Long-term risk of endometrial cancer following postmenopausal bleeding and reassuring endometrial biopsy

Predicting Endometrial Hyperplasia and Endometrial Cancer on Recurrent Abnormal Uterine Bleeding

OBJECTIVE

To develop predictive models for endometrial hyperplasia and endometrial cancer in patients with recurrent abnormal uterine bleeding (AUB).

METHODS

This retrospective cohort study analyzed patients with recurrent AUB who had previous endometrial sampling that showed benign results between January 2013 and December 2021. A model was constructed from the significant factors associated with endometrial hyperplasia and endometrial cancer using multivariate logistic regression. Risk scores were calculated from the log odds of each significant predictive factor and were subsequently subcategorized into risk groups. The overall performance and internal validation of the model were assessed with the area under the receiver operating characteristic curve (AUC) and bootstrap methods.

RESULTS

Of the total 456 patients with recurrent AUB, endometrial hyperplasia and endometrial cancer were detected in 8.3% and 2.2% of cases, respectively. The average interval between the first and second endometrial samplings was 25.1 months. Factors significantly associated with endometrial hyperplasia and endometrial cancer included age older than 45 years (odds ratio [OR] 2.86, 95% CI, 1.31-7.03), nulliparity (OR 3.50, 95% CI, 1.76-6.85), a history of endometrial polyp (OR 3.69, 95% CI, 1.93-7.05), and an interval of less than 12 months between sampling (OR 2.36, 95% CI, 1.25-4.42). Predictive factors were scored and categorized into three groups: 0-3, 5-8, and 9-11 points. The corresponding risks for endometrial hyperplasia and endometrial cancer in these groups were 4.7%, 15.5%, and 57.1%, respectively. The AUC was 73.1%, with a mean absolute error of 0.01.

CONCLUSION

Endometrial hyperplasia and endometrial cancer occur at low incidence among one-fifth of patients with AUB who experience recurrent bleeding. Older age, nulliparity, a history of endometrial polyps, and an interval of less than 12 months between samplings are predictive factors for endometrial hyperplasia and endometrial cancer in this cohort.

Diagnostic accuracy of shear wave elastography for endometrial cancer: A meta-analysis

BACKGROUND

This meta-analysis aimed to identify the accuracy of shear wave elastography (SWE) in the diagnosis of endometrial cancer (EC).

METHODS

We searched the PubMed, Cochrane Library, and chinese biomedical literature database from inception to September 30, 2022. Meta-analysis was conducted using STATA version 14.0 and Meta-Disc version 1.4 software. We calculated summary statistics for sensitivity (Sen), specificity (Spe), positive and negative likelihood ratio (LR+/LR-), diagnostic odds ratio (DOR), and receiver operating characteristic (SROC) curves.

RESULTS

Eight studies that met all the inclusion criteria were included in this meta-analysis. A total of 432 patients with EC and 548 with benign endometrial lesions were assessed. All endometrial lesions were histologically confirmed by SWE. The pooled Sen was 0.91 (95% confidence interval [CI] = 0.83-0.95); the pooled Spe was 0.90 (95% CI = 0.86-0.93); the pooled LR+ was 9.10 (95% CI = 6.20-13.35); the pooled negative LR- was 0.10 (95% CI = 0.05-0.20); the pooled DOR of SWE in the diagnosis of EC was 90.73 (95% CI = 36.62-804.5). The area under the SROC curve was 0.95 (95% CI = 0.93-0.97). No evidence of publication bias was found (t = 0.98, P = .37).

CONCLUSION

Our meta-analysis indicates that SWE may have high diagnostic accuracy in the differential diagnosis of benign and malignant endometrial lesions. Thus, SWE may be a useful tool for the diagnosis of EC.

Multimodal MRI-Based Radiomics-Clinical Model for Preoperatively Differentiating Concurrent Endometrial Carcinoma From Atypical Endometrial Hyperplasia

Objectives

To develop and validate a radiomics model based on multimodal MRI combining clinical information for preoperative distinguishing concurrent endometrial carcinoma (CEC) from atypical endometrial hyperplasia (AEH).

Materials and Methods

A total of 122 patients (78 AEH and 44 CEC) who underwent preoperative MRI were enrolled in this retrospective study. Radiomics features were extracted based on T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) maps. After feature reduction by minimum redundancy maximum relevance and least absolute shrinkage and selection operator algorithm, single-modal and multimodal radiomics signatures, clinical model, and radiomics-clinical model were constructed using logistic regression. Receiver operating characteristic (ROC) analysis, calibration curves, and decision curve analysis were used to assess the models.

