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

Abstract

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.

Hysteroscopic-view of endometrial atypical hyperplasia. A helpful diagnostic tool in the care and treatment process?

“…However, they are different from the finding in a study conducted by Kurosawa et al [15], who concluded that no hysteroscopic feature could predict concurrent EC in patients with EAH found on biopsy specimens. Conversely, a controlled series by Pace et al [16], involving 80 women who underwent hysteroscopic biopsy with EAH, showed that hysteroscopicview correctly predicted underlying EC in 80.0% of cases and excluded it in 77.8% of women with confirmed EAH on hysterectomy pathology. These findings support our results and suggest that reviewing hysteroscopic imaging following an EB report of EAH can be valuable in excluding or, to a lesser extent, predicting an underlying EC.…”

“…However, due to the limited imaging criteria for identifying endometrial hyperplasia, hysteroscopic-view can be less accurate in confirming such a diagnosis, with sensitivities ranging from 50% to 75% [4,12]. Till now, only a few controlled trials have been conducted to explore the relationship between hysteroscopic imaging and the diagnosis of EAH [13,[15][16][17]. Thus, the present study is aimed to examine hysteroscopic images of patients with EAH and to determine the accuracy of hysteroscopic-view in predicting concurrent EC following a targeted EB reporting EAH.…”

The Editorial of the Special Issue “Diagnosis of Lower Genital Tract Disease”

“…Other intriguing articles in this Special Issue focus on the use of diagnostic imaging for the diagnosis of genital diseases, particularly in the early stages of cervical cancer [5] and endometrial carcinoma [6].…”

“…In their retrospective study, Pace et al identified several ultrasonographic that, in conjunction with subjective hysteroscopic assessment by experienced clinicians, can suggest the presence of occult endometrial cancer in patients with a preoperative histologic diagnosis of atypical endometrial hyperplasia. These features include endometrial thickness, a larger diameter of the lesion, an interrupted endometrial-myometrial junction, and high vascular density on color Doppler imaging [6].…”