Fluid Hysteroscopy Research Articles

Bridging the Diagnostic Gap between Histopathologic and Hysteroscopic Chronic Endometritis with Deep Learning Models.

Chronic endometritis (CE) is an inflammatory pathologic condition of the uterine mucosa characterized by unusual infiltration of CD138(+) endometrial stromal plasmacytes (ESPCs). CE is often identified in infertile women with unexplained etiology, tubal factors, endometriosis, repeated implantation failure, and recurrent pregnancy loss. Diagnosis of CE has traditionally relied on endometrial biopsy and histopathologic/immunohistochemistrical detection of ESPCs. Endometrial biopsy, however, is a somewhat painful procedure for the subjects and does not allow us to grasp the whole picture of this mucosal tissue. Meanwhile, fluid hysteroscopy has been recently adopted as a less-invasive diagnostic modality for CE. We launched the ARCHIPELAGO (ARChival Hysteroscopic Image-based Prediction for histopathologic chronic Endometritis in infertile women using deep LeArninG mOdel) study to construct the hysteroscopic CE finding-based prediction tools for histopathologic CE. The development of these deep learning-based novel models and computer-aided detection/diagnosis systems potentially benefits infertile women suffering from this elusive disease.

Construction of deep learning-based convolutional neural network model for automatic detection of fluid hysteroscopic endometrial micropolyps in infertile women with chronic endometritis

Objective(s)Chronic endometritis (CE) is a localized mucosal inflammatory disorder associated with female infertility of unknown etiology, endometriosis, tubal factors, repeated implantation failure, and recurrent pregnancy loss, along with atypical uterine bleeding and iron deficiency anemia. Diagnosis of CE has traditionally relied on endometrial biopsy and detection of CD138(+) endometrial stromal plasmacytes. To develop a less invasive diagnostic system for CE, we aimed to construct a deep learning-based convolutional neural network (CNN) model for the automatic detection of endometrial micropolyps (EMiP), a fluid hysteroscopy (F-HSC) finding recognized as tiny protrusive lesions that are closely related to this disease. Study designThis is an in silico study using archival images of F-HSC performed at an infertility center in a private clinic. A total of 244 infertile women undergoing F-HSC on the days 6–12 of the menstrual cycle between April 2019 and December 2021 with histopathologically-confirmed CE with the aid of immunohistochemistry for CD138 were utilized. ResultsThe archival F-HSC images of 208 women (78 with EMiP and 130 without EMiP) who met the inclusion criteria were finally subjected to analysis. Following preprocessing of the images, half a set was input into a CNN architecture for training, whereas the remaining images were utilized as the test set to evaluate the performance of the model, which was compared with that of the experienced gynecologists. The sensitivity, specificity, accuracy, precision, and F1-score of the CNN model-aided diagnosis were 93.6 %, 92.3 %, 92.8 %, 88.0 %, and 0.907, respectively. The area under the receiver operating characteristic curves of the CNN model-aided diagnosis (0.930) was at a similar level (p > .05) to the value of conventional diagnosis by three experienced gynecologists (0.927, 0.948, and 0.906). ConclusionThese findings indicate that our deep learning-based CNN is capable of recognizing EMiP in F-HSC images and holds promise for further development of the computer-aided diagnostic system for CE.

Precision Medicine for Chronic Endometritis: Computer-Aided Diagnosis Using Deep Learning Model

