Predictors of malignancy in endometrial polyps: a multi-institutional cohort study

Purpose of investigation: The risk of endometrial cancer in women with endometrial polyps (EPs) has been reported to vary between 0.3% and 4.8%. There is a lack of data about the management of asymptomatic women with incidental diagnosis of EPs. In the present study the authors correlated demographic and clinical characteristics with histopathological features of the EPs hysteroscopically removed. Materials and Methods: An observational multi-institutional cohort study was conducted from February 2010 to December 2012 to identify all the premenopausal and postmenopausal women consecutively undergoing hysteroscopic polypectomy. The data of women were reviewed and clinical features were related to histopathologic results. Results: The patients recruited were 813. The mean age was 52.5 years (range 22-87). The results showed a correlation between older age, high body mass index (BMI) and obesity, postmenopausal state, abnormal uterine bleeding (AUB), hypertension, and risk of malignant EPs. On multivariable analysis, the correlation remained only for age (OR 1.08, 95% CI 1.03 - 1.14) and AUB (OR 3.53, 95% CI 1.87 - 6.65). Conclusion: Older patients in postmenopausal status with AUB, a high BMI, and hypertension are at higher risk for premalignant and malignant polyps. In these patients a surgical approach should be used, consisting in hysteroscopical removing of the polyp.

Endometrial polyps; Body mass index; Hypertension; Endometrial cancer; Hysteroscopic polypectomy.

[1] Litta P., Merlin F., Saccardi C., Pozzan C., Sacco G., Fracas M., et al.: “Role of hysteroscopy with endometrial biopsy to rule out endometrial cancer in postmenopausal women with abnormal uterine bleeding”. Maturitas, 2005, 50, 117.

[2] Rosai J., Ackerman L.V.: “Rosai and Ackerman’s Surgical Pathology”. 9th ed. Rosai J. (ed). St. Louis: Mosby, 2004, 3080.

[3] Costa-Paiva L., Godoy C.E. Jr., Antunes A. Jr., Caseiro J.D., Arthuso M., Pinto-Neto A.M.: “Risk of malignancy in endometrial polyps in premenopausal and postmenopausal women according to clinicopathologic

characteristics”. Menopause, 2011, 18, 1278.

[4] Dreisler E., Stampe Sorensen S., Ibsen P.H., Lose G.: “Prevalence of endometrial polyps and abnormal uterine bleeding in a Danish population aged 20-74years”. Ultrasound Obstet. Gynecol., 2009, 33, 102.

[5] Wethington S.L., Herzog T.J., Burke W.M., Sun X., Lerner J.P., Lewin S.N., et al.: “Risk and predictors of malignancy in women with endometrial polyps”. Ann. Surg. Oncol., 2011, 18, 3819.

[6] Ferrazzi E., Zupi E., Leone F.P., Savelli L., Omodei U., Moscarini M., et al.: “How often are endometrial polyps malignant in asymptomatic postmenopausal women? A multicenter study”. Am. J. Obstet. Gynecol., 2009, 200, 235.

[7] Litta P., Bartolucci C., Saccardi C., Codroma A., Fabris A., Borgato S., et al.: “Atypical endometrial lesions: hysteroscopic resection as an alternative to hysterectomy: European Journal of Gynecology Oncology”. Eur. J. Gynaecol. Oncol., 2013, 34, 51.

[8] Machtinger R., Korach J., Padoa A., Fridman E., Zolti M., Segal J., et al.: “Transvaginal ultrasound and diagnostic hysteroscopy as a predictor of endometrial polyps: risk factors for premalignancy and malignancy”. Int. J. Gynecol. Cancer, 2005, 15, 325.

[9] Antunes A. Jr., Costa-Paiva L., Arthuso M., Costa J.V., Pinto-Neto A.M.: “Endometrial polyps in pre- and postmenopausal women: factors associated with malignancy”. Maturitas, 2007, 57, 415.

[10] Fernández-Parra J., Rodríguez Oliver A., López Criado S., Parrilla Fernández F., Montoya Ventoso F.: “Hysteroscopic evaluation of endometrial polyps”. Int. J. Gynaecol. Obstet., 2006, 95, 144.

[11] Schmidt T., Breidenbach M., Nawroth F., Mallmann P., Beyer I.M., Fleisch M.C., et al.: “Hysteroscopy for asymptomatic postmenopausal women with sonographically thickened endometrium”. Maturitas, 2009, 62, 176.

[12] Ben-Arie A., Goldchmit C., Laviv Y., Levy R., Caspi B., Huszar M., et al.: “The malignant potential of endometrial polyps”. Eur. J. Obstet. Gynecol. Reprod. Biol., 2004, 115, 206.

[13] Litta P., Fabris A.M., Breda E., Bartolucci C., Conte L., Saccardi C., et al.: “Laparoscopic surgical staging of endometrial cancer: does obesity influence feasibility and perioperative outcome?” Eur. J. Gynaecol. Oncol., 2013, 34, 231.

[14] Litta P., Saccardi C., Conte L., Florio P.: “Reverse hysterectomy: another technique for performing a laparoscopic hysterectomy”. J. Minim. Invasive Gynecol., 2013, 20, 631.