Results

The combined radiomics signature of T2WI, DWI, and ADC maps showed better discrimination ability than either alone. The radiomics-clinical model consisting of multimodal radiomics features, endometrial thickness >11mm, and nulliparity status achieved the highest area under the ROC curve (AUC) of 0.932 (95% confidential interval [CI]: 0.880-0.984), bootstrap corrected AUC of 0.922 in the training set, and AUC of 0.942 (95% CI: 0.852-1.000) in the validation set. Subgroup analysis further revealed that this model performed well for patients with preoperative endometrial biopsy consistent and inconsistent with postoperative pathologic data (consistent group, F1-score = 0.865; inconsistent group, F1-score = 0.900).

Conclusions

The radiomics model, which incorporates multimodal MRI and clinical information, might be used to preoperatively differentiate CEC from AEH, especially for patients with under- or over-estimated preoperative endometrial biopsy.

Risk of More Advanced Lesions at Hysterectomy after Initial Diagnosis of Non-Atypical Endometrial Hyperplasia in Patients with Postmenopausal Bleeding and Oral Anticoagulant Treatment

Background and Objectives: Endometrial hyperplasia (EH) is a precursor lesion to endometrial cancer (EC), and when cellular atypia is present, in 40% of cases, they are diagnosed with EC on hysterectomy. Usually, EH is clinically manifested by uterine bleeding. In patients with oral anticoagulant therapy (OAT), the uterus is the second most common source of bleeding. The aim of the study was to show that uterine bleeding in postmenopausal patients undergoing OAT may reveal precancerous endometrial lesions with atypia, or neoplastic lesions in patients with an initial diagnosis of endometrial hyperplasia without atypia (non-atypical endometrial hyperplasia, NAEH) on dilation and curettage (D&C). We will be able to estimate the risk of a postmenopausal female patient with uterine bleeding during an OAT to have a precancerous endometrial lesion. Materials and Methods: The subjects of the study were 173 female patients with uterine bleeding, who have had total hysterectomy with bilateral salpingoovarectomy, of whom 99 underwent an OAT. There were 101 female patients initially diagnosed with NAEH, of which 60 did not have anticoagulant treatment (mean age 57.36 ± 6.51) and 41 had anticoagulant treatment (mean age 60.39 ± 7.35) (p = 0.006). From the pathology diagnosis moment, the surgery was performed at 42.09 ± 14.54 days in patients without OAT and after 35.39 ± 11.29 days in those who received such treatment (p = 0.724). Results: Initial diagnosis of NAEH established at D&C was changed at the final diagnosis after hysterectomy in EH with cellular atypia (atypical endometrial hyperplasia AEH) or EC in 18.18% of patients without OAT, and in 40.54% of patients who received this treatment. Conclusions: Based on a logistic regression model, it is estimated that female patients with an initial histopathological diagnosis of NAEH and who underwent OAT have, on average, 4.85 times greater odds (OR = 4.85, 95% CI 1.79–14.06) than the others of being identified postoperatively with more advanced lesions.

[Management of side effects under hormonal replacement therapy in menopausal women: Abnormal uterine bleeding. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

OBJECTIVES

To publish, under the aegis of the French National College of Gynecologists and Obstetricians (CNGOF) and the Study Group on Menopause and Hormonal Aging (GEMVi), recommendations based on the evidence available in the literature for the management of abnormal uterine bleeding (AUB) in women taking hormonal replacement therapy (HRT). A review of the literature was performed by consulting Medline, Cochrane Library data as well as international recommendations in French and English up to September 1, 2020.

RESULTS

AUB occurring in a woman taking HRT (FIGO 2011) is one of the main factors of poor adherence to the HRT. AUB must seek an organic cause including endometrial cancer. The main functional causes of AUB in a woman taking HRT are resumption of ovarian activity, poor compliance, and trophic disorders of the endometrium. AUB are dependent on the type of HRT. In the event of AUB under HRT, it is suggested to perform a pelvic ultrasound at the end of the progestational sequence in the event of sequential HRT. In a single episode of AUB and when the ultrasound estimates the endometrial thickness less than or equal to 4mm, it is possible to postpone further uterine exploration. In case of recurrent AUB or when the endometrium thickness is greater than 4mm in a postmenopausal woman, additional uterine investigations (hysteroscopy and histology) are recommended.

