Histopathologic features and risk factors for benignity, hyperplasia, and cancer in endometrial polyps

Glandular Crowdings in Endometrial Polyps: Clinical Follow-Up and Possible Worrisome Features

INTRODUCTION

Interpretation of changes and premalignant lesions in endometrial polyps can be challenging. We evaluated the clinical course of patients with focal gland crowdings in endometrial polyps via repeat biopsies and searched for possible morphological findings in the initial biopsy that may foresee a premalignant course.

METHODS

Specimens diagnosed as endometrial polyp and focal gland crowding in patients who had a repeat biopsy in a 1-year period were reexamined. Morphological findings in the initial biopsies were recorded. The group whose repeat biopsies were "premalignant or malignant" (Group 1), and the group with "benign" repeat biopsies (Group 2) were compared.

RESULTS

"Endometrial polyp and gland crowdings" was diagnosed in 115 specimens of which 38 patients had repeat biopsies. Among these 8 (21%) were diagnosed as "endometrial intraepithelial neoplasia (EIN)" (Group 1) and 30 (79%) as "benign" (Group 2). Morphological features in the initial biopsies were evaluated; PAX2 loss was 6 of 8 (75%) for Group 1 and 7 of 30 (23%) for Group 2 (P = .020), and altered epithelial cytological features were present in 5 of 8 (62%) versus 4 of 30 (13%) (P = .015), both significantly higher in Group 1. Dark intraluminal secretion, intraluminal histiocytes, intraglandular epithelial proliferation, and mean diameter of crowded gland areas were not statistically different between the 2 groups.

CONCLUSION

"Focal gland crowdings" in endometrial polyps do carry a risk of EIN in subsequent biopsies. We suggest that the loss/decrease of PAX2 and altered epithelial cytological features in these areas in the initial biopsy are indicative of a premalignant course.

Determinants and Assessment of Menstrual Blood Flow

Purpose of review

a)The modifiable and non-modifiable determinants and the currently available methods of assessment of menstrual blood flow will be discussed, with the goal of helping healthcare providers, researchers, and those interested in public health.

Recent findings

b)Several factors can impact menstruation. The determinants include modifiable factors such as smoking, nutrition, exercise, stress, weight fluctuation, and benign gynecologic diseases, and non-modifiable factors such as age, race, and the individual's genes. The intertwined dynamic among these determinants needs more critical attention. Currently, the methods for the assessment of menstruation all have advantages and disadvantages, often with a tradeoff between practicality and accuracy.

Summary

c)Considered by many as the fifth vital, menstruation provides a window to an individual's general health. The discussion of its determinants and assessment can be more appropriate for individual contexts, especially from a public health perspective as it can improve the reproductive health of the population.

Evaluation of Comt2, Comt3, Cyp1b1, and Esr1 gene polymorphisms as risk factor for endometrial polyp

The aim of this study is to evaluate COMT2, COMT3, CYP1B1, and ESR1 gene polymorphisms and occurrence of endometrial polyps. In addition, we intended to evaluate the clinical and epidemiological features of patients with and without the presence of the disease, characterizing the possible risk factors. A cross-sectional study was performed, with a total of 309 women, including 236 in the group of women with endometrial polyp confirmed by hysteroscopy and anatomical pathological examination and 73 in the group of people with diagnostic hysteroscopy without abnormal findings from the macroscopic point of view. Polymorphisms of four genes were studied: COMT2 (rs4680), COMT3 (rs5031015), CYP1B1 (rs1056836), and ESR1 (rs2234693). Polymorphism genotyping was determined using real-time polymerase chain reaction. Considering the results, no differences were identified between the two groups with respect to age, body mass index, diabetes, dyslipidemia, or smoking. The group of women without endometrial polyps showed higher use of hormone therapy than the other group (16.4 percent versus 3.8 percent, p < .001). The COMT2, COMT3, CYP1B1, and ESR1 genes exhibited no significant difference for the occurrence of endometrial polyp between the two groups. The research concluded that no correlation was identified between the genetic polymorphisms evaluated and the presence of endometrial polyps.

Asymptomatic endometrial thickening in postmenopausal women: predictor of malignant pathology?

It is not standardised what is the endometrial thickness that discriminates between normal and potentially malignant. The objective of this study was to determine the endometrial thickness cut-off point from which the risk of endometrial cancer (EC) increases in asymptomatic postmenopausal women; and to evaluate the risk factors linked to malignant endometrial pathology as well as other associated ultrasound findings.This was a retrospective observational study that included hysteroscopies performed at the Hospital Materno-Infantil on 267 asymptomatic menopausal women with an increase in endometrial thickness (AET) >5 mm, from 2015 to 2019. The results shows that the prevalence of malignant pathology in asymptomatic postmenopausal women with a casual finding of endometrial thickening was 3.7%. This percentage was 16.3% when the cut-off point of AET was established at 10 mm. There was a significant association for the diagnosis of malignant pathology with this cut-off point.There is a significant association between the 10 mm endometrial thickness cut-off point from which the risk of EC increases in asymptomatic postmenopausal women.Impact statementWhat is already known on this subject? Several studies have established the cut-off point for asymptomatic endometrial thickening (AET) for atypical endometrial hyperplasia and endometrial cancer at 10 mm. Although no cut-off point has optimal accuracy for the diagnosis of malignant endometrial pathology, it has been found that with a cut-off value of AET >10 mm no cases are missed. Likewise, a cut-off point of AET > 11 mm may provide a balance between cancer detection and histopathological workup extension.What do the results of this study add? A significant association was found at the cut-off point of AET > 10 mm, which suggests that screening postmenopausal women at this thickness is acceptable and unlikely to miss cases of endometrial hyperplasia and endometrial cancer.What are the implications of these findings for clinical practice and/or further research? After analysing our results we can conclude, like other published studies, that by establishing a cut-off point of 10 mm we obtain a good discrimination between benign and malignant pathology, which would allow us to diagnose 100% of malignant pathology. Above this cut-off point, the risk of endometrial cancer increases, and it would therefore be advisable to extend the study. A multicentre study is needed to confirm the cut-off point at which the risk of endometrial cancer increases in postmenopausal women with asymptomatic endometrial thickening.

Uterine disorders and iron deficiency anemia

Abnormal uterine bleeding (AUB) is a clinical entity which can lead to iron deficiency anemia. Classification according to the acronym PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia; coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified) provides a structured approach to establish the cause of AUB. The goal of this review is to discuss the different mechanisms and the relationship between uterine disorders and AUB. Heavy menstrual bleeding, a subgroup of AUB, is more closely related to the presence of uterine fibroids. The relationship between heavy menstrual bleeding and uterine fibroids remains poorly characterized, particularly the understanding of endometrial function in women with structural myometrial features such as leiomyomas. A number of theories have been proposed in the literature and are discussed in this review. Uterine adenomyosis is also a frequent cause of AUB, and its pathogenesis is still far from being fully elucidated. The mechanisms contributing to its development are multifactorial. Many theories lean toward invasion of the myometrium by endometrial cells. Both clinical and basic studies favor the theory of direct invasion, although de novo development of adenomyosis from Müllerian rests or stem cells has not been ruled out. Development of adenomyotic lesions involves repeated tissue injury and repair. In addition, this review describes the other causes of AUB such as endometrial polyps, cesarean scar defects, and uterine vascular abnormalities. Endometrial polyps are often asymptomatic, but approximately 68% of women have concomitant AUB. Histologic alterations in the lower uterine segment in patients who had undergone cesarean sections were identified and may explain the cause of AUB.

