Clinical, Sonographic, and Hysteroscopic Features of Endometrial Carcinoma Diagnosed after Hysterectomy in Patients with a Preoperative Diagnosis of Atypical Hyperplasia: A Single-Center Retrospective Study

BACKGROUND

atypical endometrial hyperplasia (AEH) is a precancerous condition implying a high risk of concurrent endometrial cancer (EC), which might be occult and only diagnosed at postoperative histopathological examination after hysterectomy. Our study aimed to investigate potential differences in preoperative clinical, sonographic, and hysteroscopic characteristics in patients with AEH and postoperative diagnosis of EC.

METHODS

a retrospective single-center study was carried out on a case series of 80 women with AEH undergoing diagnostic workup, including ultrasonography and hysteroscopy, with subsequent hysterectomy. Women with AEH confirmed at the histopathological examination were compared with patients with a postoperative diagnosis of EC.

RESULTS

in our population, EC was diagnosed in 53 women, whereas the preoperative diagnosis of AEH was confirmed in 27 cases. At ultrasonography, women with occult EC showed greater endometrial thickness (20.3 mm vs. 10.3 mm, p 0.001) and size of the endocavitary lesion (maximum diameter 25.2 mm vs. 10.6 mm, p 0.001), and a higher prevalence of irregular endometrial-myometrial junction (40.5% vs. 6.7%, p 0.022) and endouterine vascularization at color Doppler (64.2% vs. 34.6%, p 0.017). At hysteroscopy, patients with occult EC showed a higher prevalence of necrosis (44.2% vs. 4.2%, p 0.001) and atypical vessels (70.6% vs. 33.3%, p 0.003), whereas true AEH mainly presented as a protruding intracavitary lesion (77.8% vs. 50.9%, p 0.029). In EC, subjective assessment by the operator was more frequently indicative of cancer (80.0% vs. 12.5%). No difference was found for clinical variables.

CONCLUSIONS

occult EC in AEH may exhibit some differences in ultrasonographic and hysteroscopic patterns of presentation compared with real AEH, which could prompt a more significant suspect for the possible presence of concurrent EC at preoperative diagnostic workup.

Endometrial polyps: diagnosis and treatment options - a review of literature

INTRODUCTION AND AIM

Endometrial polyps (EPs) are a common gynecologic condition, associated with abnormal uterine bleeding (AUB), infertility, and premalignant and malignant conditions. Technologies for diagnosis and treatment of EPs are constantly evolving. We aim to provide an updated review on diagnosis and management options for patients with EPs.

MATERIAL AND METHODS

We conducted an electronic search in databases including MEDLINE, PubMed, Cochrane Central Register and others. We included 68 publications regarding EPs, their clinical burden, diagnostic modalities, treatment options and new technologies.

RESULTS

Transvaginal ultrasound (TVS) is the common modality for EP detection and color doppler increases its diagnostic accuracy. Dilation and curettage (D&C) should be avoided for diagnosis and treatment of EPs. Hysteroscopy shows high diagnostic value in EPs and allows for both histological diagnosis and effective treatment. Office hysteroscopy and see and treat hysteroscopy without anesthesia is feasible and safe for EP diagnosis and treatment, gaining more trained surgeons globally. Effective and safe technological tools for EP resection include Laser, resectoscopes, morcellators, MyoSure, Truclear and scissors\graspers.

CONCLUSIONS

EPs are safely and effectively diagnosed and treated with the hysteroscopic tools reviewed in this article. More research is needed to define the best treatment modality.

Specific hysteroscopic findings can efficiently distinguish the differences between malignant and benign endometrial polyps

OBJECTIVE

To evaluate differences in hysteroscopic findings between benign endometrial polyps and endometrial cancer.

MATERIALS AND METHODS

From January 2012 to December 2016, we extracted 179 cases with endometrial polyps from 3066 women who underwent hysteroscopy followed by dilatation and curettage or transcervical resection, with 154 and 25 cases of benign and malignant endometrial polyps, respectively. Clinical characteristics, histopathological and hysteroscopic findings of the women were evaluated retrospectively.

RESULTS

The hysteroscopic findings of malignant polyps were hyper-vascular (72%, 18/25), ulcerative (64%, 16/25) and polyps with irregular surfaces (24%, 6/25). In contrast, pedunculate small growths with smooth surfaces were usually seen in the benign endometrial polyps (38.3%, 59/154). Hyper-vascular (OR: 142.6, 95% CI: 25.98-783.4) and polyps with irregular surfaces (OR: 12.02, 95% CI: 1.765-81.83) in hysteroscopic findings were significant strong predictors of endometrial polyps with endometrial cancer. Hysteroscopic findings of ulcerative changes were most strongly associated with a diagnosis of malignant polyps, with sensitivity, specificity, negative (NPV) and positive (PPV) predictive values of 64.0%, 100%, 94.5%, and 100%, respectively.

CONCLUSION

Women with hysteroscopic findings of endometrial polyps with hyper-vascular, ulcerative, and polyps with irregular surfaces had a high likelihood of endometrial cancer. A target biopsy of the polyps with these specific appearances should be performed to exclude malignant lesions.