Chronic endometritis (CE) is a localized mucosal infectious and inflammatory disorder marked by infiltration of CD138(+) endometrial stromal plasmacytes (ESPC). CE is drawing interest in the field of reproductive medicine because of its association with female infertility of unknown etiology, endometriosis, repeated implantation failure, recurrent pregnancy loss, and multiple maternal/newborn complications. The diagnosis of CE has long relied on somewhat painful endometrial biopsy and histopathologic examinations combined with immunohistochemistry for CD138 (IHC-CD138). With IHC-CD138 only, CE may be potentially over-diagnosed by misidentification of endometrial epithelial cells, which constitutively express CD138, as ESPCs. Fluid hysteroscopy is emerging as an alternative, less-invasive diagnostic tool that can visualize the whole uterine cavity in real-time and enables the detection of several unique mucosal findings associated with CE. The biases in the hysteroscopic diagnosis of CE; however, are the inter-observer and intra-observer disagreements on the interpretation of the endoscopic findings. Additionally, due to the variances in the study designs and adopted diagnostic criteria, there exists some dissociation in the histopathologic and hysteroscopic diagnosis of CE among researchers. To address these questions, novel dual immunohistochemistry for CD138 and another plasmacyte marker multiple myeloma oncogene 1 are currently being tested. Furthermore, computer-aided diagnosis using a deep learning model is being developed for more accurate detection of ESPCs. These approaches have the potential to contribute to the reduction in human errors and biases, the improvement of the diagnostic performance of CE, and the establishment of unified diagnostic criteria and standardized clinical guidelines for the disease.

Unified diagnostic criteria for chronic endometritis at fluid hysteroscopy: proposal and reliability evaluation through an international randomized-controlled observer study

To develop a consensus on the diagnostic criteria for chronic endometritis (CE) at hysteroscopy (HSC), and to evaluate these proposed criteria in a randomized-controlled observer study. Systematic review of studies evaluating the diagnostic accuracy of HSC in CE diagnosis; Delphi consensus on hysteroscopic diagnostic criteria for CE; randomized-controlled observer study to evaluate the reproducibility of the proposed diagnostic criteria. Not applicable. Experts from different countries were involved in the systematic review and contributed to the Delphi consensus. Physicians from different countries were involved in the observer study. After reaching consensus on the diagnostic criteria, the Delphi poll created a questionnaire including 100 hysteroscopic pictures (50 from women with CE [domain 1] and 50 from women without CE [domain 2]), with a single question per picture (Answer_A: suggestive of CE; answer B: not suggestive of CE). A total of 200 physicians were invited to take part in the observer study. Before completing the questionnaire, physicians were randomized to receive a description of the diagnostic criteria (group A) or no such information (group B). The primary outcome was to compare the questionnaire scores for the two groups of observers. The secondary outcome was to assess the interobserver agreement in the diagnosis of CE in each group. A total of 126 physicians completed the questionnaire (62 in group A and 64 in group B). Observers in group A obtained higher total scores compared with those in group B (P<.001). Specifically, group A showed higher mean score in domain 1 (P<.001), but not in domain 2 (P=.975). A substantial agreement was found among observers in group A (intraclass correlation coefficient [ICC] 0.78), whereas a fair agreement was found among observers in group B (ICC 0.40). This randomized-controlled observer study found a positive impact of our criteria on physicians' ability to recognize CE.

Altered Transcriptional Regulation of Cytokines, Growth Factors, and Apoptotic Proteins in the Endometrium of Infertile Women with Chronic Endometritis

Chronic endometritis (CE) is a poorly investigated and probably underestimated pathology, which may cause abnormal uterine bleeding (AUB), pain, and reproductive failures. Due to undefined symptoms and the normal presence of leukocytes in the endometrial mucosa, diagnosis may be missed. Fluid hysteroscopy is a reliable technique for diagnosing this pathology. Few data exist on the biochemical and paracrine alterations that occur in the endometrium of women diagnosed with CE. The aim of the study was to find molecular modification in endometrium related to CE. Sixteen women with hysteroscopic and histological diagnosis of CE and 10 healthy women as controls were enrolled. We compared the endometrial expression profile of 25 genes encoding proteins involved in the inflammatory response, proliferation, and apoptosis in endometrium during implantation window, using high-throughput real-time RT-PCR. In women with CE, the endometrial expression of some genes was significantly altered. In particular, IGFBP1, BCL2, and BAX were up-regulated, while IL11, CCL4, IGF1, and CASP8 were down-regulated. The altered gene endometrial expression may explain the impaired endometrial receptivity and the finding of endometrial hyperplastic lesions in women affected by CE.

