A risk-scoring model for the prediction of endometrial cancer among symptomatic postmenopausal women with endometrial thickness > 4 mm

Comparing endometrial biopsy results with hysteroscopic pathology in women presenting with abnormal and postmenopausal uterine bleeding

OBJECTIVE

To compare pathology results after office-based blind endometrial biopsy and pathology results from hysteroscopy in women presenting with abnormal uterine bleeding (AUB).

METHODS

A retrospective cohort study of biologic women presenting with AUB at a tertiary care referral care center. Patients were included if they underwent evaluation with blind endometrial biopsy performed in the office followed by hysteroscopy within one year. Hysteroscopic findings and pathology were correlated with index endometrial biopsy findings.

RESULTS

689 patients met inclusion criteria. The mean age and BMI were 49 (±10) years and 31 (±8) kg/m2. The median duration of bleeding leading up to presentation was of 3.5 (1.5-9) months. Of the patients who had operative hysteroscopic pathology demonstrating endometrial polyp, 30.6 % (81) had a polyp detected on office endometrial biopsy. Of the patients who had hysteroscopic pathology demonstrating intracavitary fibroids, 0 % (0) were detected on endometrial biopsy. Of the patients who had hyperplasia without atypia on hysteroscopy, 28.6 % (4) were detected or suspected on endometrial biopsy. Of the patients who had hyperplasia with atypia on hysteroscopy, 5.9 % (1) were detected or suspected on endometrial biopsy. There were 12 cases of confirmed or suspected malignancy on hysteroscopy, of which 8.3 % (1) were detected on endometrial biopsy.

CONCLUSION

Concordance between focal findings on office hysteroscopy and endometrial biopsy is low. Endometrial biopsy when malignancy is suspected has been shown to be of benefit, but in the setting of suspected benign focal pathology, blind assessment of the endometrial cavity for definitive diagnosis should be abandoned. In women with symptomatic uterine bleeding, hysteroscopic visualization is associated with increased sensitivity in identifying intrauterine pathology.

Artificial intelligence for prediction of endometrial intraepithelial neoplasia and endometrial cancer risks in pre- and postmenopausal women

BACKGROUND

The current approach to endometrial cancer screening requires that all patients be able to recognize symptoms, report them, and carry out appropriate interventions. The current approach to endometrial cancer screening could become a problem in the future, especially for Black women and women from minority groups, and could lead to disparities in receiving proper care. Moreover, there is a lack of literature on artificial intelligence in the prediction and diagnosis of endometrial intraepithelial neoplasia and endometrial cancer.

OBJECTIVE

This study analyzed different artificial intelligence methods to help in clinical decision-making and the prediction of endometrial intraepithelial neoplasia and endometrial cancer risks in pre- and postmenopausal women. This study aimed to investigate whether artificial intelligence may help to overcome the challenges that statistical and diagnostic tests could not.

STUDY DESIGN

This study included 564 patients. The features that were collected included age, menopause status, premenopausal abnormal bleeding and postmenopausal bleeding, obesity, hypertension, diabetes mellitus, smoking, endometrial thickness, and history of breast cancer. Endometrial sampling was performed on all women with postmenopausal bleeding and asymptomatic postmenopausal women with an endometrial thickness of at least 3 mm. Endometrial biopsy was performed on premenopausal women with abnormal uterine bleeding and asymptomatic premenopausal women with suspected endometrial lesions. Python was used to model machine learning algorithms. Random forest, logistic regression, multilayer perceptron, Catboost, Xgboost, and Naive Bayes methods were used for classification. The synthetic minority oversampling technique was used to correct the class imbalance in the training sets. In addition, tuning and boosting were used to increase the performance of the models with a 5-fold cross-validation approach using a training set. Accuracy, sensitivity, specificity, positive predictive value, and F1 score were calculated.

RESULTS

The prevalence of endometrial or preuterine cancer was 7.9%. Data from 451 patients were randomly assigned to the training group, and data from another 113 patients were used for internal validation. Of note, 3 of 9 features were selected by the Boruta algorithm for use in the final modeling. Age, body mass index, and endometrial thickness were all associated with a high risk of developing precancerous and cancerous diseases, after fine-tuning for the multilayer computer to have the highest area below the receiver operating characteristic curve (area under the curve, 0.938) to predict a precancerous disease. The accuracy was 0.94 for predicting a precancerous disease. Precision, recall, and F1 scores for the test group were 0.71, 0.50, and 0.59, respectively.

