Transtubal Transport of Carcinoma Cells Into the Peritoneal Cavity After Saline Infusion via Transcervical Route in Patients With Endometrial Carcinoma

Efficacy and pregnancy outcomes of hysteroscopic surgery combined with progestin as fertility-sparing therapy in patients with early stage endometrial cancer and atypical hyperplasia

PURPOSE

This study aims to evaluate the efficacy of hysteroscopic curettage combined with progestin therapy in young patients with early-stage endometrial cancer (EC) and endometrial atypical hyperplasia (EAH) who wished to preserve their fertility.

METHODS

This prospective cohort study included 16 patients with early-stage EC and 25 patients with EAH in Dalian Maternal and Child Health Hospital from August 2014 to October 2018. All patients received fertility-sparing therapy with hysteroscopic evaluation every 3 months until achieving complete response (CR). Demographic, clinical, and pathological data follow-up information as well as fertility outcomes was analyzed.

RESULTS

There were 92.6% (37/41) patients who achieved CR. The mean treatment duration to CR was 7.47 ± 2.91 months. BMI ≤ 30 kg/m² was associated with shorter treatment duration to achieve CR (P = 0.003). Among the patients who attempted to conceive, 30.3% (10/33) had successful pregnancy, and 18.2% (6/33) delivered live births. The implementation of assisted reproductive technology (ART) is closely associated with pregnancy (P = 0.001).

CONCLUSION

The fertility-sparing therapy, hysteroscopic curettage combined with progestin therapy, of early young EC and EAH patients is safe and effective. BMI is the main factor affecting the duration of CR. After achieving CR, ART can significantly improve the pregnancy rate of these patients.

A new diagnostic test for endometrial cancer?: Cytology analysis of sonohysterography distention media

OBJECTIVE

During saline-infused sonohysterography (SIS), the distension fluid is typically discarded. If cytology analysis could identify those patients with endometrial cancer, many women would be spared from further procedures.

METHODS

Thirty consecutive patients with clinical stage I or II endometrial adenocarcinoma were prospectively recruited preoperatively. Saline-infused sonohysterography was performed by instilling 5 mL of saline, withdrawing and sending for analysis. Saline was reinfused until complete SIS images were obtained and sent separately for cytology.

RESULTS

Of the 30 women enrolled, SIS was technically successful in 29. Demographics included mean age (60.5 ± 6.99 years), body mass index (35.55 ± 8.18 kg/m), endometrioid histology (76%), and grade (grade 1, 67%). Prestudy diagnostic method included biopsy (70%), dilatation and curettage (17%), and hysteroscopy (10%). Adequate cytology specimens were obtained in 66% of the 5 mL flushes and 72% of the complete SIS collections. Of adequate specimens, the sensitivities to detect endometrial cancer for the 5-mL, complete, and combined fluid samples were 26% (95% confidence interval, 9%-51%), 36% (17%-59%), and 42% (22%-63%). Sensitivity based on the whole study sample (N = 30) was 33% (17%-53%). Statistical significance was not found in the association between a positive test and age, body mass index, grade, diagnostic method, or volume instilled or aspirated.

CONCLUSIONS

Most patients with early endometrial cancer can undergo SIS procedures with adequate cytology specimens obtained from distention media. However, the sensitivity is low, and refinements are necessary before utilizing as a diagnostic test. In cases with positive results, the patient may be able to avoid other costly and painful procedures.

Transtubal spread of endometrial carcinoma: correlation of intra-luminal tumour cells with tumour grade, peritoneal fluid cytology, and extra-uterine metastasis

AIMS

To assess the significance of intra-luminal tumour cells (ILTC) within the fallopian tubes of patients with endometrial carcinoma, with emphasis on high grade histological subtypes.

METHODS

Complete histological examination of fallopian tube tissue was performed in 36 low grade endometrioid adenocarcinomas and in a consecutive series of 226 high grade endometrial malignancies including 92 serous carcinomas, 64 grade 3 endometrioid carcinomas, 26 carcinosarcomas, 25 undifferentiated/dedifferentiated carcinomas, and 19 clear cell carcinomas. The presence of ILTC was correlated with peritoneal fluid cytology, histologically confirmed peritoneal tumour spread, and lymph node metastases.

RESULTS

ILTC were identified in 26% and 3% of high and low grade carcinomas, respectively. The presence of ILTC correlated strongly with positive peritoneal fluid cytology and with peritoneal metastasis in high grade tumours (both p < 0.001), and there was also a correlation with lymph node metastasis (p = 0.049). ILTC were more common in serous and undifferentiated carcinomas (>30%) but the differences between the high grade tumour subtypes were not statistically significant.

CONCLUSIONS

These findings suggest that ILTC associated with high grade endometrial cancers have the capacity to implant and invade the peritoneal cavity. Positive cytology in such cases may be more significant than in low grade tumours. Complete tubal examination may provide additional prognostic information in high grade endometrial carcinoma.

Iatrogenic transtubal spill of endometrial cancer: risk or myth

INTRODUCTION

Although intrauterine procedures are essential for endometrial evaluation in many cases, the significance of the amount of tumor cell dissemination during these procedures, the viability and invasive potential of the endometrial cancer (EC) cells, and their impact on prognosis remain elusive.

MATERIALS AND METHODS

An extensive search was performed in the Cochrane Central Trials Registry, the Web of Science, and PubMed for publications about the role of hysteroscopy (H/S), saline infusion sonography (SIS) and laparoscopy (L/S) in dissemination of EC cells and prognostic significance of positive peritoneal washings (PPW), between 1988 and 2010 and English language. All eligible trials were included.

CONCLUSION

PPW rates vary between 0-14% after dilatation and curettage (D&C), 0-83% after H/S, 0-10% after L/S and 12-52% after SIS. The majority of the studies about EC cell dissemination during H/S and SIS suggest that they increase the risk of spill. There is not enough evidence to support the association between tumor spill and pressure, type and volume of distension medium, duration of the procedure, stage, grade and interval between H/S or SIS and laparotomy. Investigation into the rate of spill of EC cells during laparoscopic surgery is in the early stages and not yet definitive. There are too few in vivo and in vitro studies to comment definitively on the viability of the disseminated EC cells. The limited data we do have, however, questions the ability of disseminated EC cells to maintain and grow. Most published studies support the idea that prognosis is not affected by PPW in stage I EC. The changes in FIGO 2009 staging of EC appears to have merit when considering the sum of the data. H/S and SIS probably increase the risk of spill, however this increase does not seem effect prognosis. Although peritoneal washings are still expected to be performed, PPW itself does not necessitate additional treatment.