Correspondence between hysteroscopic and histologic findings in women with chronic endometritis

To estimate if findings in women with chronic endometritis (CE) at fluid hysteroscopy correlate with the severity of inflammation at histology and to assess the possibility to score the severity of inflammation by fluid hysteroscopy. Controlled clinical study. University hospital. A total of 211 outpatient women with a hysteroscopic diagnosis of CE and 30 control women without any such signs. All patients underwent endometrial biopsy by means of a 3-mm Novak's curette connected to a 20-ml syringe without any anesthesia. Hysteroscopic records were reviewed and compared with histologic findings by using an arbitrary inflammation score (Grades 0-2, no inflammation to severe infiltration, nodules and glands disruption, respectively). A significant correlation between focal hyperemia and isolated micropolyps with Grade 1 inflammation and between generalized hyperemia, presence of diffuse micropolyps and polypoid endometrium with Grade 2 inflammation was found. Hysteroscopic and histologic grading showed good agreement (kappa index = 0.62). In women affected by CE the severity of histological alterations may be reliably evaluated by fluid hysteroscopy. This information may be clinically useful not only for giving a prognosis and as a basis for interpretation of patients' complaints, but also for monitoring treatment.

Fluid Hysteroscopy with NBI (Narrow Band Imaging): A Preliminary Experience

Fluid Hysteroscopy with NBI (Narrow Band Imaging): A Preliminary Experience

Reliability of diagnostic fluid hysteroscopy in the assessment of cervical invasion by endometrial carcinoma: A comparative study with transvaginal sonography and MRI

Objective This study aimed at comparing the reliability of diagnostic fluid hysteroscopy, transvaginal sonography (TVS), and magnetic resonance imaging (MRI) to assess pre-operatively the presence of cervical involvement by endometrial carcinoma. Methods Cervical involvement was assessed by diagnostic fluid mini-hysteroscopy, TVS and MRI before surgery in 100 patients with histological diagnosis of endometrial carcinoma. Results were compared with pathological examination on surgical specimen. The sensitivity, the specificity, the positive and negative predictive values, the accuracy, the positive and negative likelihood ratios (LR) of the three techniques for recognizing the cervical involvement by the carcinoma were calculated. Results At histology cervical involvement was found in 15 cases. Compared to TVS and MRI, hysteroscopy showed the highest sensitivity (0.53, 0.67 and 0.93, respectively). The specificity of MRI was significantly higher than both hysteroscopy and TVS (0.95, 0.88 and 0.82, respectively). The diagnostic accuracy of hysteroscopy (0.89) and MRI (0.91) was similar and significantly higher than TVS (0.78). The LR for a positive result of MRI was 14.16, that was 2.08 and 4.68 times higher than that of hysteroscopy and TVS, respectively. Conclusions In conclusion, this study demonstrates that in women with endometrial carcinoma the exclusion of cervical canal involvement at hysteroscopy is more reliable than at MRI and TVS while MRI is the most reliable technique for predicting cervical involvement. In the pre-surgical work-up of patients affected by endometrial carcinoma hysteroscopy and MRI are both useful for staging and planning the correct surgical strategy.

Detection of chronic endometritis at fluid hysteroscopy

Study objective Chronic endometritis is a subtle condition that is difficult to detect; however, it may cause abnormal uterine bleeding and infertility. Few data exist about the appearance of chronic endometritis at fluid hysteroscopy and about the value of diagnostic fluid hysteroscopy in the detection of this condition. In our experience, at fluid hysteroscopy chronic endometritis is characterized by consistent association of stromal edema and either focal or diffuse hyperemia; in some cases, this finding is associated with endometrial micropolyps (less than 1 mm in size). This study attempted to describe diagnostic criteria for chronic endometritis at fluid hysteroscopy and assess the diagnostic accuracy of fluid hysteroscopy in the detection of this condition. Design Retrospective Study (Canadian Task Force classification II-2). Setting University hospital. Patients Nine hundred-ten women in whom hysteroscopy was indicated. Interventions Fluid hysteroscopy followed by endometrial biopsy. Measurements and main results Sensitivity, specificity, positive and negative predictive values, and accuracy of fluid hysteroscopy in the detection of chronic endometritis, based on the association of edema; hyperemia; and, if present, micropolyps were calculated. Based on the presence of hyperemia and edema, chronic endometritis was diagnosed in 158 patients (17.4%); in 61 patients (6.7%), micropolyps also were present. Histology confirmed the diagnosis in 101 patients (63.9% of positive cases at hysteroscopy) and was positive in 9 additional cases not detected by hysteroscopy. Chronic endometritis at histology was found in approximately 30% of infertile women and 35% of cases related to abnormal uterine bleeding. The sensitivity, specificity, and positive and negative predictive values of hysteroscopy for chronic endometritis based on detection of only hyperemia and edema were 91.8%, 92.9%, 63.9%, and 98.8%, respectively; the diagnostic accuracy was 92.7 %. The combination of hyperemia, edema, and micropolyps had sensitivity, specificity, and positive and negative predictive values of 55.4%, 99.9%, 98.4%, 94.5%, respectively, with a diagnostic accuracy of 93.4%. Conclusions Fluid hysteroscopy is very reliable in diagnosing no inflammation, while detection of micropolyps is a very reliable sign of inflammation. When performing hysteroscopy for abnormal uterine bleeding or infertility, signs of chronic endometritis should always be sought.

