Potential for intraperitoneal dissemination of endometrial cancer
There is some concern about intraperitoneal dissemination of endometrial carcinoma at the time of hysteroscopy and effect on disease prognosis. Chang and colleagues conducted a large meta-analysis and found that hysteroscopy performed in the presence of type 1 endometrial carcinoma statistically significantly increased the likelihood of positive intraperitoneal cytology.11 In the included studies that reported survival rates (6 of 19), positive cytology did not alter the clinical outcome. The investigators recommended that hysteroscopy not be avoided for this reason, as it helps in the diagnosis of endometrial carcinoma, especially in the early stages of disease.11
In a recent retrospective analysis, Namazov and colleagues included only stage I endometrial carcinoma (to exclude the adverse effect of advanced stage on survival) and evaluated the assumed isolated effect of hysteroscopy on survival.12 They compared women in whom stage I endometrial carcinoma was diagnosed: 355 by hysteroscopy and 969 by a nonhysteroscopy method (D&C or office endometrial biopsy). Tumors were classified and grouped as low grade (endometrioid grade 1-2 and villoglandular) and high grade, consisting of endometrioid grade 3 and type 2 endometrial carcinoma (serous carcinoma, clear cell carcinoma, and carcinosarcoma) (VIDEOS 8 and 9). Positive intraperitoneal cytology at the time of surgery was 2.3% and 2.1% (P = .832), with an average interval from diagnosis to surgery of 34.6 days (range, 7–43 days).
Video 8. Carcinosarcoma
The authors proposed several explanations for the low rate of intraperitoneal cytology with hysteroscopy. One possibility is having lower mean intrauterine pressure below 100 mm Hg for saline uterine distension, although this was not standardized for all surgeons in the study but rather was a custom of the institution. In addition, the length of time between hysteroscopy and surgery may allow the immune-reactive peritoneum to respond to the cellular insult, thus decreasing the biologic burden at the time of surgery. The median follow-up was 52 months (range, 12–120 months), and there were no differences between the hysteroscopy and the nonhysteroscopy groups in the 5-year recurrence-free survival (90.2% vs 88.2%; P = .53), disease-specific survival (93.4% vs 91.7%; P = .5), and overall survival (86.2% vs 80.6%; P = .22). The authors concluded that hysteroscopy does not compromise the survival of patients with early-stage endometrial cancer.12
Video 9. Carcinosarcoma
Retrospective data from Chen and colleagues regarding type 2 endometrial carcinoma indicated a statistically significant increase in positive intraperitoneal cytology for carcinomas evaluated by hysteroscopy versus D&C (30% vs 12%; P = .008).13 Among the patients who died, there was no difference in disease-specific survival (53 months for hysteroscopy and 63.5 months for D&C; P = .34), and there was no difference in overall recurrence rates.13 Compared with type 1 endometrial carcinoma, type 2 endometrial carcinoma behaves more aggressively, with a higher incidence of extrauterine disease and an increased propensity for recurrence and poor outcome even in the early stages of the disease. This makes it difficult to determine the role of hysteroscopy in the prognosis of these carcinomas, especially in this study where most patients were diagnosed at a later stage.
Hysteroscopy and directed biopsy are highly effective for visual and histopathologic diagnosis of atypical endometrial hyperplasia and endometrial carcinoma, and they are recommended in the evaluation of AUB, especially in the postmenopausal woman. When the hysteroscopic view is negative, there is a high correlation with the absence of uterine cavity and endometrial pathology. Hysteroscopic diagnostic accuracy is improved with structured use of visual grading scales, well-defined descriptors of endometrial pathology, and hysteroscopist experience.
Low operating intrauterine pressure may decrease the intraperitoneal spread of carcinoma cells during hysteroscopy, and current evidence suggests that there is no change in type 1 endometrial carcinoma prognosis and overall outcomes. Type 2 endometrial carcinoma is more aggressive and is associated with poor outcomes even in early stages, and the effect on disease progression by intraperitoneal spread of carcinoma cells at hysteroscopy is not yet known. Hysteroscopic evaluation of the uterine cavity and directed biopsy is easily and safely performed in the office and adds significantly to the evaluation and management of endometrial carcinoma.
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Video 1. Endometrial carcinoma and visually directed biopsy
Nodular endometrioid adenocarcinoma grade 1 (type 1 endometrial carcinoma), benign endometrial polyps, and endometrial atrophy in a postmenopausal woman with bleeding. This video demonstrates visually directed biopsy to assure sampling of the most significant lesion.
Video 2. Negative hysteroscopic view
Digital flexible diagnostic hysteroscopy showing a negative hysteroscopic view in a premenopausal woman.
Video 3. Cervical spread of adenocarcinoma and visually directed biopsy
Diffuse endometrioid adenocarcinoma spread to the upper cervical canal near the internal cervical os. Hysteroscopic directed biopsy is performed.
Video 4. Endometrial adenocarcinoma
Fiberoptic flexible diagnostic hysteroscopy demonstrating diffuse endometrioid adenocarcinoma grade 3 with multiple morphologic features: polypoid, nodular, papillary, and glomerular with areas of necrosis.
Video 5. Endometrial polyp and atypical hyperplasia
Large benign endometrial polyp in an asymptomatic postmenopausal woman with enlarged endometrial stripe on pelvic ultrasound. The endometrium is atrophic except for a small whitish area on the anterior wall, which is atypical hyperplasia. This video highlights the need for visually directed biopsy to assure sampling of the most significant lesion.
Video 6. Nodular, polypoid atypical hyperplasia
Fiberoptic flexible diagnostic hysteroscopy showing diffuse nodular and polypoid atypical hyperplasia with abnormal glandular openings in a postmenopausal woman. Hysterectomy was performed secondary to the significant likelihood of concomitant endometrial carcinoma.
Video 7. Visually directed endometrial biopsy
Hysteroscopic-directed biopsy showing the technique of grasping and removing tissue of a benign adenomyosis cyst and proliferative endometrium.
Video 8. Carcinosarcoma
Carcinosarcoma (type 2 endometrial carcinoma) presents as a large intracavitary mass with soft, polypoid-like tissue in a symptomatic postmenopausal woman with bleeding.
Video 9. Carcinosarcoma
Carcinosarcoma (type 2 endometrial carcinoma) presents as a dense mass in a symptomatic postmenopausal woman with bleeding. This video shows the mass is nodular. These cancers typically grow into a spherical mass within the cavity