CONCLUSION

Our study found that artificial intelligence can be used to identify women at risk of endometrial intraepithelial neoplasia and endometrial cancer. The model is not contingent on menopausal status or symptoms. This may be an advantage over the traditional methodology because many women, especially Black women and women from minority groups, could not recognize them. We have proposed to include patients to provide age and body mass index, and measurement of endometrial thickness by either sonography or artificial intelligence may help improve healthcare for women in rural or minority communities.

Evaluation of endometrial thickness by transvaginal ultrasound and baseline risk factors as a predictor for endometrial abnormalities in postmenopausal women

Introduction/Purpose

To evaluate the endometrial thickness (ET) as a predictor of endometrial abnormalities in postmenopausal women and whether consideration of baseline risk factors increases diagnostic accuracy.

Methods

This is a retrospective observational study of postmenopausal women presenting with bleeding or thickened endometrium (≥4 mm) on ultrasound, between 2003 and 2012. Risk factors for endometrial abnormality were analysed using logistic regression. Of 301 women, 220 were symptomatic and 81 were asymptomatic. The median ET was 6 mm (IQR 4-9) for symptomatic women and 9 mm (IQR 6-12) for asymptomatic women.

Results

Abnormal pathology was found in 35 symptomatic (15.9%) and 6 asymptomatic women (7.4%). For each 1 mm increase in ET, the odds of an abnormal diagnosis increased by 16.3% (95% CI 9.6-23.5) for symptomatic and 19.9% (95% CI 3.1-39.3) for asymptomatic women. The Youden's index method identified an ET threshold of ≥7.1mm for symptomatic and ≥14.5mm for asymptomatic women. In symptomatic women the sensitivity was 88.6% (95% CI 72.3-96.3) and specificity 69.2% (95% CI 61.9-75.6), while in asymptomatic women the sensitivity was 50.0% (95% CI 13.9-86.1) and specificity was 89.3% (95% CI 79.5-95.0). The addition of age in the symptomatic women model reduced the sensitivity (82.9% (95% CI 65.7-92.8)) but increased the specificity (72.4% (95% CI 65.3-78.6)).

Conclusion

ET is a significant predictor of abnormality. In the absence of risk factors, our study suggests that invasive procedures may be withheld until the ET is ≥7.1 mm with bleeding and ≥14.5 mm in asymptomatic women with no bleeding.

The cost of diagnosing endometrial cancer: Quantifying the healthcare cost of an abnormal uterine bleeding workup

OBJECTIVE

The evaluation of women with perimenopausal abnormal uterine bleeding (AUB) and postmenopausal bleeding (PMB) to detect endometrial cancer (EC) and its precursors is not standardized and can vary widely. Consequently, costs associated with the workup and management undoubtedly vary. This study aimed to quantify costs of AUB/PMB evaluation to understand the healthcare burden associated with securing a pathologic diagnosis.

METHODS

Women ≥45 years of age presenting to a single institution gynecology clinic with AUB/PMB for diagnostic workup were prospectively enrolled February 2013-October 2017 for a lower genital tract biospecimen research study. Clinical workup of AUB/PMB was determined by individual provider discretion. Costs of care were collected from administrative billing systems from enrollment to 90 days post enrollment. Costs were standardized and inflation-adjusted to 2017 US Dollars (USD).

RESULTS

In total, there were 1017 women enrolled with 5.6% diagnosed with atypical hyperplasia or endometrial cancer (EC). Within the full cohort, 90-day median cost for AUB/PMB workup and management was $2279 (IQR $512-4828). Among patients with a diagnostic biopsy, median 90-day costs ranged from $2203 (IQR $499-3604) for benign or disordered proliferative endometrium (DPE) diagnosis to $21,039 (IQR $19,084-24,536) for a diagnosis of EC.

CONCLUSIONS

The costs for diagnostic evaluation of perimenopausal AUB and PMB vary greatly according to ultimate tissue-based diagnosis. Even reassuring benign findings that do not require further intervention-the most common in this study's cohort-yield substantial costs. The development of sensitive, specific, and more cost-effective diagnostic strategies is warranted.

