Hysteroscopic Endometrial Focal Resection followed by Levonorgestrel Intrauterine Device Insertion as a Fertility-Sparing Treatment of Atypical Endometrial Hyperplasia and Early Endometrial Cancer: A Retrospective Study

Giampaolino, Pierluigi; Sardo, Attilio Di Spiezio; Mollo, Antonio; Raffone, Antonio; Travaglino, Antonio; Boccellino, Antonio; Zizolfi, Brunella; Insabato, Luigi; Zullo, Fulvio; Placido, Giuseppe De; Bifulco, Giuseppe

doi:10.1016/j.jmig.2018.07.001

Cited by 111 publications

(128 citation statements)

References 37 publications

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“…This might imply that >10% of precancerous EHs are undertreated, increasing the risk of progression to cancer. The conservative treatment of premalignant EH has shown excellent outcomes, particularly with hysteroscopic resection and/or medicated intrauterine devices . Therefore, a highly sensitive diagnostic method, such as the EIN system, may be more appropriate than the WHO system for the initial identification of women who need to be treated.…”

Section: Discussionmentioning

confidence: 99%

“…The conservative treatment of premalignant EH has shown excellent outcomes, particularly with hysteroscopic resection and/or medicated intrauterine devices. [38][39][40] Therefore, a highly sensitive diagnostic method, such as the EIN system, may be more appropriate than the WHO system for the initial identification of women who need to be treated. On the other hand, the WHO system showed higher specificity than the EIN system in predicting the risk of coexistent cancer.…”

Section: S E N S I T I V I T Y a N D S P E C I F I C I T Ymentioning

confidence: 99%

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Endometrial hyperplasia and the risk of coexistent cancer: WHO versus EIN criteria

et al. 2019

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Endometrial hyperplasia (EH) is classified into benign and precancerous according to two different histomorphological systems: the World Health Organisation (WHO) system (based on the subjective evaluation of cytological atypia) and the endometrial intraepithelial neoplasia (EIN) system (based on a combination of several parameters that are assessable subjectively, or objectively through computerised analysis). The American College of Obstetricians and Gynecologists recommends use of the EIN system. Nonetheless, a higher prognostic value for EIN criteria was demonstrated only with the objective assessment, which is not routinely applicable. The aim of this study was to evaluate which of the subjective classifications of EH (WHO or EIN) has better prognostic value, by assessing the risk of coexistent cancer. Electronic databases were searched for relevant articles from the inception of the databases to July 2018. All studies assessing the presence of cancer on hysterectomy specimens after a preoperative histological diagnosis of EH were included. Odds ratios (ORs), sensitivity and specificity were calculated with 95% confidence intervals (CIs). Sixteen cohort studies and three case–control studies, assessing 2582 EHs, were included. The WHO criteria showed an OR of 11.15 (95% CI 7.65–16.24), a sensitivity of 0.86 (95% CI 0.82–0.90) and a specificity of 0.67 (95% CI 0.64–0.70) for coexistent cancer. The subjective EIN system showed a similar OR (11.85, 95% CI 4.91–28.62; P = 0.90), higher sensitivity (0.98, 95% CI 0.94–0.99), and lower specificity (0.29, 95% CI 0.24–0.34). The WHO system and the subjective EIN system have similar prognostic values. However, the EIN criteria appear to be more sensitive and thus more suitable for selecting women who need to be treated, whereas the WHO criteria, based on cytological atypia, seem to be more specific for lesions at higher risk of cancer. Therefore, integration of the EIN system with cytological atypia should be considered.

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Section: Discussionmentioning

confidence: 99%

Section: S E N S I T I V I T Y a N D S P E C I F I C I T Ymentioning

confidence: 99%

Endometrial hyperplasia and the risk of coexistent cancer: WHO versus EIN criteria

et al. 2019

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“…Progression rates might also vary based on the patient management (i.e., whether or not the patient was treated before hysterectomy; which type of progestin was administered; whether or not hysteroscopic resection was performed) .…”

Section: Discussionmentioning

confidence: 99%

Complexity of glandular architecture should be reconsidered in the classification and management of endometrial hyperplasia