Hysteroscopy Combined with Laser Vaporesection for Endometrial Polyps

OBJECTIVE

To compare the safety and efficiency of hysteroscopic laser vaporesection and hysteroscopic resection in the treatment of endometrial polyps.Methods: The literatures in databases were searched comprehensively, the literatures that met the inclusion criteria were screened out and the data were extracted. The data were combined with Stata12.0 statistical software.

RESULTS

4 literatures were included with a total sample size of 334. Meta-analysis showed that intraoperative blood loss in laser group was less than that in electrosurgical group [-3.043, 95% CI (-4.09, -2.00), P < 0.001]. Length of stay in the laser group was shorter than that in the electrotomy group [-1.013, 95% CI (-1.37, -0.65), P < 0.001]. The recurrence rate [0.275, 95%CI (0.135,0.563), P < 0.001] and complication rate [0.148, 95%CI (0.07,0.32), P < 0.001] in the laser group were lower than those in the electrotomy group. There was no significant difference in operative time between hysteroscopy combined with 2 μm laser and hysteroscopic electrotomy for endometrial polyps [-0.38, 95% CI (-1.34, 0.58), P = 0.441 > 0.05].

CONCLUSION

Hysteroscopic 2 μm laser vaporesection for the treatment of endometrial polyps has better safety and clinical efficacy. Compared with hysteroscopic electroresection, hysteroscopic laser vaporesection in the treatment of endometrial polyps may be safer and more effective. Given the potential limitations, we need larger, well-designed randomized controlled trials to verify our findings.

Ultrasound features of endometrial pathology in women without abnormal uterine bleeding: results from the International Endometrial Tumor Analysis study (IETA3)

OBJECTIVES

The primary aim of this study was to describe the ultrasound features of various endometrial and other intracavitary pathologies in women without abnormal uterine bleeding (AUB) using the International Endometrial Tumor Analysis (IETA) terminology. The secondary aim was to compare our findings with published data on women with AUB.

METHODS

This was a prospective observational study of women presenting at one of seven centers specialized in gynecological ultrasonography, from 2011 until 2018, for indications unrelated to AUB. All patients underwent transvaginal ultrasound using the IETA examination and measurement techniques. Ultrasonography was performed as part of routine gynecological examination or follow-up of non-endometrial pathology, or as part of the work-up before undergoing treatment for infertility, uterine prolapse or ovarian pathology. Ultrasound findings were described using the IETA terminology. Endometrial sampling was performed after the ultrasound scan. The histological endpoints were endometrial atrophy, proliferative or secretory endometrium, endometrial hyperplasia without atypia, endometrial polyp, intracavitary leiomyoma, endometrial intraepithelial neoplasia (EIN), endometrial cancer (EC) and insufficient tissue. The findings in our cohort of women without AUB were compared with those in a published cohort of women with AUB who were examined with transvaginal ultrasound between 2012 and 2015 using the same IETA examination technique and terminology.

RESULTS

In this study (IETA3), we included 1745 women without AUB who underwent a standardized transvaginal ultrasound examination followed by either endometrial sampling with histological diagnosis (n = 1537) or at least 1 year of clinical and ultrasound follow-up (n = 208). Of these, 858 (49.2%) women were premenopausal and 887 (50.8%) were postmenopausal. Histology showed the presence of EC and/or EIN in 29 (1.7%) women, endometrial polyps in 1028 (58.9%), intracavitary myomas in 66 (3.8%), proliferative or secretory changes or hyperplasia without atypia in 144 (8.3%), endometrial atrophy in 265 (15.2%) and insufficient tissue in five (0.3%). Most cases of EC or EIN (25/29 (86.2%)) were diagnosed after menopause. The mean endometrial thickness in women with EC or EIN was 11.2 mm (95% CI, 8.9-13.6 mm), being on average 2.4 mm (95% CI, 0.3-4.6 mm) thicker than their benign counterparts. Women with malignant endometrial pathology manifested more frequently non-uniform echogenicity (22/29 (75.9%)) than did those with benign endometrial pathology (929/1716 (54.1%)) (difference, +21.8% (95% CI, +4.2% to +39.2%)). Moderate to abundant vascularization (color score 3-4) was seen in 31.0% (9/29) of cases with EC or EIN compared with 12.8% (220/1716) of those with a benign outcome (difference, +18.2% (95% CI, -0.5% to +36.9%)). Multiple multifocal vessels were recorded in 24.1% (7/29) women with EC or EIN vs 4.0% (68/1716) of those with a benign outcome (difference, +20.2% (95% CI, +4.6% to +35.7%)). A regular endometrial-myometrial junction was seen less frequently in women with EC or EIN (19/29 (65.5%)) vs those with a benign outcome (1412/1716 (82.3%)) (difference, -16.8% (95% CI, -34.2% to +0.6%)). In women with endometrial polyps without AUB, a single dominant vessel was the most frequent vascular pattern (666/1028 (64.8%)). In women with EC, both in those with and those without AUB, the endometrium usually manifested heterogeneous echogenicity, but the endometrium was on average 8.6 mm (95% CI, 5.2-12.0 mm) thinner and less intensely vascularized (color score 3-4: difference, -26.8% (95% CI, -52.2% to -1.3%)) in women without compared to those with AUB. In both pre- and postmenopausal women, asymptomatic endometrial polyps were associated with a thinner endometrium, and they manifested more frequently a bright edge, a regular endometrial-myometrial junction and a single dominant vessel than did polyps in symptomatic women, and they were less intensely vascularized.

CONCLUSIONS

We describe the typical ultrasound features of EC, polyps and other intracavitary histologies using IETA terminology in women without AUB. Our findings suggest that the presence of asymptomatic polyps or endometrial malignancy may be accompanied by thinner and less intensely vascularized endometria than their symptomatic counterparts. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Symptom-related Ki-67 expression in endometrial polyps

OBJECTIVE

The aim of this study was to compare Ki-67 expression in endometrial polyps that present with different abnormal uterine bleeding patterns.

STUDY DESIGN

A total of 120 women diagnosed with endometrial polyps were included in the study. In this prospective study, tissue samples taken by hysteroscopic polypectomy method between September 2019 and September 2020 at Bursa City Hospital were examined. The main study groups were determined as premenopausal and postmenopausal patients. The patients' complaints at first admission to the hospital, demographic, histopathological and immunohistochemical features were recorded.

RESULTS

Ki-67 glandular and stromal expressions were higher in the premenopausal patient group (p = 0.016 and p = 0.005 respectively). Median Ki-67 gland and stroma measurements; was higher in patients with heavy menstrual bleeding (HMB) than in patients with intermenstrual bleeding (IMB), patients with postmenopausal bleeding (PMB), and patients who were asymptomatic [(p = 0.012, p = 0.011 and p = 0.009 respectively); (p < 0.001, p < 0.001 and p = 0.004 respectively)]. The median Ki-67 stroma measurement was found to be higher in the patient group whose complaint persisted after polypectomy (p = 0.034). In the estimation of response to treatment, the cut-off value for Ki-67 stromal expression was determined as ≤ 6%.

CONCLUSION

High Ki-67 expression in endometrial polyps is associated with HMB and may predict the continuation of abnormal uterine bleeding after polypectomy.

Prevalence and risk factors for malignancy in hysteroscopy-resected endometrial polyps

INTRODUCTION

To determine the prevalence of malignant lesions in endometrial polyps by hysteroscopic polypectomy, and risk factors for malignant transformation. The secondary aim was to evaluate background endometrium of atypical hyperplasia in endometrial polyps, and the risk of coexisting endometrial carcinoma after hysterectomy.

