The incidence of unexpected uterine malignancy in women undergoing hysteroscopic myomectomy or polypectomy: A national population-based study

The incidence of neoplasm of uncertain behavior of uterus diagnosed after surgery for presumed leiomyoma: A national population-based study

OBJECTIVE

To investigate the incidence of neoplasm of uncertain behavior of uterus (NUBU) diagnosed after hysterectomy, myomectomy, or hysteroscopy for presumed leiomyomas.

METHODS

We performed this population-based retrospective cohort study using the Korean national health insurance database between January 2002 and December 2018. Women with or without NUBU diagnosed after surgery were extracted using diagnosis codes and procedure codes.

RESULTS

The median age of patients who underwent surgery for presumed leiomyomas was 39 years (interquartile range [IQR] 31-47 years). The median age of women diagnosed with NUBU after surgery was 45 years (IQR 38-49 years). The incidence of NUBU diagnosed after surgery for presumed leiomyomas was 1.89%. The incidences of NUBU diagnosed after hysterectomy, myomectomy, or hysteroscopic myomectomy for presumed leiomyomas were 2.03%, 1.84%, or 1.64%, respectively. There was no difference in the incidence of NUBU according to these surgical methods.

CONCLUSIONS

Regardless of the surgical procedure performed, the incidence of NUBU diagnosed after surgery was higher than that of unexpected uterine malignancy diagnosed after hysterectomy (0.19%), myomectomy (0.12%), or hysteroscopic myomectomy (0.86%) for presumed leiomyoma. Compared with unexpected uterine malignancy, NUBU seems to occur in relatively young women.

Noninvasive Predictor for Premalignant and Cancerous Lesions in Endometrial Polyps Diagnosed by Ultrasound

Background

There was no consensus for management of asymptomatic endometrial polyps (EPs) up to date.

Objective

The aim of present study was to determine the risk factors of malignant lesions in EPs diagnosed by ultrasound and establish a noninvasive predictor to decrease unnecessary hysteroscopy for EPs.

Study Design

We reviewed the records of all consecutive patients who underwent hysteroscopy for EPs in the Women’s Hospital School of Medicine Zhejiang University between January 1, 2001 and December 31, 2018. The patients with histological diagnoses of atypical hyperplasia or cancer were defined as malignancy, while the patients with histological diagnoses of benign lesions were randomly selected as benign group according to the ratio of 1:4 (malignancy:benign), matching by age and year of hospitalization. Logistic regression analysis was used to analyze the clinical parameters for predicting malignancy of EPs. A Chi-squared automatic interaction detection (CHAID) decision tree analysis was performed to find a noninvasive predictor. The sensitivity, specificity, and the receiver operating characteristic curve (ROC) were used for assess the efficacy of the noninvasive predictor. New diagnosed EPs patients received in 2019 were used for verifying the accuracy of the noninvasive predictor.

Results

The age in 15,790 cases of benign lesions was significantly younger than that in 230 malignancy cases (41.97 ± 11.53 year vs 53.31 ± 11.61 years, p <0.001). AUB (OR 7.306, 95%CI 4.927–10.835), large EPs (OR 2.595, 95%CI 1.662–4.052), and blood flow signal in EPs (OR 2.690, 95%CI 1.872–3.866) were independent predictive factors of malignancy in all enrolled patients. A noninvasive predictor for malignancy of EPs was established, through combining with AUB, large polyps and blood flow signal. This predictor presented excellent sensitivity and NPV (91.3 and 95.8%), with acceptable specificity and AUC (0.801). Further validation in new diagnosed EPs also suggested excellent sensitivity and reasonable specificity (100 and 58.5%) of the predictor. Factors such as thickened endometrial thickness, menopause shorter than 10 years, hypertension, obesity and nulliparous were also validated as independent predictors of malignancy in different subgroup analysis.

Conclusions

The noninvasive predictor combined with other risk factors from subgroup analysis would be reliable to distinguish the benign lesions from malignancy for EPs diagnosed by ultrasound.

