Ultrasound, hysteroscopy and endometrial biopsy in the investigation of endometrial cancer

Diagnostic accuracy of liquid-based endometrial cytology in the evaluation of endometrial pathology in postmenopausal women

OBJECTIVE

The aim of this study was to compare liquid-based endometrial cytology with hysteroscopy and endometrial biopsy regarding its diagnostic accuracy in a series of postmenopausal women with abnormal uterine bleeding (AUB) or asymptomatic women with thickened endometrium assessed by transvaginal ultrasound as a screening procedure.

METHODS

  Inclusion criteria were: menopausal status; the presence of AUB and/or thickened endometrium assessed by ultrasound (cut-off 4 mm); a normal Papanicolaou (Pap) smear; and no adnexal pathology at ultrasound. Exclusion criteria were: previous endometrial pathology; and previous operative hysteroscopy. Of 768 postmenopausal women referred to our general gynaecology clinics, 121 fulfilled the inclusion criteria and were recruited to the trial. Twenty-one refused to participate. Cytological sampling was carried out by brushing the uterine cavity using the Endoflower device with no cervical dilation and the vial was processed using a ThinPrep® 2000 automated slide processor. The slides were stained using a Pap method.

RESULTS

  In 98 cases with histological biopsies, endometrial cytology detected five cases of endometrial carcinoma, 10 of atypical hyperplasia and 47 of non-atypical hyperplasia; 36 cases were negative. In two cases cytology was inadequate because of uterine cervical stenosis. Taking atypical hyperplasia or worse as a positive test and outcome, the diagnostic accuracy of the endometrial cytology was 93.5%, with a sensitivity of 92% and specificity of 95%, a positive predictive value of 73% and a negative predictive value of 99%. All the carcinomas were detected by cytology. Only 42% of women with a positive diagnosis were symptomatic. The cytological sampling was well tolerated by all patients. No complication was registered.

CONCLUSIONS

 Liquid-based endometrial cytology can be considered an useful diagnostic method in the detection of endometrial pathology as a first-line approach, particularly if associated with transvaginal ultrasound.

Role of hysteroscopy in the detection of endometrial pathologies in women presenting with postmenopausal bleeding and thickened endometrium

OBJECTIVES

The goal of this study was to define the diagnostic value of hysteroscopy in evaluating uterine cavity compared to endometrial biopsy in women presenting with postmenopausal bleeding and thick endometrial mucosa with particular attention to endometrial hyperplasia and carcinoma.

METHODS

Eighty-three consecutive women presenting with postmenopausal bleeding and endometrial thickness of 5 mm or more measured by transvaginal ultrasound (TVU) were enrolled in a prospective study between May 2008 and July 2010. They underwent diagnostic hysteroscopy and endometrial biopsy. Hysteroscopic data was compared with the final diagnosis established by histological examination.

RESULTS

The women's mean age was 61.2 ± 5.2 years (range 44-80). The most frequent endometrial lesion was endometrial polyps (31.1%). Hyperplastic endometrium was confirmed in 23 (27.8%), only 13 cases were suspected by the hysteroscope. Out of the 14 (16.9%) proven cases of endometrial cancer, only half of the cases were suspected. In benign endometrial lesions, the sensitivity of the hysteroscopic view was 94.7%, specificity was 97.8%, positive (PPV) and negative (NPV) predictive values were 97.3 and 95.7%, respectively. On the other hand, hysteroscopy demonstrated an overall sensitivity, specificity, PPV, and NPV of 56.5, 91.6, 72.2, and 84.6%, respectively, in endometrial hyperplasia, whereas the same parameters for endometrial cancer were 50, 94.2, 63.6, and 90.2%.

CONCLUSION

Hysteroscopy can be used as the first line diagnostic tool for evaluating the benign endometrial lesions, such as endometrial polyp and submucosal myoma, nonetheless hysteroscopy has poor validity for excluding endometrial hyperplasia and cancer in women presenting with the postmenopausal bleeding and thick endometrium.