METHODS

This retrospective study included women who underwent hysteroscopic polypectomy between January 2015 and December 2019. Demographic characteristics, hysteroscopic findings, and histopathology results of the polyp and the uterus, in the case of a hysterectomy, were collected.

RESULTS

In all, 946 women were included in the study. Endometrial carcinoma in a polyp was found in 10 women (1.06%), and atypical hyperplasia was found in 11 women (1.16%). At the multivariate logistic regression model of risk factors, old age (P = 0.022) and obesity (P = 0.011) were significantly associated with (pre-)malignant polyp. Five of the ten women (50%) with atypical hyperplasia confined to a polyp had coexisting endometrial carcinoma in the hysterectomy specimen.

CONCLUSION

Women with risk factors should be offered hysteroscopic polypectomy to allow a reliable histologic evaluation. Furthermore, hysterectomy is recommended in women with atypical hyperplasia in endometrial polyps even after complete resection.

Hysteroscopic endometrial biopsy: from indications to instrumentation and techniques. A call to action

During the last twenty years, the diagnostic approach to endometrial pathology has radically evolved. For over a century, intrauterine blind biopsy techniques were considered the gold standard procedure for the histopathological diagnosis of intrauterine diseases. The advent of hysteroscopy, which made it possible to directly visualize the uterine cavity, and the subsequent miniaturization of the instruments allowing its use in the office setting without anesthesia are considered game-changers. To date, it is feasible to retrieve a targeted eye specimen of endometrial tissue with little or no discomfort for the patient in the office setting. To pursue this aim, several technological upgrades have improved the diagnostic accuracy of hysteroscopic endometrial biopsy. In this paper we provide an up-to-date review of the latest evidence regarding indications, instrumentations, and techniques for hysteroscopic endometrial biopsy, to help the operator in providing an adequate endometrial sampling for histopathological analysis.

Effectiveness of different methods for polypectomy in the menopause: a retrospective study

Introduction: Most endometrial polyps represent focal hyperplasia of the endometrium. Endometrial polyps can be diagnosed by ultrasound, hysterocontrast sonography, hysterosalpingography, endometrial biopsy, and uterine curettage, but diagnostic hysteroscopy is considered the gold-standard method, with the greatest sensitivity and specificity and also with the opportunity for treatment at the same time.Study design: A retrospective study was conducted on 424 patients between 2006 and 2018. The polyps were verified during diagnostic hysteroscopy and were removed by resectoscopy or curettage. All samples underwent histological examination. The effectivity of the type of resection and the recurrence rate were evaluated.Results: The average age of the patients was 60.2 ± 9.3 years. Polyps were excised in 62.97% by resectoscopic polypectomy and in 37.03% by curettage. Malignancy was confirmed in 4.24% of cases. Histological verification of polyps was 79.4% in the resectoscopy group and 69.04% in the curettage group; the difference was significant (p < 0.01). The recurrence rate was 20.47% after resectoscopy and 27.12% following curettage.Conclusion: Hysteroscopy remains the best option and the gold-standard method among diagnostic procedures of endometrial pathology. In this study, there was a significant difference in matching hysteroscopic and histological findings in the two methods of polypectomy. The recurrence rate is also lower following resectoscopy.

Translocation of vaginal microbiota is involved in impairment and protection of uterine health

The vaginal and uterine microbiota play important roles in the health of the female reproductive system. However, the interactions among the microbes in these two niches and their effects on uterine health remain unclear. Here we profile the vaginal and uterine microbial samples of 145 women, and combine with deep mining of public data and animal experiments to characterize the microbial translocation in the female reproductive tract and its role in modulating uterine health. Synchronous variation and increasing convergence of the uterine and vaginal microbiome with advancing age are shown. We also find that transplanting certain strains of vaginal bacteria into the vagina of rats induces or reduces endometritis-like symptoms, and verify the damaging or protective effects of certain vaginal bacteria on endometrium. This study clarifies the interdependent relationship of vaginal bacterial translocation with uterine microecology and endometrial health, which will undoubtedly increase our understanding of female reproductive health.

Management of asymptomatic postmenopausal women referred to outpatient hysteroscopy service with incidental finding of thickened endometrium - A UK District General Hospital Experience

STUDY OBJECTIVE

The objective of this study was to review the management and outcome of asymptomatic postmenopausal women with increased endometrial thickness as there is lack of robust guidance for the same.

DESIGN

Retrospective case series over a period of 2 years.

SETTING

District general hospital.

PATIENTS

Eighty-three.

INTERVENTIONS

No prospective interventions were done. Only a review of the interventions done in an outpatient setting, namely, hysteroscopy and endometrial sampling, was carried out.

MEASUREMENTS AND MAIN RESULTS

Retrospective review of 1453 referrals to outpatient hysteroscopy service over a period of 2 years was carried out, and 83 patients referred with asymptomatic thickened endometrium on imaging were identified. Patients underwent hysteroscopy on the basis of the local policy, that is, if the endometrial thickness was more than 10 mm or in the presence of additional risk factors. The yield rate of endometrial cancer and atypical hyperplasia was 1.2% and 2.4%, respectively, among all patients (n = 83). The yield rate of endometrial cancer and atypical hyperplasia was 1.81% and 3.63%, respectively, among patients referred with endometrial thickness ≤10 mm after considering other risk factors.

CONCLUSION

It is reasonable to use endometrial thickness of 10 mm or above as a cutoff threshold to offer endometrial biopsy or outpatient hysteroscopy for asymptomatic postmenopausal women. For asymptomatic women with endometrial thickness between 4 and 10 mm, decisions about further investigations should be made on a case-by-case basis, taking into account any risk factors for endometrial pathology. As this study had a reasonably good sample size, it can contribute toward formulation of robust guidance for management of postmenopausal women with asymptomatic endometrial thickening.

Residual Disease after Operative Hysteroscopy in Patients with Endometrioid Endometrial Cancer Associated with Polyps

OBJECTIVE

 To evaluate the presence of residual disease in the uterine specimen after hysteroscopic polypectomy or polyp biopsy in patients with endometrioid endometrial cancer (EC).

METHODS

 We analyzed a series of 104 patients (92 cases from the Hospital AC Camargo and 12 from the Hospital do Servidor Público Estadual de São Paulo) with polyps that were diagnosed by hysteroscopy, showing endometrioid EC associated with the polyp or in the final pathological specimen. Patients underwent a surgical approach for endometrial cancer from January 2002 to January 2017. Their clinical and pathological data were retrospectively retrieved from the medical records.

RESULTS

 In 78 cases (75%), the polyp had EC, and in 40 (38.5%), it was restricted to the polyp, without endometrial involvement. The pathologic stage was IA in 96 cases (92.3%) and 90 (86.5%) had histologic grade 1 or 2. In 18 cases (17.3%), there was no residual disease in the final uterine specimen, but only in 9 of them the hysteroscopy suggested that the tumor was restricted to the polyp. In 5 cases (4.8%) from the group without disease outside of the polyp during hysteroscopy, myometrial invasion was noted in the final uterine specimen. This finding suggests the possibility of disease extrapolation through the base of the polyp.

CONCLUSION

 Patients with endometrioid EC associated with polyps may have the tumor completely removed during hysteroscopy, but the variables shown in the present study could not safely predict which patient would have no residual disease.