Endometrial micropolyps at fluid hysteroscopy suggest the existence of chronic endometritis

At fluid hysteroscopy the presence of endometrial micropolyps (less than 1 mm of size) is a frequent finding. Although their origin is still unknown, in our experience they are associated with stromal edema, endometrial thickening and periglandular hyperhaemia that suggest the existence of chronic endometritis. This study will aim to describe these lesions and evaluate their inflammatory significance by comparing hysteroscopic and histological findings. 820 women underwent hysteroscopy and endometrial biopsy. Sensitivity, specificity, positive and negative predictive values and accuracy of the micropolyps presence for the diagnosis of chronic endometritis were calculated. Micropolyps were found in 96 cases (11.7% of all hysteroscopies); in 90 (93.7%) of these cases histology confirmed the presence of chronic endometritis. In women without micropolyps, chronic endometritis was significantly less frequent (78 cases, 10.8%) (P < 0.000001). The likelihood of chronic endometritis for women with micropolyps was very high (odds ratio 124.2, confidence interval 50.3-205.4). The sensitivity, specificity, positive and negative predictive values were 54%, 99%, 94% and 89%, respectively; the diagnostic accuracy was 90%. The presence of endometrial micropolyps at fluid hysteroscopy is significantly associated with endometrial inflammation and can be considered a reliable diagnostic sign for this pathology.

Does fluid hysteroscopy increase the stage or worsen the prognosis in patients with endometrial cancer?: A randomized controlled trial

Objective: To determine whether fluid hysteroscopic directed biopsies, in patients with endometrial cancer upstages the tumor and worsens the prognosis. Study design: Between January 1996 and September 2001, a total of 62 consecutive patients with endometrial cancer, treated at our institution, were randomized 3:2 to have or not to have a fluid hysteroscopic biopsy just prior to surgery. A total of 38 patients underwent a hysteroscopy after the induction of anesthesia. All patients had pelvic washings performed, followed by a hysterectomy, bilateral salpingooforectomy and pelvic +/− para-aortic lymph node dissections. Only stages I and II endometrioid type tumors or stage IIIa, secondary to positive pelvic washings, were included in the study. Eight patients in the hysteroscopy group and four patients in the control group were excluded for various reasons. Patients received post-operative radiation therapy depending on the surgical–pathological risk factors. The median follow up was 34 months. Fisher’s Exact Test was performed to compare differences between the hysteroscopic ( n=30) and the control ( n=20) groups. Results: We found three patients (10%) with positive washings in the hysteroscopic group compared to one (5%) among the controls ( P=0.64), with a statistical power of <20%. If the differences would persist, we would need 588 patients in each arm to obtain a power of 80%, and reach definitive conclusions. The Odds Ratio (OR) of performing a hysteroscopy and upstaging the tumor in this study was: 2.1 95% CI (0.20–21.09). Prognostic variables were compared between both groups and no differences were observed. All patients but one (dead due to intercurrent disease), were alive and with no evidence of disease at the completion of the study. Conclusions: Fluid hysteroscopy and directed biopsies may have a small risk of upstaging early endometrial cancers, but does not seem to influence prognosis.