CONCLUSION

AUB under HRT must seek an organic cause. The measurement of endometrial thickness by pelvic ultrasound is relevant for screening for endometrial cancer.

Comparison of three biopsy forceps for hysteroscopic endometrial biopsy in postmenopausal patients (HYGREB-1): A multicenter, single-blind randomized clinical trial

OBJECTIVE

To compare three types of biopsy forceps for hysteroscopic endometrial biopsy in postmenopausal women.

METHODS

Postmenopausal women undergoing operative hysteroscopy with endometrial biopsy for abnormal uterine bleeding or endometrial thickness (≥5 mm) were included. Operative hysteroscopy with endometrial biopsy was performed by hysteroscopic forceps. Women were randomized (1:1:1 ratio) in three groups and allocated to undergo endometrial biopsy by hysteroscopy using spoon, alligator, or snake forceps.

RESULTS

Seventy-five women were included in the study, 25 in each group. The duration of the biopsy was comparable between the three groups (P = 0.334) with a median of 180 seconds (range 20-480 seconds). No differences were observed about the number of attempts (P = 0.602), the use of another instrument (P = 0.276), and the biopsy appropriateness (P = 0.592). The spoon forceps group reported higher levels of pain compared to the alligator and snake forceps groups (P < 0.001). The spoon forceps received significantly lower scores by the operator compared to the alligator and snake forceps (P < 0.001). The alligator and snake forceps reported wider biopsy than the spoon forceps (P < 0.001).

CONCLUSION

Snake and alligator hysteroscopic forceps may be considered the first choice to perform an endometrial biopsy in postmenopausal women. ClinicalTrials.gov: NCT03427957.

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Recurrent postmenopausal bleeding: a survey of practice among gynecologists in Scotland

BACKGROUND

The definition and management of recurrent postmenopausal bleeding (PMB) are not well described in the literature, with no consensus among the clinicians and no available contemporary UK evidence-based guidelines. We conducted this survey to examine the practice of gynecologists based in Scotland in relation to recurrent postmenopausal bleeding.

METHODS

A web-based questionnaire was sent to 200 non-training grade gynecologists in Scotland exploring their views on the definition, investigation and management of recurrent PMB. Data were extracted from the 61 responses received.

RESULTS

Seventy-seven percent of responders defined recurrent PMB as two or more episodes of PMB, while 21% defined it after three episodes. A bleed-free interval of 3 and 6 months was needed to identify a recurrence by 46% and 44% of responders, respectively. 70% would investigate recurrent PMB with a combination of transvaginal sonography, hysteroscopy and biopsy. Only 19% would arrange a pelvic MRI routinely, while 43% would never offer one. 72% would consider a hysterectomy at some stage, with 22% of responders offering it after 3 episodes of PMB with negative investigation. 18% would never offer a hysterectomy without an identified pathology. 32% of responders felt that the management of recurrent PMB required an individualized case-by-case approach.

CONCLUSIONS

This survey highlights the need for a clinical guideline to address the wide variation in the management of recurrent PMB.

Clinical and Sonographic Evaluation of Postmenopausal Bleeding (PMB) Followed by Diagnostic and/or Therapeutic Hysteroscopy and Guided Biopsy in Jordanian Hospitals

Background and Objectives: The goal of this study was to evaluate the clinical sonographic evaluation of postmenopausal bleeding (PMB) followed by diagnostic and/or therapeutic hysteroscopy and guided biopsy in Jordanian hospitals. Materials and Methods: A retrospective multi-centric study was performed in hospitals in Al-Karak and Amman from 2014-2016. The study recruited 189 cases to evaluate the aetiology of postmenopausal bleeding. Atrophic endometrium was observed as a major cause of postmenopausal bleeding according to histopathology. The cases were also distributed according to parity in which nulliparous patients were observed. Results: Hysteroscopy was observed to be effective for the diagnosis of postmenopausal bleeding. Conclusion: There is a need to assess more approaches for the diagnosis of postmenopausal bleeding among women.

First-time postmenopausal bleeding as a clinical marker of long-term cancer risk: A Danish Nationwide Cohort Study

Background

Data on long-term risk of cancer after a postmenopausal bleeding diagnosis are sparse.

