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The Role of Hysteroscopy in Diagnosing Endometrial Cancer

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The Role of Hysteroscopy in Diagnosing Endometrial Cancer The role of hysteroscopy in diagnosing endometrial cancer Certain hysteroscopic findings correlate with the likelihood of endometrial carcinoma—and the absence of pathology. Here is a breakdown of hysteroscopic morphologic findings and hysteroscopic-directed biopsy techniques. Amy L. Garcia, MD or more than 45 years, gynecologists He demonstrated the advantages of using have used hysteroscopy to diagnose hysteroscopy and directed biopsy in the eval- F endometrial carcinoma and to asso- uation of abnormal uterine bleeding (AUB) to ciate morphologic descriptive terms with obtain a more accurate diagnosis compared visual findings.1 Today, considerably more with dilation and curettage (D&C) alone clinical evidence supports visual pattern rec- (sensitivity, 98% vs 65%, respectively).2 ognition to assess the risk for and presence of Also derived from this work is the clini- IN THIS endometrial carcinoma, improving observer- cal application of the “negative hysteroscopic ARTICLE dependent biopsy of the most suspect lesions view” (NHV). Loffer used the following cri- (VIDEO 1). teria to define the NHV: good visualization Hysteroscopic In this article, I discuss the clinical evo- of the entire uterine cavity, no structural classification lution of hysteroscopic pattern recognition abnormalities of the cavity, and a uniformly of endometrial Ca of endometrial disease and review the visual thin, homogeneous-appearing endometrium findings that correlate with the likelihood of without variations in thickness (TABLE 1). The this page endometrial carcinoma. In addition, I have last criterion can be expected to occur only in provided 9 short videos that show hystero- the early proliferative phase or in postmeno- Negative scopic views of various endometrial patholo- pausal women. hysteroscopic gies in the online version of this article at Use of hysteroscopy therefore can pre- view criteria https://www.mdedge.com/obgyn. dict accurately the absence of intrauterine page 37 and endometrial pathology when visual find- ings are negative and tissue sampling is not Atypical The negative hysteroscopic warranted (FIGURE 1, VIDEO 2). endometrial view defined hyperplasia In 1989, Dr. Frank Loffer confirmed the diag- nostic superiority of visually directed biopsy. Efforts in hysteroscopic page 38 classification of endometrial Dr. Garcia is Medical Director, Garcia carcinoma Sloan Centers and Center for Women’s Lesion morphologic characteristics. Surgery, and Clinical Assistant Sugimoto was among the first to describe Professor, Department of Obstetrics and Gynecology, University of New the hysteroscopic identification of visual Mexico, Albuquerque. She serves on the morphologic features that are most likely OBG MANAGEMENT Board of Editors. to be associated with endometrial carci- 1 The author reports being a consultant to Karl Storz Endoscopy noma. Patients with AUB were evaluated and having a current financial relationship with Minerva Surgical. with hysteroscopy as first-line management 36 OBG Management | March 2020 | Vol. 32 No. 3 mdedge.com/obgyn to describe lesion morphology and confirm TABLE 1 Negative hysteroscopic view (NHV) indicates biopsy with histopathology. Sugimoto clas- likelihood of a normal uterine cavity and normal sified endometrial carcinoma as circum- endometriuma,2,3,6 scribed or exophytic with distinct forms, such Criteria for NHV as polypoid, nodular, papillary, and ulcerated (FIGURE 2). Diffuse or endophytic carcinoma • Good visualization of the entire uterine cavity is defined by an ulcerated type of lesion that • No structural abnormalities of the cavity indicates necrosis; this is most likely to rep- • Uniformly thin, homogeneous-appearing endometrium without variations resent an undifferentiated tumor. Sugimoto in thickness (early proliferative phase or in postmenopausal patients) also described abnormal vascularity that a often is associated with carcinoma.1 Tissue sampling is not recommended with NHV. Endometrial features. Valli and Zupi cre- ated a nomenclature and classification for hysteroscopic endometrial lesions by pro- spectively grading 4 features: thickness, sur- face, vascularization, and color.3 Features were scored based on the degree of abnor- mality and could be considered to be of low or high risk for the presence of carcinoma. High-risk hysteroscopic features included endometrial thickness greater than 10 mm, polymorphous surface, irregular vascular- FIGURE 1 Negative hysteroscope FIGURE 2 Papillary projections ization, and white-grayish color. The sensi- view in a premenopausal woman of adenocarcinoma Image courtesy of Amy Garcia, MD. Image courtesy of Amy Garcia, MD. tivity for accurately diagnosing endometrial