Atypical Endometrial Polyps and Concurrent Endometrial Cancer: A Systematic Review

Guideline No. 447: Diagnosis and Management of Endometrial Polyps

OBJECTIVE

The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the diagnosis and management of endometrial polyps.

TARGET POPULATION

All patients with symptomatic or asymptomatic endometrial polyps.

OPTIONS

Options for management of endometrial polyps include expectant, medical, and surgical management. These will depend on symptoms, risks for malignancy, and patient choice.

OUTCOMES

Outcomes include resolution of symptoms, histopathological diagnosis, and complete removal of the polyp.

BENEFITS, HARMS, AND COSTS

The implementation of this guideline aims to benefit patients with symptomatic or asymptomatic endometrial polyps and provide physicians with an evidence-based approach toward diagnosis and management (including expectant, medical, and surgical management) of polyps.

EVIDENCE

The following search terms were entered into PubMed/Medline and Cochrane: endometrial polyps, polyps, endometrial thickening, abnormal uterine bleeding, postmenopausal bleeding, endometrial hyperplasia, endometrial cancer, hormonal therapy, female infertility. All articles were included in the literature search up to 2021 and the following study types were included: randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Gynaecologists, family physicians, registered nurses, nurse practitioners, medical students, and residents and fellows.

TWEETABLE ABSTRACT

Uterine polyps are common and can cause abnormal bleeding, infertility, or bleeding after menopause. If patients don't experience symptoms, treatment is often not necessary. Polyps can be treated with medication but often a surgery will be necessary.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Association Between Endometritis and Endometrial Polyp: A Mendelian Randomization Study

Background

Endometrial polyps (EPs) are one of the most common intrauterine benign tumors, and are an important cause of uterine bleeding and female infertility. Previous studies have suggested that endometritis may contribute to the onset of EPs. This study aims to reveal the causal effect of endometritis on EPs by a two-sample Mendelian randomization (MR) study.

Methods

Utilizing summarized statistics from genome-wide association studies (GWAS) in the European population, we conducted a Mendelian randomization study. In order to select suitable instrumental variables (IVs) that were significantly related to the exposures, a number of quality control approaches were used. For endometritis, 2144 cases and 111,858 controls were included, while for EPs, 2252 cases and 460,758 controls. Utilizing the inverse variance weighted (IVW) as the primary analysis, the data were subjected to a two-sample MR analysis, and the weighted median (WM) technique and MR-Egger regression were carried out additionally. The sensitivity analysis revealed neither heterogeneity nor horizontal pleiotropy.

Results

Four independent single nucleotide polymorphisms (SNPs) from endometritis GWAS as IVs were selected. The IVW data did not agree to a causal association between endometritis and EPs (β=1.11e-04, standard error [SE] =4.88e-04, P = 0.82). Directional pleiotropy did not affect the outcome, according to the MR-Egger regression (intercept = 0.09, P = 0.10); Additionally, it showed no causation association between endometritis and EPs (β= -3.28e-03, SE = 3.54e-03, P = 0.45). Similar results were obtained using the weighted-median method (β=8.56e-05, SE=5.97e-04, P = 0.89). No proof of heterogeneity and horizontal pleiotropy between IV estimates was discovered.

Conclusion

In conclusion, by large scale genetic data, the results of this MR analysis provided suggestive evidence that the presence of endometritis is not associated with higher EPs risk.

Hypermethylated CDO1 and CELF4 in cytological specimens as triage strategy biomarkers in endometrial malignant lesions

Objective

Developing a non-invasive and reliable triage test for endometrial malignant lesions is an important goal, as it could help to reduce the number of invasive diagnostic procedures required and improve patient survival. We aimed to estimate the diagnostic value of DNA methylation levels in cervical cytological samples of endometrial cancer (EC) and endometrial atypical hyperplasia (AH).

Methods

A total of 607 women who had indications for endometrial biopsy in the Department of Obstetrics and Gynecology of Cangzhou Central Hospital from October 2022 to April 2023 were enrolled in this study. The cervical exfoliated cells were collected for gene methylation before endometrial biopsy. Clinical information, tumor biomarkers, and endometrial thickness (ET) of transvaginal ultrasonography (TVS) were also collected. With endometrial histopathology as the gold standard, multivariate unconditional logistic regression was applied to analyze the risk factors of endometrial malignant lesions. The role of cysteine dioxygenase type 1 (CDO1) and CUGBP Elav-like family member 4 (CELF4) gene methylation as a triage strategy biomarker in endometrial malignant lesions was specifically explored.