Travaglino

Raffone

Saccone

et al. 2019

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The 2014 World Health Organization (WHO) classification of endometrial hyperplasia (EH) defines premalignant EH based on only cytologic atypia, disregarding architecture complexity. We aimed to assess the impact of architecture complexity on the risk of cancer in non‐atypical EH. A systematic review and meta‐analysis was performed by searching electronic databases form their inception to October 2018. All studies assessing the rates of progression to cancer in non‐atypical EH (simple vs complex) were included. Pooled relative risk (RR) for cancer progression was calculated; a p‐value < 0.05 was considered significant. Eight studies with 1066 women were included. The risk for progression of non‐atypical EH to cancer was significantly higher in complex EH than in simple EH (p < 0.0001), with an RR of 4.90. In conclusion, the complexity of glandular architecture significantly increases the risk of cancer in non‐atypical EH. Complex non‐atypical EH may be regarded as a low‐risk premalignant lesion rather than a benign condition.

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“…Data were also subdivided into subgroups based on: administration route of progestins (oral or intrauterine), due to the recognized superiority of levonorgestrel‐medicated intrauterine device (LNG‐IUD); histological diagnosis (atypical EH/EEC or non‐atypical EH), since the first two are neoplastic lesions and the latter one is a reactive condition …”

Section: Methodsmentioning

confidence: 99%

“…• administration route of progestins (oral or intrauterine), due to the recognized superiority of levonorgestrel-medicated intrauterine device (LNG-IUD) [27][28][29][30] ;…”

Section: Ta B L E 1 Characteristics Of the Included Studiesmentioning

confidence: 99%

Should progesterone and estrogen receptors be assessed for predicting the response to conservative treatment of endometrial hyperplasia and cancer? A systematic review and meta‐analysis

Raffone

Travaglino

Saccone

et al. 2019

Acta Obstet Gynecol Scand

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Introduction Progestins are used as conservative treatment of endometrial hyperplasia (EH) and early endometrial cancer (EEC). We aimed to assess whether immunohistochemical expression of estrogens and progesterone receptors (ER and PR) predicts the treatment response. Material and methods Electronic databases were searched for studies assessing ER and PR expression in EH and EEC treated with progestins. Relative risk for poor response, sensitivity, specificity, diagnostic odds ratio positive and negative likelihood ratios (LR+ and LR−) and area under the curve (AUC) on summary receiver operating characteristic curve were calculated. Subgroup analyses were based on administration route (oral progestin or levonorgestrel‐intrauterine device) and on histological diagnosis (atypical EH/EEC or non‐atypical EH). Only high accuracy (AUC > 0.9; LR+ >10; LR− <0.1) was considered determining for the clinical practice. Results Thirteen studies with 635 patients were included in the systematic review. Studies at high risk of bias were excluded from the meta‐analysis. Negative ER expression did not significantly predict poor response (P = 0.16), with low predictive accuracy (AUC = 0.637). Negative PR significantly predicted poor response (P = 0.01), with moderate accuracy (AUC = .806). In the oral progestin subgroup, neither ER (P = 0.55) nor PR (P = 0.18) had significant predictive value. In the levonorgestrel‐intrauterine device subgroup, both ER (P < 0.0001) and PR (P = 0.02) were significantly predictive of good response, although the accuracy was suboptimal (LR+ 6.02 and 2.48, respectively; LR− 0.59 and 0.55, respectively). The atypical EH/EEC subgroup showed non‐significant results. Data about non‐atypical EH were not extractable. Conclusions ER and PR expressions are significantly predictive of response in EH and EEC treated with a levonorgestrel‐intrauterine device but not with oral progestins. However, their accuracy is insufficient to be determining in the clinical practice.

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Hysteroscopic Endometrial Focal Resection followed by Levonorgestrel Intrauterine Device Insertion as a Fertility-Sparing Treatment of Atypical Endometrial Hyperplasia and Early Endometrial Cancer: A Retrospective Study

Cited by 111 publications

References 37 publications

Endometrial hyperplasia and the risk of coexistent cancer: WHO versus EIN criteria

Endometrial hyperplasia and the risk of coexistent cancer: WHO versus EIN criteria

Complexity of glandular architecture should be reconsidered in the classification and management of endometrial hyperplasia

Should progesterone and estrogen receptors be assessed for predicting the response to conservative treatment of endometrial hyperplasia and cancer? A systematic review and meta‐analysis

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