Hysteroscopy does not increase the risk of microscopic extrauterine spread in endometrial carcinoma.

Fluid hysteroscopy has been suspected to cause tumor dissemination in the abdominal cavity in endometrial cancer patients. The aim of our study was to evaluate the incidence of microscopic extrauterine spread according to diagnostic modality (dilatation & curretage, D&C, hysteroscopy, or both) in patients with endometrial carcinoma. A retrospective study was conducted on 147 patients with histologically proven diagnosis of endometrial carcinoma without macroscopic extrauterine disease. Fluid hysteroscopy was performed by using saline solution irrigated at a final flow of 150 ml/min with a intrauterine pressure ranging between 25 and 50 mmHg. Microscopic intraperitoneal disease and positive peritoneal cytology were considered the primary end-points of this analysis. Fifty-two patients (35%) had diagnosis of endometrial cancer made only by D&C, 56 (39%) underwent D&C and then hysteroscopy, and 39 (26%) had only hysteroscopy. Distribution of the patients in this three groups was casual, and clinicopathologic characteristics of the patients in the three groups were similar. Peritoneal cytology was positive in nine patients, 13 had microscopic ovarian metastases, and eight had microscopic involvement of the pelvic peritoneum or of omentum. Neither the presence of positive peritoneal cytology nor the findings of microscopic intraperitoneal dissemination were significantly associated with the diagnostic procedure employed for primary diagnosis (D&C or D&C plus hysteroscopy or hysteroscopy alone). We conclude that fluid hysteroscopy does not increase the risk of microscopic intraperitoneal spread in endometrial cancer patients as compared to D&C.

Hysteroscopy does not increase the risk of microscopic extrauterine spread in endometrial carcinoma

Fluid hysteroscopy has been suspected to cause tumor dissemination in the abdominal cavity in endometrial cancer patients. The aim of our study was to evaluate the incidence of microscopic extrauterine spread according to diagnostic modality (dilatation &amp; curretage, D&amp;C, hysteroscopy, or both) in patients with endometrial carcinoma. A retrospective study was conducted on 147 patients with histologically proven diagnosis of endometrial carcinoma without macroscopic extrauterine disease. Fluid hysteroscopy was performed by using saline solution irrigated at a final flow of 150 ml/min with a intrauterine pressure ranging between 25 and 50 mmHg. Microscopic intraperitoneal disease and positive peritoneal cytology were considered the primary end-points of this analysis. Fifty-two patients (35%) had diagnosis of endometrial cancer made only by D&amp;C, 56 (39%) underwent D&amp;C and then hysteroscopy, and 39 (26%) had only hysteroscopy. Distribution of the patients in this three groups was casual, and clinicopathologic characteristics of the patients in the three groups were similar. Peritoneal cytology was positive in nine patients, 13 had microscopic ovarian metastases, and eight had microscopic involvement of the pelvic peritoneum or of omentum. Neither the presence of positive peritoneal cytology nor the findings of microscopic intraperitoneal dissemination were significantly associated with the diagnostic procedure employed for primary diagnosis (D&amp;C or D&amp;C plus hysteroscopy or hysteroscopy alone). We conclude that fluid hysteroscopy does not increase the risk of microscopic intraperitoneal spread in endometrial cancer patients as compared to D&amp;C.

Peritoneal Washing Cytology on Fluid Hysteroscopy and After Curettage in Women with Endometrial Carcinoma

To assess the influence of fluid hysteroscopy with target biopsy of the endometrium and the influence of added curettage on the results of peritoneal washing cytology (PWC) in endometrial carcinoma. In 42 women at risk of endometrial carcinoma, we performed fluid hysteroscopy with target biopsy of the endometrium and curettage. Evaluation of PWC of the pouch of Douglas was performed three times during the procedure: prior to hysteroscopy, after fluid hysteroscopy with target biopsy and after curettage. On cytologic slides from peritoneal washings in 11 patients with carcinoma of the endometrium, malignant endometrial cells were found after curettage in 72.7%. There was no statistically significant difference in PWC prior to hysteroscopy (two women, 20%) or after hysteroscopy with target biopsy (three women, 30%). There was a statistically significant difference (.05 level) in positive PWC after hysteroscopy with target biopsy (three women, 33.3%) and after curettage (eight women, 88.9%). Slides from carcinoma of the endometrium in PWC do not deteriorate after hysteroscopy with target biopsy of the endometrium, but tumor cells will appear in the pouch of Douglas after curettage.