Results

Multivariate logistic regression analysis showed that premenopausal ET ≥ 11 mm or postmenopausal ET ≥ 5 mm, CDO1 ΔCt ≤ 8.4, or CELF4 ΔCt ≤ 8.8 were the risk factors for AH and EC, with odds ratios (ORs) (95%CI) of 5.03 (1.83-13.82) and 6.92 (1.10-43.44), respectively (p-values < 0.05). The sensitivity and specificity of CDO1/CELF4 dual-gene methylation assay for AH and EC reached 84.9% (95%CI: 75.3%-94.5%) and 86.6% (95%CI: 83.8%-89.5%), respectively. ET combined with DNA methylation detection further improved the specificity to (94.9%, 95%CI: 93.1%-96.8%).

Conclusion

The accuracy of cervical cytology DNA methylation is superior to that of other clinical indicators in the non-invasive examination of endometrial malignant lesions. DNA methylation combined with TVS can further improve the specificity and is a promising biomarker triage strategy in women with suspected endometrial lesions.

Clinical outcomes in women with endometrial polyps underwent conservative management

OBJECTIVE

To evaluate the regression rate of endometrial polyps (EPs) in a cohort of asymmetric women after conservative follow-up.

MATERIALS AND METHODS

In this retrospective cohort study, a total of 1006 women with asymptomatic EPs were treated with expectant management or hormonal drugs between June 1999 and May 2018. Four hundred forty-eight women (44.5%) were administered with hormonal medications and 558 women were managed expectantly (55.5%). Office hysteroscopy was performed to confirm the diagnosis and regression of EPs. Hormonal administration included oral contraceptives, progestin and cyclic estrogen/progestin regimen according to physicians' preferences. Clinical characteristics, including the patient's age, body mass index, parity, and type of conservative management were collected.

RESULTS

The mean observation time was 14.1 ± 18.5 months (range, 1-162 months). The overall regression rate of EPs in this cohort was 33.5%, 24.6% occurred after medication and 8.9% after expectant management. Patient age (<50 years) (p < 0.001), follow-up period (p = 0.005) and hormonal drugs used (p < 0.001) were significantly associated with EP regression. Twenty-four (7.1%) of the 337 EP regression patients later developed recurrent disease. Follow-up period (p < 0.001) and hormonal drugs used (p = 0.032) were closely related to polyp recurrence after initial regression. Nevertheless, multivariate logistic regression analysis revealed that hormonal drugs used was significantly associated with the regression (p < 0.001) and recurrence (p = 0.016) of EPs.

CONCLUSION

Women aged 50 or less are more suitable for conservative treatment for EPs. Hormonal drugs used could increase the incidence of EP regression.

Incidence of endometrial carcinoma in patients with endometrial intraepithelial neoplasia versus atypical endometrial polyp

ObjectiveOur study's primary aim was to compare the incidence of endometrial carcinoma in patients with a presurgical diagnosis of endometrial intraepithelial neoplasia confined to the endometrium (EIN-E) versus endometrial intraepithelial neoplasia confined to a polyp (EIN-P). Our secondary aim was to examine the difference in pathological features, prognostic risk groups and sentinel lymph node involvement between the two groups.

METHODS

We conducted a retrospective cohort study between January 2014 and December 2020 in a tertiary university-affiliated medical center. The study considered the characteristics of women who underwent hysterectomy with sentinel lymph node dissection for endometrial intraepithelial neoplasia (EIN). We compared EIN-E diagnosed by endometrial sampling via dilatation curettage or hysteroscopic curettage vs EIN-P. A multivariate logistic regression analysis was used to assess risk factors for endometrial cancer.

RESULTS

Eighty-eight women were included in the study, of those, 50 were women with EIN-P (EIN-P group) and 38 were women with EIN following an endometrial biopsy (EIN-E group).The median age was 57.5 years (range; 52-68) in the EIN-P group as compared with 63 years (range; 53-71) in the EIN-E group (p=0.47). Eighty-nine percent of the women in the EIN-E group presented with abnormal uterine bleeding whereas 46% of the women in the EIN-P group were asymptomatic (p=0.001). Pathology results following hysterectomy revealed concurrent endometrial carcinoma in 26% of women in the EIN-P group compared with 47% of women in the EIN-E group (p=0.038). Multivariate analysis showed that endometrial cancer was significantly less common in the EIN-P group (overall response (OR)=0.3 95% confidence interval (CI)=0.1-0.9, p=0.03). Eighty-four percent of cancers were grade one in the EIN-P group compared with 50% in the EIN-E group (p=0.048).