Which patients on a gynecologic oncology service will require perioperative transfusion? A single-center retrospective cohort study

The purpose of this study was to determine which patient- or surgery-related factors are predictive of need for perioperative transfusion to avoid obtaining unnecessary pre-operative type and screens (T&S). We conducted an observational retrospective cohort study of 1200 women ≥ 18 years old undergoing gynecologic surgery for benign, possibly benign, or malignant indications on a gynecologic oncology service at a university medical center from 2009-2016. A logistic regression model was used to examine patient-related and surgery-related variables predictive of outcome of transfusion. Independent variables included patient demographics, comorbidities, and surgical indication surgical route, and surgical type. Dependent variable was transfusion outcome (T&S only, conversion to type and cross (T&C), or transfusion). Eight hundred ninety-nine (74.9%) women underwent pre-operative T&S, of which 118 (9.8%) were converted to T&C, and 80 (6.7%) received a transfusion of blood or blood products. Cancer indication, major surgery, and preoperative hematocrit less than 36% were significantly associated with need for transfusion (P = 0.002, P < 0.0001, P < 0.0001, respectively). Patients with a benign indication undergoing minor procedures and with normal preoperative hematocrit are least likely to require transfusion.

Ultrasound parameters of pelvic organs and their age-related changes in a cohort of asymptomatic postmenopausal women: A community-based study

OBJECTIVE

To describe the ultrasound parameters of pelvic organs and their age-related changes in a cohort of asymptomatic postmenopausal women and to describe the prevalence of ultrasound-detected pathologies in a Sri Lankan population.

STUDY DESIGN

A large community-based longitudinal study using a randomly selected sample of postmenopausal women who have never used hormone replacement therapy.

MAIN OUTCOME MEASURES

Uterine, endometrial and ovarian measurements at pelvic ultrasonography as described by the International Endometrial Tumor Analysis and the International Ovarian Tumor Analysis groups.

RESULTS

A total of 815 postmenopausal women were approached and all volunteered to participate. This included women between the ages of 45 and 74 years with a median (interquartile range (IQR)) of 62.0 (10.0) years. The median (IQR) uterine volume was 18.1 (17) ml, while the median (IQR) of right and left ovarian volumes were 17.3 (22.9) ml and 18.2 (21.5) ml. Both uterine and ovarian volumes showed an age-related decline (p < 0.01). Furthermore, the ovarian volumes demonstrated an increase in size with a higher body mass index (p < 0.03 for left and p < 0.01 for right, respectively). Median (IQR) endometrial thickness among the population was 3.0 (1.0) mm and there was no age-related change observed. Sixty-one women had an ultrasound-detected gynaecological pathology with a prevalence of 7.5% (95% confidence interval (CI) 5.6-9.5).

CONCLUSIONS

This study aimed at describing ultrasound parameters of pelvic organs among postmenopausal women of Sri Lanka was able to provide the reference values for uterine and ovarian volume among asymptomatic postmenopausal women. Both uterine and ovarian volumes demonstrated an age-related decline, whereas the endometrial thickness does not seem to relate to the age.

Introduction of the MyoSureLITE in an established outpatient hysteroscopy clinic

BACKGROUND

Endometrial polyps are a common cause of abnormal uterine bleeding. The MyoSureLITE intrauterine morcellation device is effective at resecting endometrial polyps; however, its use in the outpatient setting requires appraisal.

AIM

To assess the feasibility, utility, acceptability and costs associated with introduction of the MyoSureLITE into an established outpatient hysteroscopy (OPH) clinic.

MATERIAL AND METHODS

A prospective clinical database from a tertiary Melbourne hospital was analysed from 1 July 2015 to 30 June 2018. Three 12-month time periods were compared: pre-introduction and trial phase, early use, and established use of the MyoSureLITE. Wait times, patient acceptability, second OPH bookings and procedure costs were measured.

RESULTS

Eight hundred and seventy-one women underwent OPH during the study period, with 238 (27.3%) women presenting with endometrial polyp(s). At each timepoint, 78.5, 25 and 6.3% of women required rebooking for a subsequent hysteroscopy for pathology otherwise suitable for MyoSureLITE resection. Introduction of the MyoSureLITE avoided a subsequent procedure for 4, 60 and 69 women respectively for each year of use, with potentially reduced treatment costs for the institution. Median (IQR) wait time for definitive treatment of intrauterine pathology was 56 (24-84) days at time-period 1, decreasing to 0 (0-0) days during time-period 3, (P < 0.001); 87.6% would undergo OPH again.

CONCLUSIONS

Routine use of the MyoSureLITE is effective, feasible, and acceptable to women. Provision of this device in outpatient service allows a 'see-and-treat' model, saving theatre time and treatment costs, facilitating a more direct throughput from presentation to treatment.

Randomized Study Comparing a Reusable Morcellator with a Resectoscope in the Hysteroscopic Treatment of Uterine Polyps: The RESMO Study

STUDY OBJECTIVE

To compare a reusable hysteroscopic morcellator and standard resectoscopes in the hysteroscopic management of uterine polyps.

DESIGN

Single-center randomized prospective single-blind trial (resectoscope-morcellator study).

SETTING

Centre Médico-chirurgical Obstétrique teaching hospital, Strasbourg University Hospitals, France.

PATIENTS

All patients presenting with a single endometrial polyp of size 1 cm or larger.

INTERVENTIONS

After consent, the patients were randomized into 2 groups: hysteroscopic morcellation (HM) group or standard resection (SR) group. Office-based review hysteroscopy was performed 6 weeks to 8 weeks after surgery. Primary end point: time of morcellation or resection.

SECONDARY OUTCOMES

total operating time (minutes), volume of fluid used (mL), fluid deficit (mL), number of morcellator or resectoscope insertions, operator comfort (visual analog scale: 0 to 10) and quality of vision (0 to 5), perioperative complications, completeness of resection, need to convert to another technique, pain assessment (visual analog scale), and length of hospitalization. At review hysteroscopy, we noted whether the resection or morcellation had been effective and if synechiae were present or absent. Statistical analyses followed Bayesian methods.

MEASUREMENTS AND MAIN RESULTS

Ninety patients were randomized: 45 in the HM group and 45 in the SR group. The average size of polyps at hysteroscopy was 13.3 mm. Morcellation time was lower than resection time (6.1 minutes vs 9 minutes; p [HM < SR] = .996). This also applied to total operating time (12.7 minutes vs 15.6 minutes; p [HM < SR] = .985), number of device insertions (1.50 vs 6; p [HM < SR] > .999), volume of fluid used (766.9 mL vs 1118.9 mL; p [HM < SR] = .994), and fluid deficit (60.2 mL vs 169.8 mL; p [HM < SR] = .989). Operator comfort was better in the HM group (8.4 vs 7.4; p [HM > SR] = .999) as was visualization (4 vs 3.7; p [HM > SR] = .911, highly probable). Operative complications were higher in the SR group (5 vs 0; p [HM < SR] = .989]. One patient in the SR group died after surgery owing to an anesthetic complication (anaphylactic shock complicated by pulmonary embolism). No differences were noted between the groups for pain assessment, length of hospitalization, and outcome on review hysteroscopy.

CONCLUSION

The reusable morcellator is quicker, uses less fluid with less deficit and fewer introductory maneuvers, and offers better comfort and visualization than the resectoscope while being as effective for the hysteroscopic treatment of uterine polyps.

Prevention of Benign Endometrial Polyp Recurrence Using a Levonorgestrel-releasing Intrauterine System in Premenopausal Patients: A Retrospective Cohort Study

STUDY OBJECTIVE

To evaluate the levonorgestrel-releasing intrauterine system (LNG-IUS) to prevent the recurrence of endometrial polyps (EPs) after hysteroscopic polypectomies in premenopausal female patients.

DESIGN

A retrospective cohort study.

SETTING

A tertiary-care women's hospital.

PATIENTS

A total of 451 premenopausal female patients underwent hysteroscopic polypectomies between January 1, 2016, and December 31, 2017.

