Resectoscopic surgery may be an alternative to hysterectomy in high-risk women with atypical endometrial hyperplasia

Hysteroscopic biopsy compared with endometrial curettage to assess the preoperative rate of atypical hyperplasia underestimating endometrial carcinoma

PURPOSE

To evaluate the rate of atypical hyperplasia (AH) underestimating endometrial cancer (EC) comparing endometrial biopsy (EB) accomplished by hysteroscopic biopsy with dilatation and curettage (D&C). Second, to compare the two techniques to foresee EC grading.

METHODS

This trial was based on the findings of two Gynecological Departments within the same Public Utility, sharing pathological service and database but routinely performing EB under hysteroscopic visualization (group A) or hysteroscopy followed by D&C (group B). We retrieved the clinical data of patients showing EC on hysterectomy throughout a 10-year period. The accuracy of hysteroscopic-view diagnosis and EB pathology were compared, having the pathologic findings of hysterectomy as reference.

RESULTS

A total of 161 patients met the inclusion criteria. Among these, 109 and 52 were included in groups A and B, respectively. In group A, 32.1% of patients underwent EB in an out-patient setting. To foresee EC, hysteroscopic view showed a sensitivity of 82.5% and 70.2% in groups A and B, respectively (P = 0.019). An underestimation of EC diagnosed as AH on EB was found in 20 patients (12.4%). Among these, 18 (16.5%) and 2 (3.8%) were included in groups A and B, respectively (P = 0.022). In group A, a fault diagnosis of AH resulted higher when EB was performed as out-patient setting (P = 0.006). EB allowed the grading of EC in 73.3% and 90.3% of patients in groups A and B, respectively. The agreement was 73.7% and 85.1%, leading to moderate (κ = 0.56) and good (κ = 0.77) "κ" coefficient of concordance for groups A and B, respectively.

CONCLUSIONS

EB performed by D&C lowers the rate of AH underestimating concurrent EC and improves the grading agreement when compared with hysteroscopic sampling.

Diagnosis of endometrium hyperplasia and screening of endometrial intraepithelial neoplasia in histopathological images using a global-to-local multi-scale convolutional neural network

BACKGROUND AND OBJECTIVE

Endometrial hyperplasia (EH), a uterine pathology characterized by an increased gland-to-stroma ratio compared to normal endometrium (NE), may precede the development of endometrial cancer (EC). Particularly, atypical EH also known as endometrial intraepithelial neoplasia (EIN), has been proven to be a precursor of EC. Thus, diagnosing different EH (EIN, hyperplasia without atypia (HwA) and NE) and screening EIN from non-EIN are crucial for the health of female reproductive system. Computer-aided-diagnosis (CAD) was used to diagnose endometrial histological images based on machine learning and deep learning. However, these studies perform single-scale image analysis and thus can only characterize partial endometrial features. Empirically, both global (cytological changes relative to background) and local features (gland-to-stromal ratio and lesion dimension) are helpful in identifying endometrial lesions.

METHODS

We proposed a global-to-local multi-scale convolutional neural network (G2LNet) to diagnose different EH and to screen EIN in endometrial histological images stained by hematoxylin and eosin (H&E). The G2LNet first used a supervised model in the global part to extract contextual features of endometrial lesions, and simultaneously deployed multi-instance learning in the local part to obtain textural features from multiple image patches. The contextual and textural features were used together to diagnose different endometrial lesions after fusion by a convolutional block attention module. In addition, we visualized the salient regions on both the global image and local images to investigate the interpretability of the model in endometrial diagnosis.

RESULTS

In the five-fold cross validation on 7812 H&E images from 467 endometrial specimens, G2LNet achieved an accuracy of 97.01% for EH diagnosis and an area-under-the-curve (AUC) of 0.9902 for EIN screening, significantly higher than state-of-the-arts. In external validation on 1631 H&E images from 135 specimens, G2LNet achieved an accuracy of 95.34% for EH diagnosis, which was comparable to that of a mid-level pathologist (95.71%). Specifically, G2LNet had advantages in diagnosing EIN, while humans performed better in identifying NE and HwA.

CONCLUSIONS

The developed G2LNet that integrated both the global (contextual) and local (textural) features may help pathologists diagnose endometrial lesions in clinical practices, especially to improve the accuracy and efficiency of screening for precancerous lesions.

