Adjuvant treatment algorithm based on recent ESGO/ESTRO/ESP guidelines for early endometrial carcinoma according to prognostic risk groups

The incidence of endometrial cancer (EC) is unfortunately increasing. Often diagnosis is made at an early stage and surgery is the curative treatment. Nevertheless, adjuvant treatment is proposed to reduce the risk of relapse. This treatment is tailored based on the extent of the disease, such as the presence of distant metastasis, the extent of involvement of adjacent organs or lymph nodes. However, histological parameters such as myometrial invasion, substantial lymphovascular space invasion, invasion of the cervical stroma or tumor grade are also key to selecting adjuvant treatment. The Cancer Genome Atlas (TCGA) project has demonstrated the superiority of molecular classification over histological evaluation in EC to determine the prognosis. The International Federation of Gynecology and Obstetrics 2023 staging for EC is the first staging system that has incorporated molecular biomarkers on top of morpho-histological classification. Currently, all patients should have a molecular profile of their tumor and a lymph node assessment. The landmark treatment of stage I-III ECs is surgery followed by radiotherapy. The European guidelines updated in 2025 has divided EC in 4 risk categories with specific adjuvant treatment. For clinicians, it is seen as a complex landscape from surveillance to chemo-radiotherapy. Therefore, we propose here a practical pocket guideline for adjuvant treatment of early-stage EC patients based on a review of the different clinical trials in the adjuvant setting and on existing guidelines. This pocket guideline may also serve as a base for incorporation of new clinical trials under the RAINBO umbrella research program.