Is the finding of endometrial hyperplasia or corporal polyp an mandatory indication for biopsy?

Czech version

Authors: P. Vinklerová ¹; Michal Felsinger ¹; S. Frydová ²; P. Ovesná ³; J. Hausnerová ⁴; Vít Weinberger ¹
Authors‘ workplace: Gynekologicko-porodnická klinika FN a LF MU, Brno, přednosta doc. MUDr. V. Weinberger, Ph. D. ¹; Lékařská fakulta Masarykovy univerzity, Brno, rektor prof. MUDr. M. Repko, Ph. D. ²; Institut biostatistiky a analýzy LF MU, Brno, vedoucí prof. RNDr. L. Dušek, Ph. D. ³; Ústav patologie FN a LF MU, Brno, přednosta doc. MUDr. L. Křen, Ph. D. ⁴
Published in: Ceska Gynekol 2020; 85(2): 84-93
Category:

Overview

Objective: The aim of our study was to analyze a group of patients referred for endometrial biopsy. To evaluate the ultrasound finding of hyperplasia/polyp, the symptomatology of patients related to the result of definitive histology, to determine the severity of individual variables in connection with the detection of precancerosis/cancer. Due to the complexity of information identify women who are suitable for conservative approach.

Design: Unicentric retrospective observational study.

Setting: Department of Obstetrics and Gynecology, Masaryk University, University Hospital Brno.

Methods: All patients over 50 years who underwent surgical endometrial biopsy at our department in the period of 2017–2018 (n = 754) were included. We were interested in reasons of indication, the age of patients at the time of the procedure and at the menopause, the presence of risk factors for development precancerosis/cancer (hypertension, diabetes mellitus, using of tamoxifen), number of deliveries and pregnancies, symptomatology, the description of ultrasound scans, the result of histology examination, peroperative and postoperative complications.

Results: Perimenopause – the median of endometrial thickness in both benign and malignant histology was 8 mm (p = 0.448), the median of the largest polyp dimension was 18 mm. All patients with precancerosis/malignancy were symptomatic with irregular/excessive bleeding, no carcinoma was found in polyp. Postmenopause – the median of endometrial thickness in benign histology was 7 mm versus 16 mm in precancerosis/malignancy (p < 0.001), the median of the largest polyp dimension was the same in both histologies (13 mm, p = 0.274). The risk of malignancy was more than threefold in bleeding versus asymptomatic patients with both hyperplasia and polyp (OR 3.39, 3.79). In asymptomatic patients the risk of cancer was similar for selected cut-offs (5, 8 and 12 mm), statistically significant only for 12 mm (OR 3.54), while in symptomatic patients the risk was high for all cut-offs, however with wide confidence intervals, statistically significant for cut-offs of 8 mm (minimum 3.58) and 12 mm (minimum 4.94).

Conclusion: We have shown that symptomatology is a strong risk factor for the presence of precancerosis/malignancy in patients with endometrial hyperplasia or polyp. The thickness of the endometrium or polyp size in asymptomatic patients does not play a major role. Ultrasound alone does not have sufficient accuracy for detection or even screening of endometrial cancer. We recommend a conservative procedure, monitoring changes in the ultrasound scan and symptomatology of the patient over time.

Keywords:

curettage – endometrial cancer – endometrial hyperplasia – hysteroscopy – polyp – postmenopausal bleeding

Sources

1. Alcázar, JL., Bonilla, L., Marucco, MD., et al. Risk of endometrial cancer and endometrial hyperplasia with atypia in asymptomatic postmenopausal women with endometrial thickness ≥ 11 mm: A systematic review and meta-analysis. J Clin Ultrasound, 2018, 46, p. 565–570.

2. Bel, S., Billard, C., Godet, J., et al. Risk of malignancy on suspicion of polyps in menopausal women. Eur J Obstet Gynecol Reprod Biol, 2017, 216, p. 138–142.

3. Cavkaytar, S., Kokanali, MK., Ceran, U., et al. Roles of sonography and hysteroscopy in the detection of premalignant and malignant polyps in women presenting with postmenopausal bleeding and thickened endometrium. Asian Pac J Cancer Prev, 2014, 15, 13, p. 5355–5358.

4. Epstein, E., Fischerova, D., Valentin, L., et al. Ultrasound characteristics of endometrial cancer as defined by International Endometrial Tumor Analysis (IETA) consensus nomenclature: prospective multicenter study. Ultrasound Obstet Gynecol, 2018, 51, 6, p. 818–828.

5. Fernández-Parra, J., Rodríguez Oliver, A., López Criado, S., et al. Hysteroscopic evalutaion of endometrial polyps. Int J Gynaecol Obstet, 2006, 95, 2, p. 144–148.

6. Ferrazzi, E., Zupi, E., Leone, FP., et al. How often are endometrial polyps malignant in asymptomatic postmenopausal women? A multicenter study. Am J Obstet Gynecol, 2009, 200, p. 235.e1–235.e6.

7. Frühauf, F., Dvořák, M., Haaková, L., et al. Ultrazvukový staging karcinomu endometria – doporučená metodika vyšetření. Čes Gynek, 2014, 79, 6, s. 466–476.

8. Gemer, O., Segev, Y., Helpman, L., et al. Is there a survival advantage in diagnosing endometrial cancer in asymptomatic postmenopausal patients? An Israeli Gynecology Oncology Group study. Am J Obstet Gynecol, 2018, 219, p. 181.e1–181e6.

9. Gynecological endokrinology collaboration of Chinese Society of Obstetrics and Gynecology. Diagnosis and treatment of abnormal uterine bleeding. Chin J Obstet Gynecol, 2014, 39, 11, p. 80–86.

10. Jiang, T., Yuan, Q., Zhou, Q., et al. Do endometrial lesions require removal? A retrospective study. BMC Womens Health, 2019, 6, 19, p. 61.

11. Jokubkiene, L., Sladkevicius, P., Valentin, L. Transvaginal ultrasound examination of the endometrium in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol, 2016, 48, p. 390–396.

12. Leone, FPG., Timmerman, D., Bourne, T., et al. Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group. Ultrasound Obstet Gynecol, 2010, 35, p. 103–112.

13. Martiqnetti, JA., Pandya, D., Naqarsheth, N., el al. Detection of endometrial precancer by a targeted gynecologic cancer liquid biopsy. Cold Spring Harb Mol Case Stud, 2018, 4(6).

14. Rižner, TL. Discovery of biomarkers for endometrial cancer: current status and prospects. Expert Rev Mol Diagn, 2016, 16(12), p. 1315–1336.

15. Smith-Bindman, R., Weiss, E., Feldstein, V. How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol, 2004, 24, 5, p. 558–565.

16. Uglietti, A., Buggio, L., Farella, M., et al. The risk of malignancy in uterine polyps: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol, 2019, 237, p. 48–56.

17. Van den Bosch, T., Ameye, L., Van Schoubtoeck, D., et al. Intra-cavitary uterine pathology in women with abdormall uterine bleeding: a prospective study of 1220 women. Facts views Vis Obgyn, 2015, 7, 1, p. 17–24.

18. Wolfman, W. Asymptomatic endometrial Thickening. J Obstet Gynaecol Can, 2018, 40, 5, p. e367–e377.