Abnormal Uterine Bleeding in Perimenopausal Women: The Role of Hysteroscopy and Its Impact on Quality of Life and Sexuality

Abnormal uterine bleeding (AUB) is a frequent symptom in perimenopausal women. It is defined as uterine bleeding in which the duration, frequency, or amount of bleeding is considered excessive and negatively affects the woman’s quality of life (QoL) and psychological well-being. In cases of structural uterine pathology, hysterectomy (usually performed via a minimally invasive approach) offers definitive symptom relief and is associated with long-lasting improvement of QoL and sexuality. However, over the past 30 years, uterus-preserving treatments have been introduced as alternatives to hysterectomy. Hysteroscopic polypectomy, myomectomy, or endometrial resection/endometrial ablation are minimally invasive techniques that can be used as an alternative to hysterectomy to treat AUB due to benign conditions. Although associated with high patient satisfaction and short-term improvement in their QoL, hysteroscopic treatments do not eliminate the risk of AUB recurrence or the need for further intervention. Therefore, considering the impact of different treatment options on QoL and sexuality during preoperative shared decision making could help identify the most appropriate and personalized treatment options for perimenopausal women suffering from AUB.

Concurrent and future risk of endometrial cancer in women with endometrial hyperplasia: A systematic review and meta-analysis

BACKGROUND

To inform treatment decisions in women diagnosed with endometrial hyperplasia, quantification of the potential for concurrent endometrial cancer and the future risk of progression to cancer is required.

METHODS

We identified studies up to September 2018 that reported on the prevalence of concurrent cancer (within three months of endometrial hyperplasia diagnosis), or the incidence of cancer, identified at least three months after hyperplasia diagnosis. Random-effects meta-analyses produced pooled estimates and 95% confidence intervals (CIs).

RESULTS

A total of 36 articles were identified; 15 investigating concurrent and 21 progression to cancer. In pooled analysis of 11 studies of atypical hyperplasia, the pooled prevalence of concurrent endometrial cancer was 32.6% (95% CI: 24.1%, 42.4%) while no studies evaluated concurrent cancer in non-atypical hyperplasia. The risk of progression to cancer was high in atypical hyperplasia (n = 5 studies, annual incidence rate = 8.2%, 95% CI 3.9%, 17.3%) and only one study reported on non-atypical hyperplasia (annual incidence rate = 2.6%, 95% CI: 0.6%, 10.6%).

CONCLUSIONS

Overall, a third of women with atypical hyperplasia had concurrent endometrial cancer, although the number of studies, especially population-based, is small. Progression to cancer in atypical hyperplasia was high, but few studies were identified. Population-based estimates are required, in both atypical and non-atypical hyperplasia patients to better inform treatment strategies.

Histopathology and Clinical Outcomes of 151 Women with Postmenopausal Bleeding Treated with Resectoscopic Surgery

STUDY OBJECTIVE

Because postmenopausal bleeding (PMB) is associated with up to 10% of endometrial neoplasia and office endometrial sampling fails in approximately 10% and is inadequate in 30% of cases, the objective was to determine the role of hysteroscopic endometrial resection (HER) for the diagnosis and treatment of women with PMB.

DESIGN

A retrospective cohort.

SETTING

A university-affiliated teaching hospital.

PATIENTS

One hundred fifty-one women with PMB (September 1990-December 2010).

INTERVENTION

HER in the operating room.

MEASUREMENTS AND MAIN RESULTS

The median (range) age and body mass index were 58 (50-87) years and 29 (21-52) kg/m², respectively. Office endometrial biopsy failed in 30 (19.8%), was inadequate in 20 (13.2%), identified nonatypical endometrial hyperplasia (NAH) in 21 (14%), atypical hyperplasia (AH) in 4 (2.6%), and endometrial cancer (EC) in 2 (1.3%) women. HER in 151 women identified 7 new cases of AH (3 from failed/inadequate office biopsy and 4 from NAH) and 9 EC (5 from failed/inadequate office biopsy, 1 from proliferative endometrium, 2 from NAH, and 1 from AH). All 27 women with NAH were treated by HER alone. Of 8 women with AH, 6 were treated with HER and 2 with hysterectomy; no residual endometrium was found in hysterectomy specimens. Of the 11 women with EC, 2 refused hysterectomy and are well 10 and 15 years after HER. Hysterectomy was performed for 9 of 11 EC cases, 2 of 8 AH cases, and 1 for abnormal uterine bleeding. Six women had repeat HER for persistent abnormal uterine bleeding, and 10 were lost to follow-up. At a median follow-up of 11.5 years (range, 7-20 years), 132 (12 hysterectomies + 10 lost) of 151 (87.4%) women were satisfied with no further bleeding.