Tao brush endometrial cytology is a sensitive diagnostic tool for cancer and hyperplasia among women presenting to clinic with abnormal uterine bleeding

BACKGROUND

Abnormal uterine bleeding requires the investigation of the endometrium. Histology is typically used but there remains room for the improvement and use of cytology.

METHODS

Women presenting for clinically indicated office endometrial biopsy were prospectively enrolled. Tao endometrial brushing and office endometrial biopsy were performed, and surgical procedure if clinically indicated. Tao brush cytology specimens were blindly reviewed by up to three pathologists, consensus obtained, and scored as: benign, atypical (favor benign), suspicious, positive for malignancy, or non-diagnostic. Cytology and histology were compared to surgical pathology to determine sensitivity, specificity, positive, and negative predictive values to detect AH (atypical hyperplasia) or EC (endometrial cancer).

RESULTS

Clinical indications of 197 enrolled patients included postmenopausal bleeding (90, 45.7%), abnormal uterine bleeding (94, 47.7%), and abnormal endometrium on ultrasound without bleeding (13, 6.6%). Of the 197 patients, 185 (93.9%) had cytology score consensus and a total of 196 (99.5%) had consensus regarding cytology positivity. Surgical pathology diagnoses (N = 85) were 13 (15.3%) FIGO grade 1 or 2 EC, 3 (3.5%) AH, and 69 (81.2%) benign endometrium. Sensitivity and specificity to detect EC or AH were 93.7% and 100%, respectively, via endometrial biopsy; 87.5% and 63.8%, respectively, via endometrial cytology when scores of malignancy, suspicious, or atypical were considered positive.

CONCLUSIONS

In a high-risk population, Tao brush endometrial cytology showed high sensitivity to detect AH and EC comparable to biopsy histology when considering scores of malignancy, suspicious, atypical, and non-diagnostic. Revisiting the potential value of endometrial cytology in the contemporary era of endometrial diagnostic workup is warranted.

Pathological spectrum of endometrial biopsies in Saudi women with abnormal uterine bleeding: A retrospective study of 13-years

OBJECTIVES

To assess and age stratify the types and frequencies of endometrial pathologies in Saudi women with abnormal uterine bleeding (AUB) that underwent endometrial biopsies, at our hospital over a 13-year period.

METHODS

In a retrospective study, from 2006 to 2018, all endometrial biopsies from Saudi women with AUB, reported at the laboratory of King Saud University-Medical City, Riyadh, Saudi Arabia, were revisited and analyzed. The women were categorized into <40, between 40-55 and >55 years of age.

RESULTS

We analyzed 6458 biopsies. In <40 and 40-55 years' groups cyclical endometrium was most common followed by endometrial polyps and disordered proliferative endometrium. In the >55 years' group, atrophic endometrium was most common followed by endometrial polyps. The hyperplasias and malignancies together accounted for 7.2% of the study, majority in the >55 years' group. Simple hyperplasia without atypia was the most common (3.9%), followed by malignancies (1.9%), complex atypical hyperplasia (0.7%), complex hyperplasia without atypia (0.4%), and simple atypical hyperplasia (0.3%).

CONCLUSION

Awareness of the probable spectrum of endometrial histopathologies in the various ages is useful in guiding management. Endometrial biopsies are valuable in early detection of precancerous and cancerous endometrial lesions especially in women over 40 years.

Atypical Endometrial Hyperplasia and Unexpected Cancers at Final Histology: A Study on Endometrial Sampling Methods and Risk Factors