INTERVENTIONS

Treatment with LNG-IUS after hysteroscopic polypectomies.

MEASUREMENTS AND MAIN RESULTS

After the hysteroscopic polypectomies and placement of LNG-IUS, transvaginal ultrasounds were performed every 6 months to measure the recurrence of EPs. Overall, 5 (3.47%) of 144 patients in the LNG-IUS cohort and 49 (15.96%) of 307 patients in the control cohort experienced EP recurrence within the follow-up period of up to 3 years. The recurrence exhibited a strongly negative correlation when LNG-IUS was inserted (relative risk, 0.218; 95% confidence interval, 0.089-0.535; p <.05), but this did not significantly correlate with age, polyp size, number of polyps, previous history of polypectomy, and abnormal uterine bleeding. For the LNG-IUS and control cohorts, the recurrence in the first postoperative year was 1.39% and 6.19%, respectively, and 5.41% and 19.23% in the second postoperative year, respectively.

CONCLUSION

LNG-IUS reduces the recurrence of postoperative EPs in premenopausal patients.

Atypical endometrial polyps and the incidence of endometrial cancer: a retrospective cohort study

OBJECTIVE

The aim of this study was to evaluate the incidence of endometrial carcinoma, proven after hysterectomy, in patients diagnosed with atypical endometrial hyperplasia confined to a polyp. A secondary aim was to establish factors associated with (pre-)malignant alterations in a polyp.

DESIGN

A retrospective cohort study.

SETTING

Maastricht University Medical Centre (MUMC+) and Máxima Medical Centre in Eindhoven/Veldhoven (Máxima MC).

POPULATION

Women who underwent a hysteroscopic polyp resection between 2008 and 2016.

METHODS

Patient characteristics and histopathology results of the polyp and, in the case of a hysterectomy, uterus were collected from patients' charts.

RESULTS

A total of 1445 complete hysteroscopic polyp resections were included. Of those, 1390 polyps showed benign histopathology results, 39 polyps contained atypical hyperplasia and 16 polyps contained endometrial carcinoma. A hysterectomy was performed in 35 women who were diagnosed with atypical hyperplasia confined to a polyp after hysteroscopic polyp resection. Histopathological assessment showed no additional (pre-)malignant changes of the endometrium in 12 women (30.8%), atypical hyperplasia in 11 women (28.2%) and endometrial carcinoma in 12 women (30.8%). None of the prognostic factors under consideration were significantly associated with (pre-)malignant changes in a polyp.

CONCLUSION

The incidence of endometrial carcinoma in the surrounding endometrium after complete resection of a polyp with atypical hyperplasia is 30.8% in this study. This supports the current advice to perform a hysterectomy and bilateral salpingo-oophorectomy. No prognostic factor for (pre-)malignant changes in a polyp was established.

TWEETABLE ABSTRACT

The incidence of endometrial carcinoma after complete resection of a polyp with atypical hyperplasia is high.

Role of Hormones in Common Benign Uterine Lesions: Endometrial Polyps, Leiomyomas, and Adenomyosis

Leiomyoma, adenomyosis, and endometrial polyps are benign uterine disorders which seem to develop in the context of hormonal imbalances, due to steroid hormones, estrogen and progesterone, in association with various factors ranging from genetic factors to modifiable lifestyle factors. A growing body of evidence suggests that those hormones and their receptors are key modulators in the genesis and the growth of those pathologic entities. Further studies are required to understand their involvement in the pathogenesis of those lesions and their link to other factors such as extracellular matrix components, growth factors, chemokines, cytokines, and tissue repair mechanisms.

Computer-Aided Diagnosis in Histopathological Images of the Endometrium Using a Convolutional Neural Network and Attention Mechanisms

Uterine cancer (also known as endometrial cancer) can seriously affect the female reproductive system, and histopathological image analysis is the gold standard for diagnosing endometrial cancer. Due to the limited ability to model the complicated relationships between histopathological images and their interpretations, existing computer-aided diagnosis (CAD) approaches using traditional machine learning algorithms often failed to achieve satisfying results. In this study, we develop a CAD approach based on a convolutional neural network (CNN) and attention mechanisms, called HIENet. In the ten-fold cross-validation on ∼3,300 hematoxylin and eosin (H&E) image patches from ∼500 endometrial specimens, HIENet achieved a 76.91 ± 1.17% (mean ± s. d.) accuracy for four classes of endometrial tissue, i.e., normal endometrium, endometrial polyp, endometrial hyperplasia, and endometrial adenocarcinoma. Also, HIENet obtained an area-under-the-curve (AUC) of 0.9579 ± 0.0103 with an 81.04 ± 3.87% sensitivity and 94.78 ± 0.87% specificity in a binary classification task that detected endometrioid adenocarcinoma. Besides, in the external validation on 200 H&E image patches from 50 randomly-selected female patients, HIENet achieved an 84.50% accuracy in the four-class classification task, as well as an AUC of 0.9829 with a 77.97% (95% confidence interval, CI, 65.27%∼87.71%) sensitivity and 100% (95% CI, 97.42%∼100.00%) specificity. The proposed CAD method outperformed three human experts and five CNN-based classifiers regarding overall classification performance. It was also able to provide pathologists better interpretability of diagnoses by highlighting the histopathological correlations of local pixel-level image features to morphological characteristics of endometrial tissue.

Proliferation in Postmenopausal Endometrial Polyps-A Potential for Malignant Transformation

Background and objectives: Endometrial polyps in asymptomatic postmenopausal women are often incidentally found, yet only 1.51% of them are malignant. Their potential for malignant transformation has not been adequately addressed. The aim of this study was to investigate the proliferation within endometrial polyps as one of the indicators of their malignization potential in asymptomatic postmenopausal women. Materials and Methods: Immunohistochemical studies of Ki-67 were performed. Cases included 52 benign postmenopausal polyps, 19 endometrioid carcinoma with coexisting benign polyps, 12 polyps with foci of carcinoma and 4 cases of polyps, which later developed carcinoma. The control group included 31 atrophic endometria and 32 benign premenopausal polyps. Ki-67 was scored in either 10 or 20 “hot spot” fields, as percentage of positively stained cells. Results: The median epithelial Ki-67 score in postmenopausal benign polyps (4.7%) was significantly higher than in atrophic endometria (2.41%, p < 0.0001) and significantly lower than in premenopausal benign polyps (11.4%, p = 0.003) and endometrial cancer (8.3%, p < 0.0001). Where endometrial polyps were found in association with endometrial carcinoma, Ki-67 was significantly higher in cancer (p < 0.0001). No significant difference was found between Ki-67 scores of cancer focus and of the polyps tissue itself, respectively 2.8% and 4.55%, p = 0.37. Ki-67 expression, where polyps were resected and women later developed cancer, was not significantly different (p = 0.199). Conclusion: Polyps from asymptomatic postmenopausal women showed significantly more proliferation in both epithelial and stromal components than inactive atrophic endometria but less than premenopausal benign polyps and/or endometrial cancer. Benign postmenopausal endometrial polyps exhibit low proliferative activity, suggesting low malignant potential and may not require resection in asymptomatic women.