CONCLUSIONS

Concurrent endometrial cancer is less frequent with EIN-P than with EIN-E. The high incidence of endometrial carcinoma in both groups supports the current advice to perform hysterectomy for post-menopausal women. Our data does not support performing sentinel lymph node dissection for EIN-P that was completely resected. The benefit of sentinel lymph node dissection for women with pre-operative EIN-E is yet to be determined.

Correlation Analysis of Serum Pepsinogen, Interleukin, and TNF-α with Hp Infection in Patients with Gastric Cancer: A Randomized Parallel Controlled Clinical Study

Background

Gastric cancer pathological biopsy and visual examination have been the gold standard for gastric cancer diagnosis, but their operation is costly, demanding, and risky, so it is especially important to find an effective examination method in clinical practice.

Aims

To investigate the correlation between serum pepsinogen I (PGI), pepsinogen II (PGII), pepsinogen I and II ratio (PGR), IL-6, and TNF-α and Helicobacter pylori (Hp) infection in patients with gastric cancer.

Materials and Methods

Fifty patients with Hp-infected gastric cancer admitted to the Department of Gastroenterology of our hospital from January 2019 to December 2021 were selected for the study as the observation group, and another 50 patients without Hp-infected gastric cancer were selected as the comparison group to compare the correlation analysis of PGI, PGII, PGR, IL-6, and TNF-α with Hp infection between the two groups after admission and treatment.

Results

After measurement, PGI and PGII in the observation group were significantly lower than those in the comparison group, and TNF-α, IL-18, and IL-6 in the observation group were significantly higher than those in the comparison group, and the comparative differences were all statistically significant (P < 0.05). The results of multivariate logistic regression model analysis of independent risk factors for gastric cancer showed that IL-18, hs-CRP, and tumor necrosis factor- (TNF-) α were risk factors for Hp infection in gastric cancer.

Conclusion

The expression of IL-18, hs-CRP, and TNF-α factors in Hp-infected gastric cancer patients is correlated. IL-6, IL-18, and TNF-α are involved in the entire process from the onset to the development of Hp-positive gastric mucosal inflammation in patients, which is of great value in the diagnosis of gastric cancer and helps to assess the degree of progression and prognosis of gastric cancer.

Effect of Vaginoscopy versus Conventional Hysteroscopy on Pain, Complications, and Patient Satisfaction in Patients with Endometrial Polyps

Background

Hysteroscopy is considered the gold standard for diagnosing intrauterine pathology. Traditional hysteroscopy requires the placement of a vaginal speculum and cervical forceps, which are large in diameter, causing discomfort and pain to the patient and even causing vagal reflexes.

Aims

To investigate the impact and clinical value of vaginoscopy versus conventional hysteroscopy on pain, complications, and patient satisfaction in patients with endometrial polyps and to analyse the advantages of clinical application of vaginoscopy examination.

Materials and Methods

One hundred and twenty-five patients with endometrial polyps treated in our hospital from May 2021 to December 2021 were selected for this study and divided into 52 cases in the hysteroscopy group and 73 cases in the vaginoscopy group according to the random remainder grouping method. Conventional hysteroscopy was used, and in the vaginoscopy group, vaginoscopy was performed. The impact of pain, complications, patient satisfaction, and clinical value of the two groups was observed and compared.

Results

The time taken for the examination varied between the different hysteroscopic methods, with the hysteroscopy group taking the longest time compared to the vaginoscopy group (P < 0.01). The VAS scores immediately after the examination and 30 minutes after the examination were both significantly higher in the hysteroscopy group than in the vaginoscopy group (P < 0.01). The difference in NPY, PGE2, and 5-HT after the pain-causing mediator intervention was significantly better in the vaginoscopy group than in the hysteroscopy group. The difference in the incidence of complications such as abortion syndrome, cervical laceration, uterine perforation, and haemorrhage after treatment was significantly lower in the vaginoscopy group than in the hysteroscopy group. In the vaginoscopy group, the satisfaction rate was 91% significantly higher than that of the hysteroscopy group (P < 0.05).

Conclusion

The vaginoscopy technique shortens the examination and treatment time, reduces patient pain, improves patient compliance, reduces the use of preintervention drugs and anaesthetics, and reduces complications.