Hybrid Robotic Single-Site Myomectomy Using the GelPoint Platform

Background: To overcome the limitations of single-port laparoscopic myomectomy (SP-LM) and robotic single-site myomectomy (RSSM), we designed a new surgical technique, the so-called hybrid RSSM (H-RSSM), by integrating the advantages of both procedures. This study describes the surgical technique of H-RSSM and reports our initial experiences. Materials and Methods: Between February 2018 and September 2018, H-RSSM was performed in 25 women with symptomatic fibroids. During the H-RSSM, the enucleation of the fibroid was carried out using single-port laparoscopy and the uterine defect was repaired using robotic single-site surgery. To assess the feasibility and efficacy of H-RSSM, the results of this study were compared with those of our previous study on SP-LM and its modified surgical technique, so-called single-port laparoscopically assisted transumbilical ultraminilaparotomic myomectomy (SPLA-TUM). Results: The mean operation time, hemoglobin change, return of bowel activity, and length of hospital stay were 69.4 ± 18.2 minutes, 1.2 ± 0.9 g/dL, 37.1 ± 15.5 hours, and 4.0 ± 0.8 days, respectively. There was no conversion to laparotomy or multiport laparoscopy. There were no surgical or wound complications. Comparing with SP-LM and SPLA-TUM, H-RSSM had significantly shorter operation time and return of bowel activity. Conclusion: H-RSSM can reduce operating time and the conversion rate to multiport laparoscopy and can be considered a feasible alternative for selected patients with symptomatic fibroids. However, further studies are needed to clearly demonstrate these benefits.

The risk of malignancy in uterine polyps: A systematic review and meta-analysis

BACKGROUND

Endometrial polyps are a common condition. The risk of malignancy has often led to an overtreatment with high health care costs and huge psychological distress.

OBJECTIVE

We conducted a systematic review and a meta-analysis in order to estimate the prevalence of premalignant and malignant lesions in women undergoing hysteroscopic polypectomy.

DATA SOURCE

We developed the search using PubMed/MEDLINE and EMBASE databases to identify papers published between 2000- January 2019. The research strategy used on Pubmed was: ("polyps" (MESH) OR "endometrial polyp*") AND ("malignancy" OR "cancer" OR "histopathology" OR "hysteroscopy" OR "ultrasound", OR "sonohysterography"). The same search was modified for EMBASE.

STUDY ELIGIBILITY

We included all observational retrospective and prospective studies and studies were selected for the review if they met following inclusion criteria: pre-operative diagnosis of benign-looking endometrial polyps at ultrasound examination or at hysteroscopy, excision of endometrial polyps via surgical hysteroscopy, histopathological diagnosis of benign polyps, or hyperplasia without atypia, or premalignancy (atypical hyperplasia) or malignancy (endometrial cancer). Moreover, studies were included if number or percentage of subjects with and without malignancy was provided and if they reported data about menopausal and/or bleeding status. We excluded data presented exclusively as abstracts in national and international meetings, or case report or review articles that did not include original data and papers published in other than English language. Our primary outcome was the prevalence of endometrial premalignant or malignant polyps in the total series, among premenopausal and postmenopausal women and among women with or without abnormal bleeding and then in subgroup analysis according to study design, diagnostic method, study region and calendar year of publication.

RESULTS

A total of 51 studies reporting data on 35,345 women were included in this review. The prevalence of malignant polyps was 2.73% (95% CI 2.57-2.91) with very high heterogeneity among studies. The rates were lower for premenopausal women (1.12%) than post-menopausal ones (4.93%) and the difference was statistically significant (chi-square = 397.21. p < .0001). The risk of malignancy was higher among symptomatic (5.14%) than asymptomatic ones (1.89%) (chi-square = 133.13 p < .001). We observed higher rate of malignant polyps in prospective studies. In the meta-analysis selecting 10 prospective studies the random pooled estimate was 5.88 (95% CI: 4.06-7.97) with heterogeneity among studies (heterogeneity chi square = 17.55 P = .025) whereas in retrospective studies the random pooled estimate was 2.94 (95% CI:2.24-3.71) with high heterogeneity among studies (P < .001). This finding can be due to more strict diagnostic criteria in prospective studies.

CONCLUSION

Symptomatic vaginal bleeding and postmenopausal status in women with endometrial polyps increased the risk of malignancy. This finding could be an useful evidence to select patients who need to undergo hysteroscopic resection of endometrial polyps and women to whom, instead, an expectant management can be offer.