Methods

We used Danish medical registries to conduct a population-based cohort study of women with a first hospital-diagnosed postmenopausal bleeding during 1995–2013. We computed the absolute risk of cancer and the standardised incidence ratio (SIR) comparing the observed cancer incidence with that expected in the general population.

Results

Among 43,756 women with postmenopausal bleeding, the absolute 1- and 5-year risk of endometrial cancer were 4.66% and 5.18%, respectively. The SIR of endometrial cancer was elevated during 0–3 months (SIR = 330.36 (95% CI: 315.43–345.81)), 3–12 months (SIR = 11.39 (95% CI: 9.79–13.17)), 1–5 years (SIR = 2.55 (95% CI: 2.19–2.94)) and >5 years of follow-up (SIR = 1.63 (95% CI: 1.40–1.90)). All selected gynaecological and urological, gastrointestinal and haematological cancers had elevated 0–3 months SIRs. Beyond 1 year of follow-up the SIRs of ovarian and bladder cancer remained elevated with a 1–5-year SIR of 2.15 (95% CI: 1.71–2.65) and 1.45 (95% CI: 1.14–1.80), respectively.

Conclusions

In the Danish population, women with a first hospital-diagnosed postmenopausal bleeding have an increased 0–3 months risk of gynaecological, urological, gastrointestinal and haematological cancers. The SIR of endometrial, ovarian and bladder cancer remained elevated for several years.

Insufficient and Scant Endometrial Samples: Determining Clinicopathologic Outcomes and Consistency in Reporting

There are no widely accepted pathologic criteria for reporting endometrial samples with limited tissue and no consensus on the clinical follow-up of patients with these samples. Our study compares clinicopathologic outcomes and determines reporting consistency for these samples. This was done in 3 parts: (1) retrospective chart review of all patients with reported insufficient or scant endometrial samples from 2010 to 2013 at our center to determine repeat sampling and final pathologic diagnosis; (2) survey of gynecologists about their practice for managing patients with these samples; (3) blind review of 99 cases of previously reported scant or insufficient samples in which 4 reviewers separately reassigned cases as scant, insufficient, or diagnostic. Agreement was determined across reviewers. For part (1): 1149 patients had insufficient (49%) or scant (51%) samples with no significant difference in repeat biopsy rate (33% vs. 31%; P=0.33). Final diagnosis of uterine malignancy was higher in patients with a previous insufficient sample than with scant (19% and 9%, respectively), but this was not statistically significant. For part (2): among gynecologists surveyed, 4 of 5 reported managing patients with insufficient or scant samples similarly. For part (3): complete consensus across raters occurred in 57% of cases (Fleiss κ, 0.4891). Similar repeat biopsy rates between scant and insufficient samples suggest that our clinicians choose similar management for both terminologies. As such, distinction between insufficient and scant samples may not be necessary in pathologic reporting. Given the malignancy outcomes, both groups merit repeat sampling in the appropriate context.

The thin red line - postmenopausal abnormal uterine bleeding with endometrial thickness less than 4 mm

Aim of the study

To evaluate the risk of endometrial malignancy in postmenopausal women with abnormal uterine bleeding (AUB) with endometrial thickness ≤ 4 mm.

Material and methods

Histological assessment of endometrial samples obtained via hysteroscopy or curettage was performed in 57 women.

Results

Women with premalignancy or malignancy (24.6%) had higher endometrial thickness (by 9.7%, p = 0.01) compared to women with benign condition. Out of 12 women with atypical hyperplasia (21.1%), 5 women (8.8%) were diagnosed with simple and 7 women (12.3%) had complex hyperplasia, whereas 2 (3.5%) were diagnosed with malignancy.

Conclusions

Postmenopausal women with AUB and endometrial echo ≤ 4 mm are less likely to have a malignant condition. However, the role of histological evaluation cannot be undermined, especially in women at high risk of endometrial cancer, and routine endometrial biopsy should be considered. We recommend a change in the cut-off to 2 mm in routine practice.