Conservative Surgery in Endometrial Cancer

Endometrial cancer (EC) is the sixth most common female cancer worldwide. The median age of diagnosis is 65 years. However, 4% of women diagnosed with EC are younger than 40 years old, and 70% of these women are nulliparous. These data highlight the importance of preserving fertility in these patients, at a time when the average age of the first pregnancy is significantly delayed and is now firmly established at over 30 years of age. National Comprehensive Cancer Network (NCCN guidelines state that the primary treatment of endometrial endometrioid carcinoma, limited to the uterus, is a total hysterectomy, bilateral salpingo-oophorectomy and surgical staging. Fertility-sparing treatment is not the standard of care, and patients eligible for this treatment always have to undergo strict counselling. Nowadays, a combined approach consisting of hysteroscopic resection, followed by oral or intrauterine-released progestins, has been reported to be an effective fertility-sparing option. Hysteroscopic resection followed by progestins achieved a complete response rate of 95.3% with a recurrence rate of 14.1%. The pregnancy rate in women undergoing fertility-sparing treatment is 47.8%, but rises to 93.3% when only considering women who tried to conceive during the study period. The aim of the present review is to provide a literature overview reflecting the current state of fertility-sparing options for the management of EC, specific criteria for considering such options, their limits, the implications for reproductive outcomes and the latest research trends in this direction.

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.

Preoperative Factors of Endometrial Carcinoma in Patients Undergoing Hysterectomy for Atypical Endometrial Hyperplasia

OBJECTIVE

To identify clinicopathological preoperative factors associated with concurrent endometrial carcinoma in patients undergoing surgical management of atypical endometrial hyperplasia.

METHODS

The records of all patients who underwent hysterectomy for preoperatively diagnosed atypical endometrial hyperplasia at a tertiary care hospital from April 2017 to April 2020 were retrospectively reviewed. Clinicopathological characteristics of patients were extracted. Patients who did not undergo hysterectomy or who had evidence of simple hyperplasia or carcinoma on initial biopsy were excluded. Univariate analysis was performed. A multivariate regression model for progression to endometrial carcinoma was developed.

RESULTS

A total of 126 patients were included. Of these patients, 19 (15.1%) had a final diagnosis of endometrial carcinoma, whereas 86 (68.2%) retained the diagnosis of atypical endometrial hyperplasia and 21 (16.7%) were found to have no residual atypical endometrial hyperplasia. The odds of a patient being diagnosed with endometrial carcinoma were 6.1 times higher (95% CI 1.32-27.68) if they had an endometrial stripe thickness >1.1 cm and 13.5 times higher (95% CI 3.56-51.1) if there was histological suspicion of carcinoma. The odds of a patient being diagnosed with endometrial carcinoma were significantly lower if the patient had an initial diagnosis of atypical endometrial hyperplasia in a polyp (OR 0.07; 95% CI 0.02-0.34).

CONCLUSION

Our results suggest that an endometrial stripe thickness >1.1 cm, a histological suspicion of carcinoma on preoperative pathology, and the absence of polyp involvement on initial diagnosis are the strongest predictors of endometrial carcinoma at the time of hysterectomy in patients with atypical endometrial hyperplasia.

Mendelian randomization analysis of the association between human blood cell traits and uterine polyps

Human blood cells (HBCs) play essential roles in multiple biological processes but their roles in development of uterine polyps are unknown. Here we implemented a Mendelian randomization (MR) analysis to investigate the effects of 36 HBC traits on endometrial polyps (EPs) and cervical polyps (CPs). The random-effect inverse-variance weighted method was adopted as standard MR analysis and three additional MR methods (MR-Egger, weighted median, and MR-PRESSO) were used for sensitivity analyses. Genetic instruments of HBC traits was extracted from a large genome-wide association study of 173,480 individuals, while data for EPs and CPs were obtained from the UK Biobank. All samples were Europeans. Using genetic variants as instrumental variables, our study found that both eosinophil count (OR 0.85, 95% CI 0.79-0.93, P = 1.06 × 10^-4) and eosinophil percentage of white cells (OR 0.84, 95% CI 0.77-0.91, P = 2.43 × 10^-5) were associated with decreased risk of EPs. The results were robust in sensitivity analyses and no evidences of horizontal pleiotropy were observed. While we found no significant associations between HBC traits and CPs. Our findings suggested eosinophils might play important roles in the pathogenesis of EPs. Besides, out study provided novel insight into detecting uterine polyps biomarkers using genetic epidemiology approaches.

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.

Nulliparity and postmenopausal status are independent factors of malignancy potential of endometrial intraepithelial neoplasia in polyps

OBJECTIVE

To estimate the risk of concurrent endometrial cancer in endometrium when endometrial intraepithelial neoplasia (EIN) is found within an endometrial polyp and to identify the possible predictive factors for concurrent endometrial cancer.