Prevalencia de carcinoma en pólipos endometriales resecados por histeroscopia

La prevalencia de pólipos endometriales (PE) es alrededor de 24% en la población femenina general y entre 10 y 30% en aquellas con hemorragia uterina anormal.  Son lesiones de crecimiento rápido que pueden transformarse en una neoplasia maligna. Objetivo: determinar la frecuencia de cáncer endometrial en pacientes con PE diagnosticados por histeroscopia. Metodología: serie de casos retrospectivos atendidos en el Hospital de San José, Bogotá, Colombia, de 2005 a 2014. Resultados: se analizaron en total 408 historias clínicas de pacientes con diagnóstico histopatológico de PE, 10 (2.4%) presentaron patología premaligna y 9 (2,2%) lesión maligna confirmada por microscopía (endometrioides 6, seroso papilar 2 y carcinosarcoma 1). Todas las pacientes con patología maligna tenían más de 60 años y estaban en posmenopausia. Cuatro eran nulíparas, ninguna consumía tamoxifeno ni medicamentos hormonales Conclusión: la prevalencia de carcinomas endometriales en PE diagnosticados a través de histeroscopia en mujeres posmenopáusicas fue de 7.7%. Estos datos son similares a los reportados en la literatura, por lo que recomendamos la implementación de histeroscopia para el tratamiento de todos los PE y su riguroso estudio histopatológico.

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.

Risk of malignancies among asymptomatic postmenopausal women with thickened endometrium: A cohort study

The risk of malignancies and related factors among asymptomatic postmenopausal women with thickened endometrium in transvaginal sonography (TVS) are unclear.In this longitudinal study at a tertiary teaching hospital, all medical records of hysteroscopy were searched and retrospectively reviewed according to age, TVS results and diseases coded as International Classification of Diseases version 10. Asymptomatic postmenopausal women with endometrial thickness ≥5 mm from January 2006 to January 2016 were included. A follow-up was provided up to January 2017.Four hundred eighty-eight patients were included with a median endometrial thickness of 8 mm (range 5-30) in TVS. The most common pathologic findings were polyps (51.0%) and normal endometrium (34.2%). Fifteen (3.1%) and 10 cases (2.0%) had endometrial intraepithelial neoplasia (EIN) and carcinoma. Patients with carcinoma had significantly more abnormal serum CA125, thicker endometrium, and more lesions with positive Doppler flow signals. In receiver operating characteristic curve analysis, endometrial thickness of 12 mm had the best predictive ability for malignancies. In multivariate analysis, endometrial lesion with positive Doppler flow signals in TVS was the only independent factor for EIN/carcinoma (odds ratio [OR] 8.0, 95% confidence interval [CI] 1.4-45.1) and for carcinoma (OR 16.0, 95% CI 1.3-192.8). After a median follow-up of 45 months, carcinoma occurred in 1 of 35 (2.8%) women with repeated thickened endometrium.Among asymptomatic postmenopausal women with thickened endometrium, the risk of EIN and malignancy was minimal but worth of long-term follow-up. Endometrial lesions with positive Doppler flow signals in TVS suggested a high risk of malignancy.

Evaluation and Management of Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) is a common condition that leads to increased health care costs and decreased quality of life. A systematic approach to AUB evaluation can simplify management and enhance women's well-being. Abnormal uterine bleeding describes any variation from normal bleeding patterns in nonpregnant, reproductive-aged women beyond menarche lasting for at least 6 months. Ambiguous and inconsistent use of terminology and definitions to characterize AUB in the past decades necessitated a new, consensus-based approach to nomenclature and AUB evaluation. This led to the International Federation of Gynecology and Obstetrics (FIGO) System 1 in 2007, which standardized nomenclature, set parameters, and defined normal and abnormal bleeding based on the 5th to 95th percentile data from available large-scale epidemiologic studies. FIGO System 1, endorsed by several national and international societies, improved worldwide communication among educators, clinicians, and researchers. FIGO System 2, published in 2011, focused on classifications of AUB etiology into structural and nonstructural entities using the PALM-COEIN (polyp[s], adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, endometrial disorders, iatrogenic, and not yet classified) classification system. The PALM-COEIN classification is facilitated by a complete patient history combined with appropriate imaging, histopathologic analysis, or laboratory evaluation to ensure accurate diagnostic and treatment approaches to AUB. Herein we present the systematic evaluation of AUB.

The incidence and predictors of gynecologic malignancies among postmenopausal patients with endometrial fluid collection

OBJECTIVE

To investigate the incidence and predictors of gynecologic malignancies among postmenopausal patients with endometrial fluid collection (EFC).

METHODS

All patients with EFC diagnosed by transvaginal sonography (TVS) were retrospectively reviewed if they had undergone biopsy of the endometrium from January 2008 to January 2016 in a tertiary teaching hospital. Follow-up ended in June 2017. The incidence of gynecologic malignancies was described, and predictive factors were determined by comparing the epidemiological and clinico-pathological characteristics of the patients.

RESULTS

During the study period, 273 women with EFC (3.4%) were enrolled. Biopsy pathology and the following hysterectomy revealed 29 (10.6%) cases of gynecological cancer. In the multivariable analysis, patient-reported genital symptoms [odds ratio (OR) 16.2, 95% confidence interval (CI) 1.9-139.3], abnormal serum CA125 (OR 14.5, 95% CI 4.5-46.5), lesions in the uterine cavity (OR 18.8, 95% CI 6.0-59.1) and endometrial thickness (OR 1.1, 95% CI 1.0-1.2) determined by TVS were independent factors associated with malignancy. Only 1.1% (1/90) of the asymptomatic patients had gynecologic cancer. During the follow-up, gynecologic cancer was diagnosed in nine patients, six of whom had vaginal bleeding at the time of initial enrollment. The prognosis of patients with cancer was worse than that of patients with benign results.

CONCLUSION

The risk of gynecologic malignancies in postmenopausal patients with EFC is related to genital symptoms, TVS findings and CA 125 levels. Asymptomatic EFC is associated with an extremely low risk of malignancy.

Is there any relationship between benign endometrial pathologies and metabolic status?

The aim of this study was to assess the relation between benign endometrial pathologies (polyp and/or hyperplasia without atypia) and the metabolic status (insulin resistance and metabolic syndrome) of the patients. A total of 168 cases were enrolled in the study. The patients were classified according to the presence of benign endometrial pathologies and their menopausal status. Then, the subjects were evaluated according to the metabolic syndrome criteria and the presence of an insulin resistance. The insulin resistance levels of the cases were analysed by four different methods. Obesity and a waist circumference of greater than 88 cm were observed significantly more in the study group with endometrial pathologies (p = .005 and p < .001, respectively). It was also observed that a fasting blood glucose level of higher than 110 mg/dL increased the risk of developing endometrial polyps and/or hyperplasia without atypia by almost five folds (OR: 5.26, 95% CI: 1.25-22.12). Furthermore, an insulin resistance was found to be significantly high in the study group (p = .002). Based on the observed significant relationship between an insulin resistance and benign endometrial pathologies, it can be concluded that insulin resistance plays an important role in the development of benign endometrial pathologies. Impact Statement What is already known on this subject? Metabolic anomalies such as obesity, type 2 diabetes, hypertension and dyslipidaemia play an important role in abnormal endometrial proliferation. Also, these metabolic anomalies have been known as risk factors for type I endometrial cancer. What the results of this study add? A significant relationship between an insulin resistance and benign endometrial pathologies was observed. What the implications are of these findings for clinical practice and/or further research? Based on this finding, we concluded that an insulin resistance may play an important role in the development of benign endometrial pathologies. The prevention and the treatment of obesity as a key factor of developing an insulin resistance, may reduce not only the incidence of malignant endometrial pathologies, but also the incidence of benign pathologies and of a malignant transformation.

