Preoperative Diagnosis Of Atypical Endometrial Hyperplasia Research Articles

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.

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. 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. 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. 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.

Risk of endometrial cancer in patients with a preoperative diagnosis of atypical endometrial hyperplasia treated with total laparoscopic hysterectomy

Abstract Objective Distinguishing atypical endometrial hyperplasia (AEH) and endometrial cancer (EC) is often difficult, and patients with a preoperative diagnosis of AEH are sometimes diagnosed with EC after hysterectomy. In this study, we assessed the risk factors for EC in patients who underwent total laparoscopic hysterectomy (TLH) with a preoperative diagnosis of AEH. Patients and methods We retrospectively analyzed 20 patients with a preoperative diagnosis of AEH using endometrial cytology, biopsy (fractional and total curettage), and hysteroscopic inspection. Results Four of 20 (20%) patients were diagnosed with EC after TLH, all of whom had endometrioid adenocarcinoma Grade 1 and Stage IA without lymph node metastasis. Four of seven (57%) patients who were highly suspected of having EC by three diagnostic modalities (cytology, fractional curettage, and by hysteroscopy) were diagnosed with EC after TLH, whereas none of the 13 without any suspicious findings in these examinations were diagnosed with EC ( p =0.007 by Fisher's exact test). Hysteroscopic findings were positive (suspicious of EC) in six of 11 patients tested, including all four EC patients. However, either endometrial cytology or fractional curettage alone failed to predict cancer in two EC patients. All four EC patients were also suspected of having EC by total curettage. Ovarian preservation was performed in 12 (60%) patients. Three of the four EC patients received subsequent surgery, including pelvic lymphadenectomy. Conclusion Careful preoperative examinations, including hysteroscopy, might be useful to evaluate the risk of EC. Accordingly, we should be still careful about the possibility of overdiagnosis in patients with AEH.

Supervised clustering of immunohistochemical markers to distinguish atypical and non-atypical endometrial hyperplasia

The risk of endometrial hyperplasia (EH) progressing into endometrioid endometrial cancer ranges from 1% for simple EH without atypia (EHWA) to 46.2% for atypical EH (AEH). Differentiation between both entities is crucial to determine optimal management. As preoperative diagnosis of AEH can be difficult, we aimed to establish clusters of immunohistochemical markers to distinguish EHWA from AEH. We studied 13 immunohistochemical markers (steroid receptors, pro/anti-apoptotic proteins, metalloproteinases (MMP), tissue inhibitor of metalloproteinase (TIMP), CD44 isoforms) known for their role in endometrial pathology. Using supervised clustering, we determined clusters of co-expressed proteins which contributed the most in differentiating EHWA from AEH. From 39 tissue samples (17 EHWA and 22 AEH), we found three clusters of co-expressed proteins: Cluster 1 included two proteins (over-expression of estrogen receptor (ER) and under-expression of progesterone receptor (PR) B in AEH compared to EHWA); Cluster 2: an ER, PR A, MMP-2 and TIMP-1 over-expression and a PR B and TIMP-2 under-expression; Cluster 3: over-expression of ER and MMP-7 and under-expression of PR B and TIMP-2. AEH can be accurately distinguished from EHWA using a supervised clustering of immunohistochemical markers. This promising approach could be useful to improve the preoperative diagnosis of EH.

Supervised clustering of immunohistochemical markers to distinguish atypical endometrial hyperplasia from grade 1 endometrial cancer

ObjectivesDifferentiation between grade-1 endometrial cancer (EC) and atypical endometrial hyperplasia (AEH) is crucial to determine optimal surgical management. However, discrepancies exist between preoperative diagnosis of AEH and final histology. Our aim was to establish clusters of immunohistochemical markers to distinguish AEH from grade-1 EC. MethodsWe studied 13 immunohistochemical markers (steroid receptors, pro/anti apoptotic proteins, metalloproteinases (MMP) and tissue inhibitor of metalloproteinase (TIMP), and CD44 isoforms) known for their role in endometrial pathology. Using supervised clustering, we determined clusters of co-expressed proteins which contributed the most in differentiating grade-1 EC from AEH. ResultsFrom 42 tissue samples (20 ECs and 22 AEHs), we found 3 clusters of co-expressed proteins: Cluster 1 included 3 proteins (over-expression of MMP-9 and under-expression of estrogen receptor (ER) and progesterone receptor (PR) A in grade-1 EC compared to AEH); cluster 2 showed an MMP-9 over-expression and ER under-expression; cluster 3 showed over-expression of MMP-9 and bcl-2 and under-expression of ER, PR A and CD44-v6 variant. These three clusters together predicted grade-1 EC with a misclassification rate of 8%. ConclusionSupervised clustering of immunohistochemical markers in grade-1 EC and AEH tissue identified proteins acting together and resulted in accurate differentiation between these two histological entities.

