and nerve injury.
• Sentinel node biopsy with indocyanine green and pathological ultrastaging is a reasonable alternative and is what her team offers; it is diagnostic and does not itself improve survival in low-risk disease, but it identifies the occasional unexpected node-positive case and spares a full dissection.
• If she is node-negative on ultrastaging, no further nodal surgery. If a sentinel node is positive, she needs multidisciplinary discussion about completion lymphadenectomy versus adjuvant treatment.

So the honest answer: the nodes do not 'have to' come out in her situation; the two defensible options are no nodal staging or sentinel node biopsy.

Adjuvant treatment

• She falls into the low-risk group (stage IA, grade 1, LVSI negative, <50% invasion). No adjuvant radiotherapy or chemotherapy is indicated: vaginal brachytherapy does not improve survival in this group, and external-beam radiotherapy would add bowel and bladder toxicity for no benefit.
• If the final assessment had shown LVSI or deeper invasion (stage IB, or grade 3), she would move into a high-intermediate or high-risk group where vaginal brachytherapy (PORTEC-2 type approach) and, for high-risk disease, chemotherapy plus radiotherapy (PORTEC-3 type approach) would be discussed at a multidisciplinary tumour board.

Surveillance

• Clinical review with history and examination every 3–6 months for the first 2–3 years, then annually; vaginal vault cytology is no longer routinely recommended, but many Czech centres still perform vaginal vault smears - explain the limited evidence.
• Investigate any vaginal bleeding, pelvic pain or unexplained weight loss with imaging; do not order routine CA-125 or CT in asymptomatic low-risk patients.

Counselling

• Overall prognosis is excellent, with 5-year disease-specific survival above 95% for stage IA grade 1 disease.
• Address the modifiable drivers: obesity and diabetes are the dominant risk factors for endometrial cancer. Structured weight management, glycaemic control and physical activity reduce recurrence risk and overall mortality. Her long-term cardiovascular risk is at least as great as her cancer risk.
• Discuss the increased risk of further obesity-related cancers (colon, breast) and ensure she is included in national screening programmes; discuss Lynch syndrome testing per local criteria, since it changes surveillance for her relatives.
• Discuss hormone therapy and any future bleeding promptly.