Background: Up to 40% of women with atypical endometrial hyperplasia (AEH) can reveal endometrial cancer (EC) at hysterectomy. The pre-operative endometrial sampling method (ESM) and some independent cancer predictors may affect this outcome. The present study aimed to compare the rate of EC at hysterectomy in women with AEH undergoing dilation and curettage (D&C), hysteroscopically-guided biopsy (HSC-bio), or hysteroscopic endometrial resection (HSC-res). The secondary outcome was to compare the reliability of ESMs in women showing independent variables associated with EC. Methods: Two-hundred-and-eight consecutive women with AEH and undergoing hysterectomy between January 2000 and December 2017 were analyzed retrospectively. Based on pre- and post-test probability analysis for EC, three ESMs were compared: D&C, HSC-bio, and HSC-res. Univariate and multivariate analyses were performed to assess risk factors predicting cancer on final histology. Finally, the patient’s characteristics were compared between the three ESM groups. Results: D&C and HSC-bio included 75 women in each group, while HSC-res included 58 women. Forty-nine women (23.6%) revealed cancer at hysterectomy (pre-test probability). Post-test probability analysis showed that HSC-res had the lowest percentage of EC underestimation: HSC-res = 11.6%; HSC-bio = 19.5%; D&C = 35.3%. Patient characteristics showed no significant differences between the three ESMs. Multivariate analysis showed that body mass index ≥40 (Odds Ratio (OR) = 19.75; Confidence Intervals (CI) 2.193–177.829), and age (criterion > 60 years) (OR = 1.055, CI 1.002–1.111) associated significantly with EC. In women with one or both risk factors, post-test probability analysis showed that HSC-res was the only method with a lower EC rate at hysterectomy compared to a pre-test probability of 44.2%: HSC-res = 19.96%; HSC-bio = 53.81%; D&C = 63.12%. Conclusions: HSC-res provided the lowest rate of EC underestimation in AEH, also in women showing EC predictors. These data may be considered for better diagnostic and therapeutic planning of AEH.

Ultrasound detection of endometrial cancer in women with postmenopausal bleeding: Systematic review and meta-analysis

OBJECTIVE

To assess the performance of endometrial thickness (ET) cut-offs for detecting endometrial cancer (EC) in women with postmenopausal bleeding (PMB) and evaluate the clinical utility of additional ultrasound measures such as endometrial volume (EV), vascular flow index (VFI), vascularization index (VI), and uterine artery flow index (FI).

METHODS

Clinicaltrials.gov and MEDLINE database via PubMed were queried for studies published between 1/1990 and 3/2016 using specific MeSH terms. Original, peer-reviewed cohort studies reporting EC outcomes and specific ultrasound findings by PMB status were included.

RESULTS

Study design, country, clinical setting inclusion/exclusion criteria, aggregate study-level demographic and clinical data were extracted from 44 studies including 17,339 women with PMB and 1341 cases of EC (7.7%). In women with PMB and EC (n = 417), pooled mean ET was 16.4 mm (95% CI, 14.8-18.1 mm). In women with PMB without EC, pooled mean ET was 4.1 mm. 31 studies reported outcomes using different ET cut-off values ranging from 3 to 20 mm. Compared to ≥3 or 4 mm, a cutoff of ≥5 mm had similar sensitivity (96.2, 95%CI 92.3, 98.1) with improved specificity for EC (51.5, 95%CI 42.3-60.7), allowing to reduce the rate of invasive workup for PMB by 17%. EV, VI, VFI, and FI were significantly correlated with EC, but performance of specific cut-offs was not analyzed due to limited data.

CONCLUSION

Among women with PMB mean ET is substantially higher in women with EC compared to those without EC. An ET cutoff of ≥5 mm shows an acceptable tradeoff between sensitivity and specificity for diagnosis of EC.

New perspectives on screening and early detection of endometrial cancer

Due to the anatomical continuity of the uterine cavity with the cervix, genomic exploitation of material from routine Pap smears and other noninvasive sampling methods represent a unique opportunity to detect signs of disease using biological material shed from the upper genital tract. Recent research findings offer a promising perspective in the detection of endometrial cancer, but certain questions need to be addressed in order to accelerate the implementation of novel technologies in a routine screening or clinical setting. We discuss here new perspectives on detection of endometrial cancer using genomic and other biomarkers in minimally invasive sampling methods with a special focus on public health classic screening criteria, highlighting current gaps in knowledge.

Prediction of Endometrial Hyperplasia and Cancer among Premenopausal Women with Abnormal Uterine Bleeding

Objective

To create a prediction model including clinical variables for the prediction of premalignant/malignant endometrial pathology in premenopausal women with abnormal uterine bleeding (AUB).

Methods

This is an observational retrospective study including 240 premenopausal women with AUB referred to diagnostic hysteroscopy. Based on the presence of endometrial hyperplasia (EH) or cancer (EC), the women were divided into cases (EH/EC) and controls (no EH/EC). Univariate, stepwise logistic regression and ROC curve analysis were performed.