Hysteroscopic Inspection and Total Curettage Are Insufficient for Discriminating Endometrial Cancer from Atypical Endometrial Hyperplasia

Endometrial cancer (EC) is the most prevalent gynecologic malignancy in Japan. Atypical endometrial hyperplasia (AEH) is viewed as the premalignant lesion of EC, however it is often difficult to distinguish EC from AEH. The rate of concurrent EC in women diagnosed preoperatively with AEH based on endometrial biopsy was reported as 17-52%. Although hysteroscopic inspection and total curettage are considered as useful methods to make diagnosis of endometrial lesions, there is no report using this combined method to discriminate EC from AEH. The purpose of this study was to examine whether hysteroscopic inspection and total curettage improve the prevalence of EC among women diagnosed preoperatively with AEH. We reviewed 22 patients who underwent hysteroscopic inspection and total curettage and were diagnosed with AEH before undergoing hysterectomy between November 2001 and May 2011. The diagnosis made with the hysterectomy specimens revealed AEH in 10 patients (45.5%), endometrial hyperplasia without atypia in 3 (13.6%), and endometrioid adenocarcinoma, the most common type of EC, in 9 (40.9%). Endometrioid adenocarcinoma included 7 patients without myometrial invasion (31.8%) and 2 patients with superficial myometrial invasion (9.1%). There was no hysteroscopic finding that was specific for EC or AEH. In conclusion, about 41% of women who underwent hysterectomy under a diagnosis of AEH were found to have coexisting adenocarcinoma, although the prevalence of EC among those women was similar to that in earlier reports with endometrial biopsy. Accordingly, we must be careful in planning the therapeutic strategy for women with a preoperative diagnosis of AEH.

Significance of Concurrent Endometrial Cancer in Women With a Preoperative Diagnosis of Atypical Endometrial Hyperplasia

ObjectivesOur objectives were (1) to review the rate of concurrent endometrial cancer in patients with a preoperative diagnosis of atypical endometrial hyperplasia (AEH); (2) to determine the proportion of patients with concurrent endometrial cancer who have high-risk disease; and (3) to re-evaluate our surgical management of AEH. MethodsWe performed a retrospective chart review of all patients who had surgery on the basis of a preoperative diagnosis of atypical endometrial hyperplasia between January 2001 and December 2006. Demographic data, the method of preoperative diagnosis, postoperative grade of tumour, and other postoperative findings were recorded. When applicable, this included cancer stage, lymph node status, and presence of lymphovascular space invasion. In postoperative review, patients were considered to be high risk if they had disease beyond the uterus or a combination of other risk factors. ResultsOf 70 patients, 25 (35.7%) were found to have concurrent endometrial cancer. This was higher than the commonly accepted rate of 25% (P = 0.03). Of the 25 patients upgraded, 4 (16%) had high-risk cancer on final pathologic evaluation. ConclusionSimple hysterectomy in women with AEH may result in inadequate surgical management. Simple methods are required to identify patients with a preoperative diagnosis of AEH who may harbour significant cancers.

Prevalence of Underlying Adenocarcinoma in Women with Atypical Endometrial Hyperplasia

There is controversy regarding the prevalence of underlying endometrial adenocarcinoma among women with a diagnosis of atypical endometrial hyperplasia. This study further defines that risk. At our institution atypical endometrial proliferations non-diagnostic for invasive adenocarcinoma are diagnosed as either atypical endometrial hyperplasia (ATHY) or as an "atypical proliferative lesion of the endometrium, suggestive but not diagnostic of atypical endometrial hyperplasia" (APL). Between 1996 and 2003, these diagnoses were made on either endometrial biopsy or endometrial curettings in 60 women who subsequently received a hysterectomy. Endometrial adenocarcinoma was identified in 48% (29/60) of the hysterectomy specimens. Age and sampling method had no significant impact on the prevalence of adenocarcinoma. Adenocarcinoma was no more likely to be subsequently identified when a woman had a preoperative diagnosis of ATHY (24 of 52, 46%) compared to APL (5 of 8, 63%). In some women with a diagnosis of ATHY a comment was made in the report that "carcinoma cannot be ruled out". These cases had a significantly higher prevalence of underlying adenocarcinoma (16 of 25, 64%) compared to cases of ATHY in which such a comment was not made (8 of 27, 30%) (p = 0.025). In conclusion, there is a high prevalence of underlying endometrial adenocarcinoma among women undergoing hysterectomy for any of atypical endometrial proliferation.

Coexisting endometrial cancer in patients with a preoperative diagnosis of atypical endometrial hyperplasia.

To investigate the possibility of coexisting endometrial cancer (EC) in patients with atypical endometrial hyperplasia (AEH). Forty-six consecutive women who underwent hysterectomy for AEH were analyzed. Final histopathological evaluation of hysterectomy specimens revealed EC in 11 patients (23.9%). Preoperative diagnosis of AEH was established by pipelle biopsy in eight patients and curettage was performed in the remaining patients. Of the patients with pipelle biopsy, two had a diagnosis of EC (25%), whereas nine women who underwent curettage, were further diagnosed as having EC (23.7%) (P > 0.05). Four (13.3%) of 30 women who had frozen sections at hysterectomy, were diagnosed with EC. Diagnosis of EC was missed in two patients (50%) at frozen section. In contrast, seven of 16 women (43.7%) who did not have frozen section, had EC. A relatively high incidence of EC is seen in patients with a diagnosis of AEH. Diagnostic results of pipelle biopsy and curettage were comparable. Frozen sections of hysterectomy specimens does not guarantee to exclude the possibility of EC, especially in patients with no myometrial invasion.