lesions was 86.9% for mild lesions and 96% for severe lesions.3 Also, these investigators confirmed the clinical value of the NHV and associated overall risk of precancer or cancer of the endometrium. Amount of endometrial involvement. A few years later, Garuti and colleagues retro- spectively related the hysteroscopic tumor features of known endometrial adenocarci- noma to stage, grade, and overall survival.4 In this system, they focused on classification of FIGURE 3 Adenocarcinoma with tumor morphology as nodular (bulging), pol- spread to the upper cervical canal ypoid (thin pedicles), or papillary (numerous near the internal os Image courtesy of Amy Garcia, MD. dendritic projections), as well as whether the amount of abnormal tissue present was less than or more than half of the endometrium (97%, 33 of 34). Last, when more than half of and if the lesion involved the cervix. the endometrium was involved, advanced Several important findings associated disease beyond stage I was found (9 of 26, 6 of with this system may improve visual diag- whom had poorly differentiated disease).4 nosis. First, hysteroscopic evaluation had a Structured pattern analysis. Recently, 100% negative predictive value for the cervical Dueholm and co-investigators published a spread of disease (FIGURE 3, VIDEO 3). Second, prospective evaluation of women with post- the hysteroscopic morphologic tumor type did menopausal bleeding and an endometrial not relate to surgical stage or pathologic grade. thickness of 5 mm or greater.5 They used a Third, when less than half of the endome- structured system of visual pattern analysis trium was involved, stage I disease was found during hysteroscopy that they termed the mdedge.com/obgyn Vol. 32 No. 3 | March 2020 | OBG Management 37 The role of hysteroscopy in diagnosing endometrial cancer FIGURE 4 Cotton candy endometrium likely representing tissue necrosis Image courtesy of Amy Garcia, MD. FIGURE 5 Hysteroscopic morphologic abnormal vessels of endometrial carcinoma (A) S-shaped; serpiginous. (B) Loop. (C) Irregular diameter. (D) Irregular branching. hysteroscopic cancer (HYCA) scoring system. showed a high negative predictive value of The HYCA scoring system is based on sur- 99.5% for endometrial adenocarcinoma asso- face outline (uneven, polypoid, and papillary ciated with a negative view at hysteroscopy. projections), necrosis (cotton candy endo- Similar to the Dueholm data, Ianieri and col- metrium [FIGURE 4], whitish-grayish areas leagues’ morphologic pattern analysis pre- without vessels on the surface), and vessel dicted cancer with high accuracy. pattern (tortuous S-shaped, loops, irregular Glomerular pattern association. Su and caliber, irregular branching, and irregular colleagues also showed that pattern recogni- distribution [FIGURE 5]). Structured pattern tion could aid in the accurate hysteroscopic analysis predicted cancer with higher accu- diagnosis of endometrial adenocarcinoma.7 racy than subjective evaluation.5 They used the hysteroscopic presence of a Morphologic variables as indicators. glomerular pattern to predict the association In 2016, Ianieri and colleagues published a with endometrial adenocarcinoma. A glo- retrospective study on a risk scoring system merular pattern was described as polypoid for diagnosing endometrial hyperplasia and endometrium with a papillary-like feature, adenocarcinoma via hysteroscopy.6 They cre- containing an abnormal neovascularization ated a statistical risk model for development feature with “intertwined neovascular vessels of the scoring system. A number of morpho- covered by a thin layer of endometrial tissue” logic variables were prognostic indicators (FIGURE 6, page 40). The presence of a glo- of atypical endometrial hyperplasia (AEH) merular pattern indicated grade 2 or grade 3 and adenocarcinoma. These included wide- disease in 25 of 26 women (96%; sensitivity, spread and irregular endometrial thickness, 84.6%, specificity, 81.8%)7 (see video 4). presence of multiple polyps with irregular TABLE 2 summarizes significant mor- aspects, dilated glandular orifices, irregular phologic findings relating to the presences of endometrial color (grey, white, or hyper- endometrial carcinoma. emic), atypical vessels, crumbling of the endometrial neoplasms, and growth of cer- ebroid and arborescent aspects (VIDEO 4). Atypical endometrial The scoring system for endometrial ade- hyperplasia: A difficult nocarcinoma correctly classified 42 of 44 can- diagnosis cers (sensitivity, 95.4%; specificity, 98.2%), The most common type of endometrial can- and AEH had a sensitivity of 63.3% and a cer is endometrioid adenocarcinoma (type 1 6 specificity of 90.4%. These investigators also endometrial carcinoma), and it accounts for FOR OBG MANAGEMENT MARCIA HARTSOCK ILLUSTRATION: 38 OBG Management | March 2020 | Vol. 32 No. 3 mdedge.com/obgyn TABLE
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