CONCLUSION

In women with PMB, hysteroscopic endometrial resection concomitantly with resection of intrauterine pathology by experienced surgeons is feasible, safe, and effective for diagnosis in all cases and treatment of the majority of intrauterine pathology including NAH and selected cases of AH and EC.

The fertility-sparing treatment in patients with endometrial atypical hyperplasia and early endometrial cancer: a debated therapeutic option

Fertility-sparing treatment may represent a realist option for accurately selected young patients with endometrial atypical hyperplasia or well differentiated, early endometrial cancer. Oral progestins, and especially medroxyprogesterone acetate (MPA) and megestrol acetate with different doses and schedules, represent the most commonly used hormone agents in this clinical setting. Approximately three fourths of the women achieve a histologically documented complete response, with an mean response time of 12 weeks, but about one third of these subsequently developed a recurrence after a mean time of 20 months. The expression of receptor for progesterone receptor (PR), PTEN gene, DNA mismatch repair gene MLH1 and phospho-AKT on tissue specimens may be useful for selecting patients fit for a conservative management. Several successful pregnancies have occurred after a fertility-sparing treatment of endometrial atypical hyperplasia or endometrial cancer, more frequently with assisted reproductive technologies. The implementation of in vitro fertilisation techniques not only increases the chance of conception, but it may also decrease the interval to conception. The opportunity of a demolitive surgery after delivery or after childbearing being no longer required is a still debated issue. Large multicenter trials are strongly warranted to better define the selection criteria for a conservative treatment, endocrine regimen of choice, the optimal dosing, the duration of treatment and follow-up protocols. In any case, the patient should be accurately informed about the relatively high recurrence rates after complete response to hormone treatment and expectations for pregnancy.

Cancer issues

The potential for hormone therapy to cause cancer is the greatest fear for postmenopausal women considering hormone replacement therapy (HRT). Breast cancer is the most common female malignancy, for which HRT is one of many modifiable risk factors, often attracting disproportionate attention. Randomized controlled trials have confirmed that in postmenopausal women aged 50-59 years taking combined oestrogen and progestogen HRT over 5 years, there will be three extra cases of breast cancer per 1000 women. With the use of unopposed conjugated equine oestrogens, there would be four fewer cases over the same time. Women can be advised that the risk of breast cancer is not significantly increased with up to 3 years of combined HRT and up to 5 years of unopposed oestrogen. Unopposed oestrogen increases the risk of endometrial hyperplasia and carcinoma significantly, and this is dose and duration dependent. The addition of progestogen prevents the proliferative effect of oestrogen on the endometrium, and may even reduce the risk of endometrial cancer compared with non-users if given continuously. The use of combined oral contraception in premenopausal women also reduces the risk of endometrial cancer but increases the risk of cervical carcinoma significantly. HRT does not influence the risk of cervical cancer. Epithelial ovarian cancer risk may be slightly increased with long-term use of unopposed oestrogen, is not altered by the addition of progestogen, and is reduced significantly in users of combined oral contraception. The mechanism for these effects is not understood. Colorectal cancer and possibly lung and gastric cancers are reduced by the use of HRT. Apart from a slight increased risk of gallbladder disease and carcinoma with HRT, there are no data linking oestrogen or progestogen with any other malignancies.

Progression of conservatively treated endometrial complex atypical hyperplasia in a young woman: a case report

OBJECTIVE

To describe a case of progression of endometrial complex atypical hyperplasia (CAH) to extrauterine endometrioid adenocarcinoma in a patient who had requested fertility-sparing management.

DESIGN

Case report.

SETTING

Division of Gynecologic Oncology, National Cancer Institute "Regina Elena," Rome, Italy.

PATIENT(S)

A nulliparous 36-year-old woman with endometrial CAH who decided on a conservative approach.

INTERVENTION(S)

Conservative hysteroscopic resection of the lesion, the surrounding endometrium, and underlying myometrium plus hormone therapy regimen of megestrol acetate (160 mg) daily for 6 months.

MAIN OUTCOME MEASURE(S)

Failure of the conservative therapy and progression of disease.

RESULT(S)

Eighteen months after fertility-sparing management, a laparoscopic operation revealed grade 2 endometrium adenocarcinoma with superficial myometrial invasion and a microscopic metastasis of the left ovary and Douglas peritoneum. The patient underwent adjuvant chemotherapy followed by external beam radiation of the pelvis and brachytherapy. Twenty-five months after, she was free of disease.

CONCLUSION(S)

Conservative therapy is feasible in carefully selected young women with endometrial CAH. However, close follow-up is required because of possible progression to endometrial cancer.