[15] Litta P., Cosmi E., Saccardi C., Esposito C., Rui R., Ambrosini G.: “Outpatient operative polypectomy using a 5 mm-hysteroscope without anaesthesia and/or analgesia: advantages and limits”. Eur. J. Obstet. Gynecol. Reprod. Biol., 2008, 139, 210.

[16] Florio P., Filippeschi M., Imperatore A., Mereu L., Franchini M., Calzolari S., et al.: “The practicability and surgeons’ subjective experiences with vaginal danazol before an operative hysteroscopy”. Steroids, 2012, 77, 528.

[17] Colacurci N., De Franciscis P., Mollo A., Litta P., Perino A., Cobellis L., et al.: “Small-diameter hysteroscopy with Versapoint versus resectoscopy with a unipolar knife for the treatment of septate uterus: a prospective randomized study”. J. Minim. Invasive Gynecol., 2007, 14, 622.

[18] Florio P., Puzzutiello R., Filippeschi M., D’Onofrio P., Mereu L., Morelli R., et al.: “Low-dose spinal anesthesia with hyperbaric bupivacaine with intrathecal fentanyl for operative hysteroscopy: a case series study”. J. Minim. Invasive Gynecol., 2012, 19, 107.

[19] Litta P., Merlin F., Pozzan C., Nardelli G.B., Capobianco G., Dessole S., Ambrosini A.: “Transcervical endometrial resection in women with menorrhagia: long-term follow-up”. Eur. J. Obstet. Gynecol. Reprod. Biol., 2006, 125, 99.

[20] Kurman R.J.: “Blaustein’s pathology of the female genital tract”. 5th ed. New York: Springer-Verlag, 2002.

[21] Baiocchi G., Manci N., Pazzaglia M., Giannone L., Burnelli L., Giannone E., et al.: “Malignancy in endometrial polyps: a 12-year experience”. Am. J. Obstet. Gynecol., 2009, 201, 462.

[22] Savelli L, De Iaco P, Santini D, Rosati F, Ghi T, Pignotti E, et al. Histopathologic features and risk factors for benignity, hyperplasia, and cancer in endometrial polyps. Am. J. Obstet. Gynecol., 2003, 188, 927.

[23] Lee S.C., Kaunitz A.M., Sanchez-Ramos L., Rhatigan R.M.: “The oncogenic potential of endometrial polyps: a systematic review and meta-analysis”. Obstet. Gynecol., 2010, 116, 1197.

[24] Bettocchi S., Ceci O., Di Venere R., Pansini M.V., Pellegrino A., Marello F., et al.: “Advanced operative office hysteroscopy without anaesthesia: analysis of 501 cases treated with a 5 Fr. Bipolar electrode”. Hum. Reprod., 2002, 17, 2435.

[25] Wang J.H., Zhao J., Lin J.: “Opportunities and risk factors for premalignant and malignant transformation of endometrial polyps: management strategies”. J. Minim. Invasive Gynecol., 2010, 17, 53.

[26] Giordano G., Gnetti L., Merisio C., Melpignano M.: “Postmenopausal status, hypertension and obesity as risk factors for malignant transformation in endometrial polyps”. Maturitas, 2007, 20, 190.

[27] Ward K.K., Roncancio A.M., Shah N.R., Davis M.A., Saenz C.C., McHale M.T., Plaxe S.C.: “The risk of uterine malignancy is linearly associated with body mass index in a cohort of US women”. Am. J. Obstet. Gynecol., 2013, 209, 579.e1.

[28] Liberis V., Tsikouras P., Christos Z., Ammari A., Dislian V., Koutlaki N., et al.: “The contribution of hysteroscopy to the detection malignancy in symptomatic postmenopausal women”. Minim. Invasive Ther. Allied Technol., 2010, 19, 83.

[29] World Cancer Research Fund/American Institute for Cancer Research: “Food, Nutrition, Physical Activity, and Prevention of Cancer: a Global Perspective”. Washington DC: AIRC, 2007. Available at: http://www.dietandcancerreport.org/cancer_resource_center/downloads/Second_Expert_Report_full.pdf

[30] Crosbie E.J, Zwahlen M., Kitchener H.C., Egger M., Renehan A.G.: “Body mass index, hormone replacement therapy, and endometrial cancer risk: a meta-analysis”. Cancer Epidemiol. Biomarkers Prev., 2010, 19, 3119.

[31] Tinelli R., Litta P., Meir Y., Surico D., Leo L., Fusco A., et al.: “Advantages of Laparoscopy Versus Laparotomy in Extremely Obese Women (BMI>35) with Early-stage Endometrial Cancer: A Multicenter Study”. Anticancer Res., 2014, 34, 2497.

[32] Daniele A., Ferrero A., Maggiorotto F., Perrini G., Volpi E., Sismondi P.: “Suspecting malignancy in endometrial polyps: value of hysteroscopy”. Tumori, 2013, 99, 204.

[33] DeWaay D.J., Syrop C.H., Nygaard I.E., Davis W.A., Van Voorhis B.J.: “Natural history of uterine polyps and leiomyomata”. Obstet. Gynecol., 2002, 100, 3.