Macrophages in patients with recurrent endometrial polyps could exacerbate Th17 responses

Endometrial polyps (EPs) are outgrowths in the endometrium with unknown etiology. The fact that EPs can often recur after surgical removal suggests that EPs are not induced by random events but by continuous or recurrent processes in patients. We previously demonstrated that the risk of EP development was positively associated with overactive Th17 responses. However, the requirements of Th17 upregulation are yet unclear. Here, we recruited 26 women with symptomatic EP and 24 without EP, and peripheral mononuclear cells were harvested for the examination of circulating immunity. Compared to controls without EP, the patients with symptomatic EP presented significantly elevated levels of monocyte activation. The circulating monocytes from patients secreted higher levels of tumor necrosis factor (TNF), interleukin (IL)-1β, IL-6 and IL-23 directly ex vivo and with LPS stimulation. In memory CD4⁺ T cells, monocytes were not required for IL-17 expression, but the presence of activated monocytes significantly increased the secretion of IL-17. In naive CD4⁺ T cells, activated monocytes were required for significant IL-17 secretion and RORC transcription. Interestingly, the monocytes from EP individuals were significantly more potent in promoting Th17 differentiation from naive CD4⁺ T cells than the monocytes from controls. Furthermore, we showed that monocyte-mediated Th17 differentiation required the secretion of TNF, IL-1β and IL-6. Together, this study demonstrated activated monocytes supported Th17 inflammation in patients with EP.

CD4+ T cell imbalance is associated with recurrent endometrial polyps

Endometrial polyps (EPs) are localized benign overgrowths at the endometrium, with currently unknown aetiology and pathogenesis. Although symptoms of EP can be alleviated or resolved by hysteroscopic polypectomy, a significant fraction of individuals develop recurrent EPs after initial EP removal. In rare cases, EPs may also undergo malignant transformation. In-depth understanding of the mechanisms that are involved in EP development is urgently needed. Recent works indicate that dysregulations in the immune system participate in the development of a variety of symptoms, such as aging, obesity and hypertension, many of which are EP risk factors. Based on these discoveries, we investigated the cellular immune system in premenopausal women with and without EP. Compared to EP-free controls, the women with EP presented significantly higher RORC expression but unchanged TBX21 and FOXP3 expression in the circulating CD4⁺ T cells. When stimulated with PMA/ionomycin, CD4⁺ T cells from women with EP presented significantly higher interferon (IFN)-γ and interleukin (IL)-17 secretion, and lower transforming growth factor (TGF)-β secretion. Hysteroscopic polypectomy did not significantly alter the composition of CD4⁺ T cells, as the women with EP presented a similar upregulation of Th17 inflammation and a downregulation of regulatory T cell (Treg) response postoperatively. Notably, in women that developed recurrent EP, the CD4⁺ T cells presented higher preoperative and postoperative RORC, IFN-γ, and IL-17 expression, as well as lower postoperative FOXP3 and TGF-β expression, than hysteroscopic polypectomy-treated women without EP recurrence. These data demonstrated an association between CD4⁺ T cell imbalance and recurrent EP development.

Suspecting Malignancy in Endometrial Polyps: Value of Hysteroscopy

Aims and background

Hysteroscopic polypectomy is the gold standard to treat endometrial polyps and obtain specimens for histological evaluation. There is continuing debate as to when to offer hysteroscopic polypectomy, especially in asymptomatic women with incidental lesions. The aims of this study were to assess the accuracy of hysteroscopy and Vabra sampling in diagnosing atypical hyperplasia and cancer growing on the surface of endometrial polyps and to investigate the association between atypical endometrial polyps and some potential clinical risk factors.

Methods and study design

This was a retrospective study. We assessed 1039 hysteroscopies and we identified 345 women with endometrial polyps. All patients with endometrial polyps underwent hysteroscopic polypectomy. Data about age, menopausal status, abnormal uterine bleeding (AUB), hormone replacement therapy and tamoxifen use were collected. Hysteroscopic, histological and clinical data were analyzed.

Results

The incidence of endometrial hyperplasia or cancer growing on the surface of endometrial polyps was significantly low (1.7%). Hysteroscopy correctly excluded (negative predictive value: 100%) and accurately predicted (positive predictive value: 85.7%) preneoplastic or neoplastic lesions growing within the epithelial layer of endometrial polyps. Vabra sampling was inadequate for the histological diagnosis in 38.5% of cases. Age over 60 years and postmenopausal AUB were associated with an 8.3-fold ( P = 0.022) and 8.8-fold ( P = 0.020) increased risk, respectively, of preneoplastic and neoplastic lesions growing on the surface of endometrial polyps.

Conclusions

Diagnostic hysteroscopy is a good tool to predict malignancy of the epithelial layer of endometrial polyps. Age over 60 years and AUB are associated with an increased risk of malignant polyps. Few suspicious endometrial polyps should undergo surgical resection.

Clinical indications for hysteroscopic removal of uterine masses: Time, age at diagnosis, and mass size

AIM

The aim of this study was to investigate clinical factors associated with abnormal pathologies of uterine masses resected via hysteroscopy.

METHODS

Women who underwent hysteroscopic surgery for presumptive diagnoses of abnormal endometrial or endocervical masses, such as polyps or leiomyomas on ultrasonography, between January 2012 and April 2015, were enrolled. Clinical and pathologic data were retrospectively reviewed.

RESULTS

Among 189 patients, pathologic diagnoses of the uterine mass were abnormal in 172 (91.0%) cases, including polyps in 119 (63.0%), leiomyomas in 49 (26.0%), endometrial hyperplasia in two (1.0%), and endometrial cancer in two (1.0%). Seventeen (9.0%) women who underwent hysteroscopic removal showed unremarkable results on pathology, and the most common finding among them was the proliferative phase of the normal endometrium. Women aged over 40 years with uterine masses and a time since last menstrual period of over 15 days are four times more likely to be diagnosed with neoplastic masses than others (odds ratio [OR], 4.39, 95% confidence interval [CI], 1.33-14.48 and OR, 4.22, 95%CI, 1.35-13.21, respectively); those with masses over 1.5 cm in size are three times more likely to be neoplastic than others (OR, 3.08, 95%CI, 1.04-9.12).

CONCLUSION

Large mass size, longer time after last menstrual period, and older age are risk factors for abnormal histologies of uterine masses resected via hysteroscopy. Clinicians should take particular care when contemplating hysteroscopic removal for women younger than 40 years, and those with masses of <1.5 cm in size in the proliferative phase of the endometrium to avoid an unnecessary surgery.

Analysis of differential genetic expression in endometrial polyps of postmenopausal women

OBJECTIVES

To evaluate the expression of four genetic markers (PTEN, BCL2, MLH1, and CTNNB1), linked to endometrial carcinogenesis, in endometrial polyps of patients with and without postmenopausal bleeding in order to determine whether symptomatic endometrial polyps have a genetic phenotype similar to that of endometrial cancer.

METHODS

Samples were obtained hysteroscopically from endometrial polyps of postmenopausal patients, and the expression of genetic markers involved in the pathogenesis of endometrial cancer (PTEN, BCL2, MLH1, and CTNNB1) was analyzed. The expression of these markers was then compared between patients with and without symptoms, which was characterized as postmenopausal bleeding. Other clinical characteristics of the patients, such as duration of menopause, polyp size, presence of systemic hypertension, diabetes mellitus, and smoking habits were also analyzed.

RESULTS

Samples from a total of 60 patients were obtained, as calculated for a test power of 0.80. No statistical differences (p > 0.05) were observed between the two groups concerning the expression of the studied endometrial cancer risk factor genes, or with regard to the clinical aspects evaluated.

CONCLUSION

The study found no evidence that symptomatic endometrial polyps have a similar phenotype to type 1 endometrial cancer; further studies are needed in order to establish whether endometrial polyps are in fact true cancer precursors, or simply raise cancer incidence due to a detection bias.