Results

12 women had EH/EC (5%). Stepwise logistic regression analysis showed that EH/EC associated significantly with BMI ≥ 30 (OR=7.70, 95% CI 1.90 to 31.17), diabetes (OR=9.71, 95% CI 1.63 to 57.81), and a thickened endometrium (OR=1.20, 95% CI 1.08 to 1.34, criterion > 11 mm). The AUC was 0.854 (95% confidence intervals 0.803 to 0.896, p<0.0001). Considering the pretest probability for EH/EC of 5%, the prediction model with a positive likelihood ratio of 8.14 showed a posttest probability of 30%. The simultaneous presence of two or three risk factors was significantly more common in women with EH/EC than controls (50% vs. 6.6 and 25% vs. 0%, respectively, p<0.0001).

Conclusion

When premenopausal vaginal bleeding occurs in diabetic obese women with ET > 11 mm, the percentage of premalignant/malignant endometrial pathology increases by 25%. It is likely that the simultaneous presence of several risk factors is necessary to significantly increase the probability of endometrial pathology.

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.

A Clinicopathological Evaluation of Postmenopausal Bleeding and Its Correlation with Risk Factors for Developing Endometrial Hyperplasia and Cancer: A Hospital-Based Prospective Study

Objective:

The aim of this study is to investigate the clinical data from history and endometrial pathology by endometrial sampling in patients with postmenopausal bleeding and to identify risk factors associated with future development of endometrial cancer (EC).

Methods:

We prospectively studied 76 postmenopausal women with vaginal bleeding and endometrial thickness (ET) >5 mm undergoing endometrial biopsy or dilatation and curettage. Patient characteristics and endometrial assessment of women with or without EC and hyperplasia were compared. Univariate and multivariate logistic regression identified factors associated with risks of endometrial neoplasia.

Results:

In this study, the mean age at the time of presentation was 57.17 ± 7.11 years, mean menopausal age was 49.18 ± 3.69 years, and mean thickness of endometrial was 11.13 ± 6.37 mm. The histopathological analysis showed atrophic endometrium (30.3%), proliferative endometrium (27.6%), EC (15.8%), endometrium hyperplasia (11.8%), disordered proliferative endometrium (9.2%), and endometrial polyp (5.3%). Women of EC and hyperplasia group were more likely to be multiparous, diabetic, hypertensive, obese or overweight, has a history of recurrent bleeding episodes or thick endometrium. Using multivariate logistic regression, we found ET (adjusted odds ratio [AOR] = 17.76, confidence interval [CI] 1.91–165.02, P < 0.011, criterion ≥11 mm), recurrent episode of bleeding (AOR = 13.21, CI 1.10–158.91, P < 0.042), diabetes (AOR = 8.03, CI 1.15–55.78, P < 0.035) the best predictors of EC.

Conclusion:

As clinical characteristics are possible predictors of EC, these should also be taken into account in risk estimations and in the formulation of management plans. This not only has benefit in the process of disease detection but also may result in improved the efficiency of care.

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.

Asymptomatic Endometrial Thickening of 8 mm or Greater on Postcontrast Computed Tomography in Postmenopausal Women Is a Predictor of Endometrial Cancer

OBJECTIVES

The aim of this study was to assess the value of opportunistic endometrial thickness measurement on postcontrast computed tomography (CT) as a predictor of endometrial cancer in asymptomatic postmenopausal women.

METHODS

For this Health Insurance Portability and Accountability Act-compliant, institutional review board-approved retrospective study with waiver of informed consent, our institution's tumor board database was searched for postmenopausal patients, diagnosed with endometrial cancer between August 2003 and December 2016 and who had a postcontrast pelvic CT within 12 months prior to the cancer diagnosis (while they were asymptomatic)-"cancer group." Same number of age-matched patients who had postcontrast pelvic CT constituted the noncancer control group. Endometrial thickness was measured on sagittal postcontrast CT images.

RESULTS

After applying exclusion criteria, 22 asymptomatic patients who were diagnosed with endometrial cancer within 1 year after the CT comprised the cancer group, and 22 age-matched patients comprised the control group. Average endometrial thickness was 18.7 ± 14.8 mm (range, 2-70 mm) in the cancer group and 3.6 ± 2.5 mm (range, 1.8-10 mm) in the control group (P < 0.0001). Endometrial thickness 8 mm or greater predicted endometrial cancer with 86% sensitivity and 91% specificity in these asymptomatic patients. Area under the receiver operating characteristic curve for endometrial thickness as a predictor of endometrial cancer was 0.92.