Are Endometrial Carcinoma Cells Disseminated at Hysteroscopy Functionally Viable?

Objective. The aim of this study was to evaluate the rate of transtubal dissemination of endometrial carcinoma cells by hysteroscopy and the functional viability of disseminated tumor cells by assessing cell adhesion in an in vitro model.Methods. We studied 24 uteri obtained at TAH+BSO in patients with endometrial carcinoma. Further inclusion criteria were negative peritoneal cytology, no involvement of the uterine serosa or extrauterine disease, and endometrial surface involvement >1 cm in diameter. In vitro fluid hysteroscopy was performed with a 5-mm single-flow rigid hysteroscope. A maximum of 150 ml saline was infused at a maximum pressure of 100 mm Hg for a maximum of 3 min. Fluid running off through the tubes was collected. The cell suspension was enriched by a density gradient centrifugation. The isolated cells had a mean viability of 90% as judged by trypan blue exclusion. Viable cells (5 × 104 per 2-cm2 polyvinyl chloride well plate) were cultured with equal parts of Dulbecco's modified Eagle's minimal essential medium and Ham's F-12 for 24 h. The endpoint of the analysis was the adherence of tumor cells to the polyvinyl chloride well plate, which was taken as a proxy for functional cell viability. Cytological evaluation was performed separately by two cytologists blinded to the source and date of the smears.Results. Transtubal fluid dissemination was seen in 20 of 24 (83%) uteri. Tumor cells were found in 17 specimens (71%). In 10 (42%) specimens the disseminated tumor cells were functionally viable.Conclusions. Our model suggests that hysteroscopy can cause dissemination of malignant cells into the abdominal cavity from uteri containing endometrial carcinoma and that these cells can be functionally viable and adhere to a matrix.

Uterine and Fetal Findings at Hysteroscopic Evaluation of Spontaneous Abortions before D&C

Study ObjectiveTo evaluate the diagnostic benefit of fluid hysteroscopy before dilatation and curettage (D&C) in women with missed abortion, with respect to frequency of congenital and acquired uterine anomalies and geographic relationship of uterine anomalies to nidation site. DesignProspective case study (Canadian Task Force classification II–2). SettingObstetric-gynecologic clinic of an academic teaching hospital. PatientsOne hundred five women with one or more recurrent missed abortions. InterventionHysteroscopy before D&C. Inspection of the fetus was attempted in 62 patients. Control hysteroscopy of the nonpregnant uterus was performed in 20 patients. Measurements and Main ResultsThe uterine cavity was visualized in 87 patients (83%). These women had an obstetric history significant for 143 spontaneous abortions in 208 pregnancies. Except for three small, finger-shaped polyps in the tubal ostia, no uterine anomalies were detected. In 20 women control hysteroscopy of the nonpregnant uterus confirmed initial findings. The fetus was successfully visualized in 30 cases (48%). We observed one case of umbilical cord torsion at 12 weeks' gestation. ConclusionAbsence of uterine anomalies in patients with single as well as recurrent spontaneous abortions was unexpected since it contradicts the existing literature. However, all previous data were gathered from hysteroscopies of nonpregnant uteri. Larger comparative studies are required.

Risk of retrograde spill of endometrial cells at hysteroscopy.

Objective: Distension and irrigation of the uterine cavity during fluid hysteroscopy were suspected to cause tumor cell dissemination into the abdominal cavity in patients with endometrial carcinoma. To evaluate the potential risk of spread of endometrial cells through Fallopian tubes at hysteroscopy, and assess the possible spread of malignant cells to peritoneal cavity comparing gas versus fluid distension media.