METHODS

Histopathologic data of women who underwent hysteroscopy for resection of endometrial polyps at Ankara Baskent University Hospital, between 2011 and 2019 were screened. Patients whose polypectomy report was EIN in a polyp, and who had a final report of the hysterectomy specimen were included. Patients were divided into two groups according to the presence of concurrent cancer in the hysterectomy material: group 1, concurrent cancer present and group 2, concurrent cancer absent. Statistical analyses were performed using SPSS.

RESULTS

A total of 4125 women underwent hysteroscopy for the resection of endometrial polyps. Of those women, 161 (3.9%) were diagnosed as having EIN and 115 met the criteria. The rate of concurrent endometrial cancer was 28.6% (33/115). According to multivariate analysis, nulliparity (odds ratio [OR] 0.38; 95% confidence interval [CI] 1.04-3.67; p = 0.036) and postmenopausal status (OR 0.64; 95% CI 0.42-0.98; p = 0.042) were found to be independent factors significantly associated with concurrent endometrial cancer.

CONCLUSION

The incidence of concurrent cancer is higher in postmenopausal or nulliparous women when EIN is detected in a polyp.

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.

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.

Endometrial Tumour Microenvironment

Endometrial cancer (EC) is the most common gynaecological tumour in developed countries, and its incidence is increasing in part due to the prevalence of obesity and its related hormone dysregulation. As described in this chapter, the tumour microenvironment plays a principal role in unopposed oestrogen stimulation promoting tumour cell proliferation. Factors and cytokines secreted by the different cell types defining the reactive tumour stroma also determine the invasive abilities of the tumour cells. Cancer-associated fibroblasts and tumour-associated macrophages actively participate through SDF-1, TGF-b or HGF to promote epithelial-to-mesenchymal transition or to generate an appropriate tumour niche. Likewise, endothelial cells facilitate lymph node and vascular infiltration through VEGF. Finally, the possibility to balance the immunosuppressive phenotypes in advanced endometrial cancer through the tumour microenvironment will probably represent a main therapeutic strategy in the near future.

Diagnostic value of histopathological examination results obtained during screening of patients with diagnosed atypical hyperplasia

Vulvovaginal atrophy accompanied by lower urinary tract dysfunction related to low levels of estrogen and androgens is labeled as genitourinary syndrome of menopause (GSM). Although this condition affects most postmenopausal women worldwide, it seems to be underdiagnosed and undertreated. Women should be properly advised to choose an adequate treatment modality to improve their quality of life, sexual relationships and social activity. The aim of this article is to increase knowledge of GSM. The current treatment options, both hormonal and non-hormonal, are reviewed. Topical estrogen therapy still remains the gold standard, but the demand for individually tailored therapy is growing. New treatment modalities are continuously included in clinical practice. They should consider the whole personality of a woman as well as cultural and social factors. Further studies on GSM and on the effectiveness of various treatment options are necessary to achieve this purpose.

Converging endometrial and ovarian tumorigenesis in Lynch syndrome: Shared origin of synchronous carcinomas

OBJECTIVE

The diagnosis of carcinoma in both the uterus and the ovary simultaneously is not uncommon and raises the question of synchronous primaries vs. metastatic disease. Targeted sequencing of sporadic synchronous endometrial and ovarian carcinomas has shown that such tumors are clonally related and thus represent metastatic disease from one site to the other. Our purpose was to investigate whether or not the same applies to Lynch syndrome (LS), in which synchronous cancers of the gynecological tract are twice as frequent as in sporadic cases, reflecting inherited defects in DNA mismatch repair (MMR).

METHODS

MMR gene mutation carriers with endometrial or ovarian carcinoma or endometrial hyperplasia were identified from a nationwide registry. Endometrial (n = 35) and ovarian carcinomas (n = 23), including 13 synchronous carcinoma pairs, were collected as well as endometrial hyperplasias (n = 56) and normal endometria (n = 99) from a surveillance program over two decades. All samples were studied for MMR status, ARID1A and L1CAM protein expression and tumor suppressor gene promoter methylation, and synchronous carcinomas additionally for somatic mutation profiles of 578 cancer-relevant genes.

RESULTS

Synchronous carcinomas were molecularly concordant in all cases. Prior or concurrent complex (but not simple) endometrial hyperplasias showed a high degree of concordance with endometrial or ovarian carcinoma as the endpoint lesion.

CONCLUSIONS

Our investigation suggests shared origins for synchronous endometrial and ovarian carcinomas in LS, in analogy to sporadic cases. The similar degrees of concordance between complex hyperplasias and endometrial vs. ovarian carcinoma highlight converging pathways for endometrial and ovarian tumorigenesis overall.