CONCLUSIONS

Endometrial thickness 8 mm or greater on sagittal postcontrast CT was shown to have high sensitivity in opportunistic detection of endometrial cancer in asymptomatic postmenopausal women.

Association of Endometrial Cancer Risk With Postmenopausal Bleeding in Women: A Systematic Review and Meta-analysis

IMPORTANCE

As the worldwide burden of endometrial cancer continues to rise, interest is growing in the evaluation of early detection and prevention strategies among women at increased risk. Focusing efforts on women with postmenopausal bleeding (PMB), a common symptom of endometrial cancer, may be a useful strategy; however, PMB is not specific for endometrial cancer and is often caused by benign conditions.

OBJECTIVE

To provide a reference of the prevalence of PMB in endometrial cancers and the risk of endometrial cancer in women with PMB.

DATA SOURCES

For this systematic review and meta-analysis, PubMed and Embase were searched for English-language studies published January 1, 1977, through January 31, 2017.

STUDY SELECTION

Observational studies reporting the prevalence of PMB in women with endometrial cancer and the risk of endometrial cancer in women with PMB in unselected populations were selected.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers evaluated study quality and risk of bias using items from the Newcastle-Ottawa Quality Assessment Scale and the Quality Assessment of Diagnostic Accuracy Studies tool. Studies that included highly selected populations, lacked detailed inclusion criteria, and/or included 25 or fewer women were excluded.

MAIN OUTCOMES AND MEASURES

The pooled prevalence of PMB in women with endometrial cancer and the risk of endometrial cancer in women with PMB.

RESULTS

A total of 129 unique studies, including 34 432 unique patients with PMB and 6358 with endometrial cancer (40 790 women), were analyzed. The pooled prevalence of PMB among women with endometrial cancer was 91% (95% CI, 87%-93%), irrespective of tumor stage. The pooled risk of endometrial cancer among women with PMB was 9% (95% CI, 8%-11%), with estimates varying by use of hormone therapy (range, 7% [95% CI, 6%-9%] to 12% [95% CI, 9%-15%]; P < .001 for heterogeneity) and geographic region (range, 5% [95% CI, 3%-11%] in North America to 13% [95% CI, 9%-19%] in Western Europe; P = .09 for heterogeneity).

CONCLUSIONS AND RELEVANCE

Early detection strategies focused on women with PMB have the potential to capture as many as 90% of endometrial cancers; however, most women with PMB will not be diagnosed with endometrial cancer. These results can aid in the assessment of the potential clinical value of new early detection markers and clinical management strategies for endometrial cancer and will help to inform clinical and epidemiologic risk prediction models to support decision making.

Intraluminal Uterine Hypodensity in CT Scans of Postmenopausal Women: Recommendations for Interpretation

OBJECTIVE

This study aims to investigate the association between intraluminal uterine hypodensity and uterine malignancy and establish thresholds that would minimize routine gynecological evaluation.

METHODS

Two groups were recruited retrospectively: cancer group, which comprised 32 sequential endometrial cancer patients, and postmenopausal group, which comprised 63 women, with no known gynecologic malignancy.Two radiologists independently measured hypodensity, transversely in the axial plane and anterioposteriorly in the sagittal plane.The association between cancer and hypodensity was evaluated. Receiver operating characteristic curves were evaluated diameters predictive of cancer.

RESULTS

Hypodensity was associated with cancer (cancer group, 93.8% vs. postmenopausal group, 38.1%; P < 0.0001). Hypodensity diameters correlated highly with prediction of cancer (transverse area under the curve, 0.899; anteroposterior area under the curve, 0.892). Diameters of 19.5 mm transverse and 6.0 mm anteroposterior yielded a sensitivity of 87% and 83% and specificity of 91% and 83%, respectively.

CONCLUSIONS

Intrauterine hypodensity is a common finding in computed tomography scans of postmenopausal women. A transverse diameter of 19.5 mm and an anteroposterior diameter of 6.0 mm are suggested as thresholds for further gynecological sonographic evaluation.

Diagnostic value of sonography for detecting endometrial pathologies in postmenopausal women with and without bleeding

PURPOSE

To investigate the diagnostic value of endometrial thickness measurement on sonography in predicting endometrial pathologies in postmenopausal women with vaginal bleeding and in those with asymptomatic thickened endometrium.

