Abstract
BackgroundSurgeons sometimes have difficulty determining which result to favor when preoperative results (MRI + preoperative endometrial biopsy [pre-op EB]) differ from intraoperative frozen section histology (FS) results. Investigation of how FS can complement ordinary preoperative examinations like MRI and pre-op EB in identification of patients at high risk of lymph node metastasis (high-risk patients) could provide clarity on this issue. Therefore, the aim of this study is to assess the utility of pre-op EB, MRI and FS results and determine how to combine these results in identification of high-risk patients.MethodsThe subjects were 172 patients with endometrial cancer. Patients with a histological high-grade tumor (HGT), namely, grade 3 endometrioid cancer, clear cell carcinoma or serous cell carcinoma, or with any type of cancer invading at least half of the uterine myometrium were considered high-risk. Tumors invading at least half of the uterine myometrium were classified as high-stage tumors (HST). We compared (a) detection of HGT using pre-op EB versus FS, (b) detection of HST using MRI versus FS, and (c) identification of high-risk patients using MRI + pre-op EB versus FS. Lastly, we determined to what degree addition of FS results improves identification of high-risk patients by routine MRI + pre-op EB.Results(a) Sensitivity, specificity, and accuracy for detecting HGT were 59.6, 98.4 and 87.8% for pre-op EB versus 55.3, 99.2 and 87.2% for FS (P = 0.44). (b) These figures for detecting HST were 74.4, 83.0 and 80.8% for MRI versus 46.5, 99.2 and 86.0% for FS (P < 0.001). (c) These figures for identifying high-risk patients were 78.3, 85.4 and 82.6% for MRI + pre-op EB versus 55.1, 99.0 and 81.2% for FS (P < 0.001). The high specificity of FS improved the sensitivity of MRI + pre-op EB from 78.3 to 81.2%, but this difference was not statistically significant (P < 0.16).ConclusionFrozen section enables identification of high-risk patients with nearly 100% specificity. This advantage can be used to improve sensitivity for identification of high-risk patients by routine MRI + pre-op EB, although this improvement is not statistically significant.
Highlights
Addition of lymphadenectomy to surgery for endometrial cancer increases the risk of complications such as surgery-related systemic morbidity, lymphedema and lymphocele formation [1]
Current guidelines for the treatment of endometrial cancer suggest that lymphadenectomy can be omitted in low-risk patients because recent randomized trials have shown that lymphadenectomy does not provide survival benefit in these patients [2,3,4]
The characteristics of low- and high-risk patients are summarized in Table 1. (a) The respective sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for detecting high-grade tumor (HGT) were 59.6% (95% confidence interval [CI]: 0.45, 0.72), 98.4%, 93.3, 86.6 and 87.8% for pre-op preoperative endometrial biopsy (EB) versus 55.3%, 99.2%, 96.3, 85.5 and 87.2% for frozen section histology (FS)
Summary
Addition of lymphadenectomy to surgery for endometrial cancer increases the risk of complications such as surgery-related systemic morbidity, lymphedema and lymphocele formation [1]. Histologic type and grade are determined by preoperative endometrial biopsy (pre-op EB), while preoperative magnetic resonance imaging (MRI) can assess the depth of MI as well as the extent of disease, including cervical involvement, peritoneal dissemination, and adnexal tumors [5]. Both tests aid in preoperative stratification of patients into high- and low-risk groups. Surgeons sometimes have difficulty determining which result to favor when preoperative results (MRI + preoperative endometrial biopsy [pre-op EB]) differ from intraoperative frozen section histology (FS) results. The aim of this study is to assess the utility of pre-op EB, MRI and FS results and determine how to combine these results in identification of high-risk patients
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