Hysteroscopic-view of endometrial atypical hyperplasia. A helpful diagnostic tool in the care and treatment process?

This present study was conducted over a 10-year period to investigate the hysteroscopic-view features of Endometrial Atypical Hyperplasia (EAH) and evaluate the accuracy of hysteroscopy imaging in detecting concurrent Endometrial Carcinoma (EC). A total of 69 patients diagnosed with EAH via hysteroscopy-guided biopsy and subsequently undergoing hysterectomy were eligible for analysis, and the uterine specimen histology was used as a reference for comparison. Of the included patients, EAH was confirmed in 40 women based on the hysterectomy specimens, while EC was identified in 29 cases (42.0% underestimation). Among the 40 patients with EAH, hysteroscopic-view reports of 37 cases (92.5%) indicated benign conditions, mostly diagnosed as polyps or hyperplasia. In the group of 29 women with underestimated EC, hysteroscopic-view agreed with the definitive diagnosis in 20 cases (68.9%), while in 9 patients, non-neoplastic patterns were observed. Overall, hysteroscopic imaging reported a benign endometrial overgrowth in 46 patients, and among them, EAH was identified in 37 cases based on the hysterectomy specimen (80.4%). Hysteroscopic-view demonstrated a sensitivity, specificity, negative predictive value, and positive predictive value of 76.3%, 93.0%, 81.6% and 90.6%, respectively, in predicting EC among patients who underwent hysteroscopic biopsy and received a diagnosis of EAH. However, no specific hysteroscopic features were associated with EAH diagnosis. Overall, despite hysteroscopic-view showing suboptimal sensitivity in detecting a concurrent EC, it can still exclude the presence of underlying EC in approximately 80% of patients when hysteroscopic imaging indicates a non-neoplastic growth.

Atypical endometrial hyperplasia; Endometrial cancer; Endometrial biopsy; Hysteroscopy

[1] Fagioli R, Vitagliano A, Carugno J, Castellano G, De Angelis MC, Di Spiezio Sardo A. Hysteroscopy in postmenopause: from diagnosis to the management of intrauterine pathologies. Climacteric. 2020; 23: 360–368.

[2] Dueholm M, Hjorth IMD, Dahl K, Ørtoft G. Hysteroscopic resectoscope-directed biopsies and outpatient endometrial sampling for assessment of tumor histology in women with endometrial cancer or atypical hyperplasia. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2020; 251: 173–179.

[3] Dueholm M, Hjorth IMD, Secher P, Jørgensen A, Ørtoft G. Structured hysteroscopic evaluation of endometrium in women with postmenopausal bleeding. Journal of Minimally Invasive Gynecology. 2015; 22: 1215–1224.

[4] Ianieri MM, Staniscia T, Pontrelli G, Di Spiezio Sardo A, Manzi FS, Recchi M, et al. A new hysteroscopic risk scoring system for diagnosing endometrial hyperplasia and adenocarcinoma. Journal of Minimally Invasive Gynecology. 2016; 23: 712–718.

[5] Lu KH, Broaddus RR. Endometrial cancer. The New England Journal of Medicine. 2020; 383: 2053–2064.

[6] Doherty MT, Sanni OB, Coleman HG, Cardwell CR, McCluggage WG, Quinn D, et al. Concurrent and future risk of endometrial cancer in women with endometrial hyperplasia: a systematic review and meta-analysis. PLOS ONE. 2020; 15: e0232231.

[7] Nees LK, Heublein S, Steinmacher S, Juhasz-Boss I, Bruker S, Templer CB, et al. Endometrial hyperplasia as a risk factor of endometrial cancer. Archives of Gynecology and Obstetrics. 2022; 306: 407–421.

[8] Allison KH, Reed SD, Voigt LF, Jordan CD, Newton KM, Garcia RL. Diagnosing endometrial hyperplasia. The American Journal of Surgical Pathology. 2008; 32: 691–698.

[9] Kurman RJ, Carcangiu ML, Herrington CS, Young RH. WHO classification of tumours of female reproductive organs, World Health Organization classification of tumours. 4th edn. International Agency for Research on Cancer (IARC): Lyon. 2014.

[10] Bourdel N, Chauvet P, Tognazza E, Pereira B, Botchorishvili R, Canis M. Sampling in atypical endometrial hyperplasia: which method results in the lowest underestimation of endometrial cancer? A systematic review and meta-analysis. Journal of Minimally Invasive Gynecology. 2016; 23: 692–701.

[11] Garuti G, Sagrada PF, Frigoli A, Fornaciari O, Finco A, Mirra M, et al. Hysteroscopic biopsy compared with endometrial curettage to assess the preoperative rate of atypical hyperplasia underestimating endometrial carcinoma. Archives of Gynecology and Obstetrics. 2023; 308: 971–979.

[12] Di Spiezio Sardo A, Saccone G, Carugno J, Pacheco LA, Zizolfi B, Haimovich S, et al. Endometrial biopsy under direct hysteroscopic visualization versus blind endometrial sampling for the diagnosis of endometrial hyperplasia and cancer: systematic review and meta-analysis. Facts, Views & Vision in ObGyn. 2022; 14: 103–110.

[13] Garuti G, Mirra M, Luerti M. Hysteroscopic view in atypical endometrial hyperplasia: a correlation with pathologic findings on hysterectomy specimens. Journal of Minimally Invasive Gynecology. 2006; 13: 325–330.

[14] Lasmar RB, Barrozo PRM, de Oliveira MAP, Coutinho ESF, Dias R. Validation of hysteroscopic view in cases of endometrial hyperplasia and cancer in patients with abnormal uterine bleeding. Journal of Minimally Invasive Gynecology. 2006; 13: 409–412.

[15] Kurosawa H, Ito K, Nikura H, Takano T, Nagase S, Utsunomiya H, et al. Hysteroscopic inspection and total curettage are insufficient for discriminating endometrial cancer from atypical endometrial hyperplasia. The Tohoku Journal of Experimental Medicine. 2012; 228: 365–370.

[16] Pace L, Actis S, Mancarella M, Novara L, Mariani L, Perrini G, et al. 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. Diagnostics. 2022; 12: 3029.

[17] Zhang C, Wang EY, Liu F, Sung CJ, Quddus MR, Ou J, et al. Routine histologic features in complex atypical hyperplasia can predict the presence of endometrial carcinoma: a clinicopathological study of 222 cases. Human Pathology. 2018; 80: 40–46.

[18] Trimble CL, Kauderer J, Zaino R, Silverberg S, Lim PC, Burke JJ, et al. Concurrent endometrial carcinoma in women with a biopsy diagnosis of atypical endometrial hyperplasia. A gynecologic oncology group study. Cancer. 2006; 106: 812–819.

[19] Di Spiezio Sardo A, De Angelis MC, Della Corte L, Carugno J, Zizolfi B, Guadagno E, et al. Should endometrial biopsy under direct hysteroscopic visualization using the grasp technique become the new gold standard for the preoperative evaluation of the patient with endometrial cancer? Gynecologic Oncology. 2020; 158: 347–353.

[20] De Marchi F, Fabris AM, Tommasi L, Nappi L, Saccardi C, Litta P. Accuracy of hysteroscopy made by young residents in detecting endometrial pathologies in postmenopausal women. European Journal of Gynecologic Oncology. 2014; 35: 219–223.