Endometrial changes with tamoxifen: comparison between tamoxifen-treated and nontreated asymptomatic, postmenopausal breast cancer patients

The evaluation of laparotomy results in breast cancer patients with gynecological pathologies

AIM

The aim of the study was to evaluate the results of the laparotomies due to gynecological pathologies in breast cancer patients and to assess the distribution of gynecological pathologies and the clinical and laboratory findings contributing to the diagnosis.

METHODS

This study was conducted between years 2002 and 2011 at Hacettepe University Hospital. We obtained information about 86 consecutive breast cancer patients, including age, time of diagnosis and pathology of breast cancer, hormone receptor status, history of endocrine therapy, presenting symptoms, ultrasonography findings, CA 125 levels, endometrial biopsy results, type of gynecological surgery and pathology results. Data were analyzed with the use of SPSS software.

RESULTS

Twenty-one (24.4%) out of 86 patients had endometrial pathology, and 24 (27.9%) had adnexal pathology. Fourteen patients (16.2%) had malignant pathology, and of them, 11 had ovarian cancer 3 had endometrial cancer. There were five abnormal cytological findings: 2 ASCUS, 1 LSIL, 1 ASC-H and 1 adenocarcinoma. The patient with the cytology report of adenocarcinoma had the final diagnosis of endometrial cancer. Of the patients, 67 (77.9%) used tamoxifen, whereas 19 (22.1%) did not. Thirty-three patients (38.4%) with gynecological pathologies were detected incidentally during routine follow-up of breast cancer.

CONCLUSION

This study supports the increase of the gynecological pathology incidence in breast cancer patients and the recommendation of close gynecological follow-up in these patients. Asymptomatic patients might also develop genital cancer. The ultrasonographic appearance of the adnexal masses or endometrial thickness and any abnormal vaginal bleeding or high CA 125 levels are important parameters for evaluating breast cancer patients.

Post-menopausal bleeding - Is transvaginal ultrasound a useful first-line investigation in tamoxifen users?

Objective To evaluate the role of transvaginal ultrasound triage in women with a history of tamoxifen treatment who present with post-menopausal bleeding. Study design A retrospective review was undertaken of patients who presented with symptoms of post-menopausal bleeding and underwent ultrasound triage. Endometrial thickness and ultrasonographic features were then correlated with hysteroscopic and histopathological outcome data. The findings and outcomes for women with a history of tamoxifen use (tamoxifen group) were compared to those who had not taken tamoxifen (non-tamoxifen group). Results A total of 614 women with post-menopausal bleeding underwent transvaginal ultrasound triage, of whom 53 had a history of current or previous tamoxifen treatment. An endometrial thickness of ≥5 mm or the presence of other abnormal features was used to triage women to further investigation by hysteroscopy and biopsy. Endometrial thickness was significantly greater in the tamoxifen group (11 mm vs. 6 mm). Nearly all of the tamoxifen group were triaged to further investigation (98.1%), compared with significantly fewer in the non-tamoxifen group (68.3%) Overall, the incidence of endometrial pathology was also significantly higher in tamoxifen patients (43.4% vs. 31.7%). Conclusion For women presenting with post-menopausal bleeding, the use of transvaginal ultrasound as a triage tool is rarely helpful in evaluating women who have a history as tamoxifen use, as most will require further investigation with hysteroscopy and biopsy. A post-menopausal bleeding protocol that omits transvaginal ultrasound for women with a history of tamoxifen use may be an appropriate and effective pathway for managing these patients.

Treatment of Desmoids and Mesenteric Fibromatosis in Familial Adenomatous Polyposis with Raloxifene

Background

Among the great variety of extracolonic manifestations of familial adenomatous polyposis, the most serious are desmoids and fibromatosis of the abdominal cavity. These may be a danger to the patient and a concern to the clinician. Pharmacological management of this relentless problem is favored by surgical intervention. At present, however, beneficial actions of medical therapy are not separable from undesirable side effects.

Methods

We studied the effects of 120 mg daily of raloxifene, a non-steroidal benzothiophene, on progressive desmoid tumors and mesenteric fibromatosis by evaluation of lesion size and symptoms in 13 patients with familial adenomatous polyposis, selected on the basis of intra-abdominal localization of the lesion, on refractoriness to other medical treatments, and on estrogen receptor-α expression.

Results

The patients had a significant response to raloxifene therapy, with complete remission in 8 cases and partial response in 5 cases, evaluated by regression of symptoms and tumor size. Serum biochemical parameters did not show any significant changes. Side effects were never observed.

Conclusions

Although the number of patients included in the study is limited and in spite of some limitations, the available results support that, in the evaluation of response, daily therapy with raloxifene decreases desmoid tumor and mesenteric fibromatosis size and symptoms and does not cause side effects. These findings offer a novel option in the pharmacological treatment of desmoids, leading to medical therapy of these neoplastic lesions in familial adenomatous polyposis patients.