An overview of the main intrauterine pathologies in the postmenopausal period

Hysteroscopy is the gold standard for evaluating the uterine cavity, diagnosing intrauterine pathology, and operative intervention for some causes of abnormal uterine bleeding. The American College of Obstetricians and Gynecologists concluded that, when the endometrium measures ≤4 mm with transvaginal ultrasonography, the likelihood that bleeding is secondary to endometrial carcinoma is less than 1% (negative predictive value 99%), and endometrial biopsy is not recommended. Endometrial sampling in this clinical scenario will likely result in insufficient tissue for evaluation and it is reasonable to consider initial management for atrophy. A thickened endometrium on transvaginal ultrasonography (>4 mm in a postmenopausal woman with postmenopausal bleeding) warrants additional evaluation with endometrial sampling. A negative tissue biopsy following 'blind' endometrial sampling in women with postmenopausal bleeding is not considered to be an endpoint, and further evaluation of the endometrial cavity with hysteroscopy to exclude focal disease is imperative.

Hysteroscopy in postmenopause: from diagnosis to the management of intrauterine pathologies

With the increase in life expectancy, women now live up to one-third of their life in menopause. Postmenopausal bleeding (PMB) is a common gynecologic complaint encountered by the clinician. Endometrial cancer is present in about 10% of patients with PMB. Nevertheless, many other conditions such as endometrial or cervical polyps, genital atrophy, or non-gynecologic conditions may also be present. Hysteroscopy has replaced blind diagnostic procedures and is now considered the gold-standard technique for the diagnosis and management of intrauterine pathology. Gynecologists in clinical practice should be familiar with the use of hysteroscopy in the diagnosis and treatment of the menopausal patient presenting with gynecologic complaints. The aim of this article is to report the current evidence on the role of hysteroscopy in the evaluation and management of the postmenopausal patient with intrauterine pathology.

Endometrial polyps: Pathogenesis, sequelae and treatment

Endometrial polyps are overgrowths of endometrial glands that typically protrude into the uterine cavity. Endometrial polyps are benign in nature and affect both reproductive age and postmenopausal women. Although endometrial polyps are relatively common and may be accompanied by abnormally heavy bleeding at menstruation. In asymptomatic women, endometrial polyps may regress spontaneously, in symptomatic women endometrial polyps can be treated safely and efficiently with hysteroscopic excision.

The risk of malignancy in uterine polyps: A systematic review and meta-analysis

BACKGROUND

Endometrial polyps are a common condition. The risk of malignancy has often led to an overtreatment with high health care costs and huge psychological distress.

OBJECTIVE

We conducted a systematic review and a meta-analysis in order to estimate the prevalence of premalignant and malignant lesions in women undergoing hysteroscopic polypectomy.

DATA SOURCE

We developed the search using PubMed/MEDLINE and EMBASE databases to identify papers published between 2000- January 2019. The research strategy used on Pubmed was: ("polyps" (MESH) OR "endometrial polyp*") AND ("malignancy" OR "cancer" OR "histopathology" OR "hysteroscopy" OR "ultrasound", OR "sonohysterography"). The same search was modified for EMBASE.

STUDY ELIGIBILITY

We included all observational retrospective and prospective studies and studies were selected for the review if they met following inclusion criteria: pre-operative diagnosis of benign-looking endometrial polyps at ultrasound examination or at hysteroscopy, excision of endometrial polyps via surgical hysteroscopy, histopathological diagnosis of benign polyps, or hyperplasia without atypia, or premalignancy (atypical hyperplasia) or malignancy (endometrial cancer). Moreover, studies were included if number or percentage of subjects with and without malignancy was provided and if they reported data about menopausal and/or bleeding status. We excluded data presented exclusively as abstracts in national and international meetings, or case report or review articles that did not include original data and papers published in other than English language. Our primary outcome was the prevalence of endometrial premalignant or malignant polyps in the total series, among premenopausal and postmenopausal women and among women with or without abnormal bleeding and then in subgroup analysis according to study design, diagnostic method, study region and calendar year of publication.

RESULTS

A total of 51 studies reporting data on 35,345 women were included in this review. The prevalence of malignant polyps was 2.73% (95% CI 2.57-2.91) with very high heterogeneity among studies. The rates were lower for premenopausal women (1.12%) than post-menopausal ones (4.93%) and the difference was statistically significant (chi-square = 397.21. p < .0001). The risk of malignancy was higher among symptomatic (5.14%) than asymptomatic ones (1.89%) (chi-square = 133.13 p < .001). We observed higher rate of malignant polyps in prospective studies. In the meta-analysis selecting 10 prospective studies the random pooled estimate was 5.88 (95% CI: 4.06-7.97) with heterogeneity among studies (heterogeneity chi square = 17.55 P = .025) whereas in retrospective studies the random pooled estimate was 2.94 (95% CI:2.24-3.71) with high heterogeneity among studies (P < .001). This finding can be due to more strict diagnostic criteria in prospective studies.

CONCLUSION

Symptomatic vaginal bleeding and postmenopausal status in women with endometrial polyps increased the risk of malignancy. This finding could be an useful evidence to select patients who need to undergo hysteroscopic resection of endometrial polyps and women to whom, instead, an expectant management can be offer.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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