METHODS

Six hundred two postmenopausal women with vaginal bleeding or asymptomatic thickened endometrium were evaluated in this study. Two hundred seventy-four women with postmenopausal bleeding regardless of endometrial thickness (group 1: symptomatic) and 328 women with an incidental finding of thickened endometrium (≥5 mm) without bleeding (group 2: asymptomatic) underwent endometrial biopsy for histopathologic examination. The receiver operating characteristics curves of endometrial thickness measurement for prediction of endometrial pathologies were analyzed.

RESULTS

Endometrial carcinoma was detected in eight women (2.9%) in group 1 and in three (0.9%) in group 2. The best cutoff point for endometrial thickness in predicting endometrial carcinoma in group 1 was 8.2 mm, which provided 75% sensitivity (95% confidence interval [CI], 40.9-92.9%) and 74% specificity (95% CI, 68-78.5%); area under the receiver operating characteristics curve (AUC), 0.88; 95% CI, 0.76-1.00%; p = 0.0001. In group 2, the AUC was 0.76 (95% CI, 0.46-1.00; p = 0.114); the evidence was inconclusive as to the relationship between endometrial thickness and malignancy. For the prediction of polyps, the AUCs of endometrial thickness were 0.77 for group 1 (95% CI, 0.71-0.83%; p = 0.0001) and 0.61 for group 2 (95% CI, 0.54-0.67%; p = 0.002).

CONCLUSIONS

Sonographically determined endometrial thickness measurement shows high diagnostic performance for detection of endometrial cancer in symptomatic postmenopausal women at the optimal cutoff thickness of approximately 8 mm, although the evidence supporting the use of sonography for predicting malignancy in asymptomatic women is inconclusive. For polyp detection, this technique shows moderate diagnostic ability in symptomatic women, but its predictive value is low in asymptomatic women. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:339-346, 2016.

Development and validation of prediction models for endometrial cancer in postmenopausal bleeding

OBJECTIVE

To develop and assess the accuracy of risk prediction models to diagnose endometrial cancer in women having postmenopausal bleeding (PMB).

METHODS

A retrospective cohort study of 4383 women in a One-stop PMB clinic from a university teaching hospital in Hong Kong. Clinical risk factors, transvaginal ultrasonic measurement of endometrial thickness (ET) and endometrial histology were obtained from consecutive women between 2002 and 2013. Two models to predict risk of endometrial cancer were developed and assessed, one based on patient characteristics alone and a second incorporated ET with patient characteristics. Endometrial histology was used as the reference standard. The split-sample internal validation and bootstrapping technique were adopted. The optimal threshold for prediction of endometrial cancer by the final models was determined using a receiver-operating characteristics (ROC) curve and Youden Index. The diagnostic gain was compared to a reference strategy of measuring ET only by comparing the AUC using the Delong test.

RESULTS

Out of 4383 women with PMB, 168 (3.8%) were diagnosed with endometrial cancer. ET alone had an area under curve (AUC) of 0.92 (95% confidence intervals [CIs] 0.89-0.94). In the patient characteristics only model, independent predictors of cancer were age at presentation, age at menopause, body mass index, nulliparity and recurrent vaginal bleeding. The AUC and Youdens Index of the patient characteristic only model were respectively 0.73 (95% CI 0.67-0.80) and 0.72 (Sensitivity=66.5%; Specificity=68.9%; +ve LR=2.14; -ve LR=0.49). ET, age at presentation, nulliparity and recurrent vaginal bleeding were independent predictors in the patient characteristics plus ET model. The AUC and Youdens Index of the patient characteristic plus ET model where respectively 0.92 (95% CI 0.88-0.96) and 0.71 (Sensitivity=82.7%; Specificity=88.3%; +ve LR=6.38; -ve LR=0.2). Comparison of AUC indicated that a history alone model was inferior to a model using ET alone (difference=0.19, 95% CI 0.15-0.24; p<0.0001) and History plus ET (difference=0.19, 95% CI 0.16-0.23, p<0.0001) and history plus ET was similar to that of using ET alone (difference=0.001 95% CI -0.015 to 0.0018, p=0.84).

CONCLUSIONS

A risk model using only patient characteristics showed fair diagnostic accuracy. Addition of patient characteristics to ET did not improve the diagnostic accuracy as compared to ET alone in our cohort.