Tamoxifen use and endometrial lesions: hysteroscopic, histological, and immunohistochemical findings in postmenopausal women with breast cancer

OBJECTIVE

To evaluate immunohistochemical, hysteroscopic, and histological findings in postmenopausal women taking tamoxifen for breast cancer.

METHODS

Forty postmenopausal women taking 20 mg/day tamoxifen for breast cancer underwent hysteroscopy and endometrial biopsy from January 2000 to December 2003. Medical records and paraffin blocks were analyzed retrospectively, and Ki-67, estrogen receptors (ERs), and progesterone receptors were measured using an immunohistochemical technique.

RESULTS

The mean +/- SD age of the women was 59 +/- 14 years at hysteroscopy (95% CI, 54.2-63.7) and 45.1 +/- 7 years at menopause (95% CI, 42.6-47.6). Mean +/- SD duration of tamoxifen therapy was 27.3 +/- 16.5 months (95% CI, 22.0-32.5). Hysteroscopies were performed because of abnormal sonographic findings in 60% of the women and postmenopausal bleeding in 40%. The most common hysteroscopic and histological findings were endometrial polyps (32.5%) and atrophic endometria (22.5%). Immunohistochemistry showed that 85% of the women were progesterone receptor positive, 75% were ER positive, and 50% were Ki-67 positive. Endometrial polyps and polyps associated with atrophic endometrium were ER positive (P = 0.019). Results that were ER negative were more frequent in atrophic endometria (P = 0.01). The longer the time since menopause, the lower the Ki-67 expression in the endometrium was (P = 0.03). Ki-67 expression was greater in the endometrium of younger postmenopausal women (P = 0.01).

CONCLUSIONS

The expression of steroid receptors in the endometrium was high in our series. All cases of endometrial polyps were ER positive. Estrogen receptors may play a major role in the development of endometrial polyps in postmenopausal women taking tamoxifen. Although most histological findings were benign, 22.5% were atrophic.

Long-term endometrial effects in postmenopausal women with early breast cancer participating in the Intergroup Exemestane Study (IES)--a randomised controlled trial of exemestane versus continued tamoxifen after 2-3 years tamoxifen

BACKGROUND

The antiestrogen tamoxifen may have partial estrogen-like effects on the postmenopausal uterus. Aromatase inhibitors (AIs) are increasingly used after initial tamoxifen in the adjuvant treatment of postmenopausal early breast cancer due to their mechanism of action: a potential benefit being a reduction of uterine abnormalities caused by tamoxifen.

PATIENTS AND METHODS

Sonographic uterine effects of the steroidal AI exemestane were studied in 219 women participating in the Intergroup Exemestane Study: a large trial in postmenopausal women with estrogen receptor-positive (or unknown) early breast cancer, disease free after 2-3 years of tamoxifen, randomly assigned to continue tamoxifen or switch to exemestane to complete 5 years adjuvant treatment. The primary end point was the proportion of patients with abnormal (> or =5 mm) endometrial thickness (ET) on transvaginal ultrasound 24 months after randomisation.

RESULTS

The analysis included 183 patients. Two years after randomisation, the proportion of patients with abnormal ET was significantly lower in the exemestane compared with tamoxifen arm (36% versus 62%, respectively; P = 0.004). This difference emerged within 6 months of switching treatment (43.5% versus 65.2%, respectively; P = 0.01) and disappeared within 12 months of treatment completion (30.8% versus 34.7%, respectively; P = 0.67).

CONCLUSION

Switching from tamoxifen to exemestane significantly reverses endometrial thickening associated with continued tamoxifen.

The effect of adjuvant hormonal therapy on the endometrium and ovary of breast cancer patients

OBJECTIVE

To investigate the effect of adjuvant hormonal therapy on the endometrium and ovary of breast cancer patients.

METHODS

A retrospective review was performed on the 207 patients who had taken tamoxifen or anastrozole, as adjuvant hormonal therapy after breast cancer surgery between January 2003 and December 2006. Gynecologic surveillance constituted of ultrasonographic exam of the endometrial thickness and ovarian cyst formation. The patients were classified into three groups and analyzed; premenopausal/postmenopausal women receiving tamoxifen and women receiving anastrozole.

RESULTS

Mean duration of follow up was 20.6+/-6.6 months. There was no difference of mean endometrial thickness before hormonal therapy among the three groups (p=0.327). In women receiving tamoxifen, the endometrium was continuously thickened in proportion to the duration of the therapy irrespective of menopausal status while it remained unchanged in women receiving anastrozole (p<0.05). Endometrial biopsies were performed in 28 patients receiving tamoxifen. The most common histologic finding was proliferative endometrium in premenopausal women (7/21) and atrophic endometrium in postmenopausal women (6/7). There was no case of endometrial cancer in both groups. Ovarian cyst was found in 32 women and the most were developed in premenopausal women receiving tamoxifen (30/32). All of them showed benign nature on transvaginal ultrasonographic findings.