Genomic Analysis of Uterine Lavage Fluid Detects Early Endometrial Cancers and Reveals a Prevalent Landscape of Driver Mutations in Women without Histopathologic Evidence of Cancer: A Prospective Cross-Sectional Study

BACKGROUND

Endometrial cancer is the most common gynecologic malignancy, and its incidence and associated mortality are increasing. Despite the immediate need to detect these cancers at an earlier stage, there is no effective screening methodology or protocol for endometrial cancer. The comprehensive, genomics-based analysis of endometrial cancer by The Cancer Genome Atlas (TCGA) revealed many of the molecular defects that define this cancer. Based on these cancer genome results, and in a prospective study, we hypothesized that the use of ultra-deep, targeted gene sequencing could detect somatic mutations in uterine lavage fluid obtained from women undergoing hysteroscopy as a means of molecular screening and diagnosis.

METHODS AND FINDINGS

Uterine lavage and paired blood samples were collected and analyzed from 107 consecutive patients who were undergoing hysteroscopy and curettage for diagnostic evaluation from this single-institution study. The lavage fluid was separated into cellular and acellular fractions by centrifugation. Cellular and cell-free DNA (cfDNA) were isolated from each lavage. Two targeted next-generation sequencing (NGS) gene panels, one composed of 56 genes and the other of 12 genes, were used for ultra-deep sequencing. To rule out potential NGS-based errors, orthogonal mutation validation was performed using digital PCR and Sanger sequencing. Seven patients were diagnosed with endometrial cancer based on classic histopathologic analysis. Six of these patients had stage IA cancer, and one of these cancers was only detectable as a microscopic focus within a polyp. All seven patients were found to have significant cancer-associated gene mutations in both cell pellet and cfDNA fractions. In the four patients in whom adequate tumor sample was available, all tumor mutations above a specific allele fraction were present in the uterine lavage DNA samples. Mutations originally only detected in lavage fluid fractions were later confirmed to be present in tumor but at allele fractions significantly less than 1%. Of the remaining 95 patients diagnosed with benign or non-cancer pathology, 44 had no significant cancer mutations detected. Intriguingly, 51 patients without histopathologic evidence of cancer had relatively high allele fraction (1.0%-30.4%), cancer-associated mutations. Participants with detected driver and potential driver mutations were significantly older (mean age mutated = 57.96, 95% confidence interval [CI]: 3.30-∞, mean age no mutations = 50.35; p-value = 0.002; Benjamini-Hochberg [BH] adjusted p-value = 0.015) and more likely to be post-menopausal (p-value = 0.004; BH-adjusted p-value = 0.015) than those without these mutations. No associations were detected between mutation status and race/ethnicity, body mass index, diabetes, parity, and smoking status. Long-term follow-up was not presently available in this prospective study for those women without histopathologic evidence of cancer.

CONCLUSIONS

Using ultra-deep NGS, we identified somatic mutations in DNA extracted both from cell pellets and a never previously reported cfDNA fraction from the uterine lavage. Using our targeted sequencing approach, endometrial driver mutations were identified in all seven women who received a cancer diagnosis based on classic histopathology of tissue curettage obtained at the time of hysteroscopy. In addition, relatively high allele fraction driver mutations were identified in the lavage fluid of approximately half of the women without a cancer diagnosis. Increasing age and post-menopausal status were associated with the presence of these cancer-associated mutations, suggesting the prevalent existence of a premalignant landscape in women without clinical evidence of cancer. Given that a uterine lavage can be easily and quickly performed even outside of the operating room and in a physician's office-based setting, our findings suggest the future possibility of this approach for screening women for the earliest stages of endometrial cancer. However, our findings suggest that further insight into development of cancer or its interruption are needed before translation to the clinic.

The value of hysteroscopic biopsy in the diagnosis of endometrial polyps

Several studies have demonstrated that the combination of hysteroscopy with endometrial biopsy is more accurate in differentiating endometrial polyps from endometrial hyperplasia and cancer. However, blind biopsy not always confirms hysteroscopic findings due to high rates of inadequate or insufficient material. The objective of this clinical, prospective, and comparative study was to establish a correlation between the histological results of office-based endometrial biopsies (hysteroscopically guided and blind) with the surgical polypectomy specimens. We evaluated 82 patients with hysteroscopic diagnosis of endometrial polyp, who randomly underwent hysteroscopically guided biopsy or blind biopsy, referred for surgical resection. A total of 36 women (43.9%) underwent hysteroscopically guided biopsy and 46 women (56.1%) underwent blind biopsy. The sensitivity of hysteroscopically guided biopsy for the diagnosis of endometrial polyps ranged between 35.3 and 36.8%, when carried out at the apex and base of the lesion, compared with 29.2% for blind biopsy. Specificity was 33.3, 50, and 60%, respectively, for each biopsy. The positive predictive values were 75, 77.8, and 87.5%, and negative predictive values were 8.3, 14.3, and 8.1% respectively, compared with surgical polypectomy specimens. The office-based endometrial biopsies had low diagnostic accuracy for endometrial polyps compared with surgical polypectomy specimens.

Comparison of saline infusion sonography (SIS) versus SIS-guided endometrial sampling in the diagnosis of endometrial pathology

PURPOSE

To compare saline infusion sonography (SIS) to tissue obtained from SIS-guided endometrial sampling (SISES) to determine sensitivity and specificity for benign and malignant conditions of the endometrium.

METHODS

Added value of SISES after SIS was evaluated over 5 years. SIS and SISES techniques have been previously described. Women with abnormal uterine bleeding and endometrial findings underwent SIS. Criteria for SISES included atypical polypoid mass, focal irregularity or global endometrial thickening, nondiagnostic SIS, discordance between SIS and endometrial biopsy, or request from the primary team. Final surgical pathology was compared with SIS and SISES.

RESULTS

One-hundred twenty-three SIS patients had SISES. SIS alone had a sensitivity of 100%, specificity of 42%, positive predictive value of 16%, and negative predictive value of 100%. A total of 120 patients had final clinical or surgical outcomes. Specificity was greatly improved with addition of SISES (95.5%, p < 0.001). Combination of SIS with SISES detected all 12 premalignant and malignant endometrial lesions. Three cases had small foci of hyperplasia (n = 2) or atypia (n = 1) in polyps on final surgical pathology, which were not prospectively identified on SISES.

CONCLUSIONS

SISES significantly improves the specificity in the diagnosis of endometrial lesions. False-negative findings of SISES in polyps in postmenopausal women with bleeding suggest the need for surgical removal in this setting. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:416-422, 2016.

Utility of a standardized protocol for submitting clinically suspected endometrial polyps to the pathology laboratory

The purpose of the study is to assess whether a protocol for submitting clinically suspected endometrial polyps will improve the detection rate of polyps and evaluation of the background endometrium. A retrospective review from 1999 to 2015 was performed. Cases were divided into (1) polyps and curettings placed in 2 containers (separate, n=61) and (2) polyps and curettings placed in 1 container (combined, n=80). Polyps were identified in 100% of cases in the separate compared with 95% in the combined group (P=.62). The background endometrium was evaluable in 79% of cases in the combined compared to 90% in the separate group (P=.07). The frequency of hyperplasia without atypia, atypical hyperplasia, and carcinoma was 4.4%, 3.6%, and 1.5%, respectively. In conclusion, the enhanced rate of polyp detection and evaluation of the background endometrium in the separate group is minimal. This supports the recommendation of submitting endometrial polyps and curettings combined in 1 container.