Impact of hysteroscopy on disease-free survival in clinically stage I endometrial cancer patients

Recent data strongly suggest tumor cell dissemination of endometrial carcinoma cells in the course of fluid hysteroscopy. In patients who had endometrial cancer which was (except for peritoneal cytology) confined to the uterus, the disease-free survival (DFS) of 135 patients who underwent hysteroscopy prior to staging laparotomy was compared with the DFS of 127 patients without hysteroscopy. After a median follow-up of 23 months, 10 patients experienced tumor recurrence. Although there was a trend towards a higher incidence of positive peritoneal cytology at laparotomy in patients who underwent hysteroscopy, this difference did not achieve statistical significance (P = 0.47). For 5 years, the DFS was 92.4% in patients with hysteroscopy and 84.7% in patients without hysteroscopy before laparotomy (log-rank, P = 0.782). Our data therefore suggest a similar short-term DFS in endometrial cancer patients with and without hysteroscopy prior to laparotomy.

Does hysteroscopy facilitate tumor cell dissemination?

In several case reports, distension and irrigation of the uterine cavity during fluid hysteroscopy was suspected to cause tumor cell dissemination into the abdominal cavity in patients with endometrial carcinoma. It was the aim of this study to compare the incidence of positive peritoneal cytology in patients who underwent dilatation and curettage (D & C) with or without previous hysteroscopy. The authors conducted a multicentric, retrospective cohort analysis. One hundred thirteen consecutive patients with endometrial carcinoma treated between 1996 and 1997 were included. Endometrial carcinoma had to be limited to the inner half or less than the inner half of the myometrium (pathologic Stage IA,B). Positive peritoneal cytology was obtained during staging laparotomy. Patients underwent D & C either with or without prior diagnostic fluid hysteroscopy. No selection or randomization was applied to the two groups. Positive peritoneal cytology, defined as malignant or suspicious, was considered the primary statistical endpoint. Peritoneal cytology was suspicious or positive in 10 of 113 patients (9%). The presence of suspicious or positive peritoneal cytology was associated with a history of hysteroscopy (P = 0.04) but not with myometrial invasion (P = 0.57), histologic subtype (P = 1.00) or grade (r = 0.16, P = 0.10), or the time between D & C and staging laparotomy (r = 0.04, P = 0.66). Based on the limited extent of endometrial carcinoma in the current analysis, our data strongly suggest dissemination of endometrial carcinoma cells after fluid hysteroscopy. Determining whether a positive peritoneal cytology affects the prognoses of patients without further evidence of extrauterine disease will require longer follow-up.

Does hysteroscopy facilitate tumor cell dissemination?

BACKGROUND In several case reports, distension and irrigation of the uterine cavity during fluid hysteroscopy was suspected to cause tumor cell dissemination into the abdominal cavity in patients with endometrial carcinoma. It was the aim of this study to compare the incidence of positive peritoneal cytology in patients who underwent dilatation and curettage (D & C) with or without previous hysteroscopy. METHODS The authors conducted a multicentric, retrospective cohort analysis. One hundred thirteen consecutive patients with endometrial carcinoma treated between 1996 and 1997 were included. Endometrial carcinoma had to be limited to the inner half or less than the inner half of the myometrium (pathologic Stage IA,B). Positive peritoneal cytology was obtained during staging laparotomy. Patients underwent D & C either with or without prior diagnostic fluid hysteroscopy. No selection or randomization was applied to the two groups. Positive peritoneal cytology, defined as malignant or suspicious, was considered the primary statistical endpoint. RESULTS Peritoneal cytology was suspicious or positive in 10 of 113 patients (9%). The presence of suspicious or positive peritoneal cytology was associated with a history of hysteroscopy (P = 0.04) but not with myometrial invasion (P = 0.57), histologic subtype (P = 1.00) or grade (r = 0.16, P = 0.10), or the time between D & C and staging laparotomy (r = 0.04, P = 0.66). CONCLUSIONS Based on the limited extent of endometrial carcinoma in the current analysis, our data strongly suggest dissemination of endometrial carcinoma cells after fluid hysteroscopy. Determining whether a positive peritoneal cytology affects the prognoses of patients without further evidence of extrauterine disease will require longer follow-up. Cancer 2000;88:139–43. © 2000 American Cancer Society.