Application of transvaginal sonographic elastography to distinguish endometrial cancer from benign masses

Transvaginal sonographic elastography can be used for the differentiation of malignant and benign lesions in different systems. Recent studies on strain elastography showed that different endometrial tissues demonstrated different stiffness characteristics. In this study, we aim to evaluate the diagnostic value of transvaginal sonographic elastography to distinguish endometrial cancer from benign masses. A prospective study was conducted on patients with suspected intracavitary uterine focal lesions, abnormal uterine bleeding for routine ultrasound examination of the pelvis. A total of 217 patients were included and underwent both conventional B-mode sonography and elastography. Endometrial lesions were categorized into 3 types for qualitative analysis and the strain ratio (SR) was measured for quantitative analysis. Pathological examinations were also conducted to establish final diagnosis. There were 104 patients diagnosed with endometrial cancer and 113 with benign lesions. All type 1 endometrial lesions were diagnosed as benign, while 95.8% of type 3 were malignant. For quantitative elastography results, the AUC for SR was 0.904 with 95% CI between 0.866 and 0.942. Using an ROC curve, the best cut-off SR value was found to be 3.02 and it could achieve a sensitivity of 81.7%, a specificity of 85%, a positive predictive value of 83.3% and a negative predictive value of 83.5%. Our results suggested that transvaginal sonographic elastography is a promising diagnostic tool for differentiating endometrial cancer from benign masses, and that SR has excellent diagnostic performance.

Thickened Endometrium in Postmenopausal Women With an Initial Biopsy of Limited, Benign, Surface Endometrium: Clinical Outcome and Subsequent Pathologic Diagnosis

Endometrial biopsy or curetting is indicated for postmenopausal women with abnormal uterine bleeding and/or thickened endometrium. Often, endometrial biopsy or curetting yields limited benign surface endometrium, which may indicate insufficient sampling. This study addresses the clinical outcome and subsequent pathologic diagnoses in postmenopausal women who received this initial diagnosis. Among a total of 370 endometrial biopsy or curetting between 2012 and 2015, 192 (52%) were diagnosed as limited benign surface endometrial epithelium. The women ranged in age from 55 to 91 yr old. Their clinical presentations mainly included postmenopausal bleeding, pelvic pain, and enlarged uterus. Primarily because the initial report was interpreted as "benign," 108 (57%) had no subsequent follow-up. Interestingly, women with an increased endometrial thickness were more likely to receive repeat evaluation. Among the 84 women who underwent follow-up endometrial sampling, 6 (7%) had hyperplasia with atypia or malignancy, 21 (25%) had a repeat diagnosis of limited surface sample, 4 (5%) had insufficient materials, and 53 (63%) had other benign findings. Among the subset of women who did receive subsequent follow-up, endometrial atypia or malignancies are more likely found in those with increased body mass index. In conclusion, a slight majority of women with postmenopausal bleeding and/or thickened endometrium had an initial limited surface endometrial sample. Most had no subsequent endometrial sampling. Among those with subsequent follow-up, the majority had benign findings. The study highlights the inconsistencies in adequacy criteria for endometrial sampling and the lack of standardization of subsequent management.

Long-term risk of endometrial cancer following postmenopausal bleeding and reassuring endometrial biopsy

Introduction

Women with postmenopausal bleeding and endometrial thickness >4 mm undergo endometrial sampling to exclude endometrial cancer. The aim of this study is to investigate the relative risk of developing endometrial cancer in a prospective cohort after initial work‐up for postmenopausal bleeding showing reassuring histology or insufficient sampling.

Material and methods

All women presenting with postmenopausal bleeding were prospectively included from January 2009 to April 2011. Follow‐up data were collected from patient charts and PALGA (Dutch Pathology Registry). Hazard ratios for endometrial cancer were determined by calculating standardized incidence ratios.

Results

A total of 668 women were included and 568 women were available for follow‐up [median follow‐up time 47 (range 7–63) months]. Women who presented with postmenopausal bleeding, endometrial thickness >4 mm and hyperplasia without atypia on biopsy at the first presentation showed a significantly increased risk (standardized incidence ratio 17.15, 95% confidence interval 1.96–61.93) of being diagnosed with endometrial cancer during the first four years of follow up compared with the age‐specific population. All women that developed endometrial cancer after initial reassuring histology presented with recurrent postmenopausal bleeding. None of the women with endometrial thickness >4 mm and no or insufficient sample for histology at the first presentation developed endometrial cancer during the follow up.

Conclusions

Although in general, women with endometrial hyperplasia without atypia are considered to have a low risk for cancer, we observed a significant long‐term risk of endometrial cancer after postmenopausal bleeding. Whether additional diagnostics or a more stringent follow‐up regimen would be cost‐effective, needs to be studied.