CONCLUSION

Women undergoing adjuvant hormonal therapy after breast cancer surgery exhibited changes in the endometrium and ovary. However most changes were not a serious problem in this study and frequent gynecologic surveillance in these patients needs further investigation.

The effect of tamoxifen on the genital tract

Tamoxifen is a selective estrogen receptor modulator (SERM) that is widely used in the treatment of patients with breast cancer and for chemoprophylaxis in high risk women. Tamoxifen results in a spectrum of abnormalities involving the genital tract, the most significant being an increased incidence of endometrial cancer and uterine sarcoma. This article reviews the effects of tamoxifen on the genital tract and the strengths and weaknesses of various imaging modalities for evaluating the endometrium.

Long-term follow-up of postmenopausal breast cancer patients following discontinuation of tamoxifen therapy

BACKGROUND

There is a need to evaluate the extent of endometrial pathologies that might develop in postmenopausal breast cancer patients following discontinuation of tamoxifen (TAM) therapy.

METHODS

The medical records of 153 postmenopausal breast cancer patients who remained untreated following discontinuation of tamoxifen therapy were evaluated for various clinical features, for endometrial thickness measurements, as detected by transvaginal ultrasonography, and for various endometrial pathologies detected. The last endometrial thickness measurement performed before discontinuation of tamoxifen was compared with endometrial thickness measured following discontinuation of tamoxifen.

RESULTS

Patients were followed for 37.5+/-31.3 months. There was a gradual and significant decrement of endometrial thickness measured at the last ultrasonographic study performed before cessation of tamoxifen, compared to that observed in all four ultrasonographic studies performed following discontinuation of tamoxifen (P=0.001). Endometrial thickness gradually and significantly decreased in correlation with the time intervals of the four ultrasonographic studies performed following discontinuation of tamoxifen (P=0.001). Overall, 40 hysteroscopies were performed in 38 (24.8%) patients. No tissue was obtained in 18 (11.8%) patients. Overall endometrial pathologies were diagnosed in 22 (14.4%) patients. Benign endometrial polyps were the most frequent endometrial pathology recovered: 17 (11.1%) patients. No endometrial malignancy was diagnosed. The rate of endometrial pathologies considerably decreased with the extension of time following discontinuation of tamoxifen therapy.

CONCLUSIONS

Long-term follow-up of postmenopausal breast cancer patients who remained untreated following discontinuation of TAM therapy did not reveal any malignant endometrial pathology. Only few benign endometrial pathologies were diagnosed, which became fewer in time.

Selective estrogen receptor modulators: an update on recent clinical findings

Recent clinical data on selective estrogen receptor modulators (SERMs) have provided the basis for reassessment of the SERM concept. The molecular basis of SERM activity involves binding of the ligand SERM to the estrogen receptor (ER), causing conformational changes which facilitate interactions with coactivator or corepressor proteins, and subsequently initiate or suppress transcription of target genes. SERM activity is intrinsic to each ER ligand, which accomplishes its unique profile by specific interactions in the target cell, leading to tissue selective actions. We discuss the estrogenic and anti-estrogenic effects of early SERMs, such as clomiphene citrate, used for treatment of ovulation induction, and the triphenylethylene, tamoxifen, which has ER antagonist activity in the breast, and is used for prevention and treatment of ER-positive breast cancer. Since the development of tamoxifen, other triphenylethylene SERMs have been studied for breast cancer prevention, including droloxifene, idoxifene, toremifene, and ospemifene. Other SERMs have entered clinical development more recently, including benzothiophenes (raloxifene and arzoxifene), benzopyrans (ormeloxifene, levormeloxifene, and EM-800), lasofoxifene, pipendoxifene, bazedoxifene, HMR-3339, and fulvestrant, an anti-estrogen which is approved for breast cancer treatment. SERMs have effects on tissues containing ER, such as the breast, bone, uterine and genitourinary tissues, and brain, and on markers of cardiovascular risk. Current evidence indicates that each SERM has a unique array of clinical activities. Differences in the patterns of action of SERMs suggest that each clinical end point must be evaluated individually, and conclusions about any particular SERM can only be established through appropriate clinical trials.

Signaling by estrogens and tamoxifen in the human endometrium

Tamoxifen is used as adjuvant treatment for postmenopausal breast cancer patients. The mechanism of action of tamoxifen in breast cancer patients is that tamoxifen inhibits growth of cancer cells by competitive antagonism for estrogens at the estrogen receptor (ER). In the endometrium, tamoxifen has an effect that varies with the ambient concentration of estrogen: in premenopausal women (high estrogen levels), tamoxifen displays an estrogen-antagonistic effect, while in postmenopausal women (low estrogen levels), tamoxifen displays an estrogen-agonistic mode of action. Here, using microarray technology we have compared estrogen signaling with tamoxifen signaling in the human endometrium. It was observed that on the one hand tamoxifen-treatment results in modulation of expression of specific genes (370 genes) and on the other hand tamoxifen-treatment results in modulation of a set of genes which are also regulated by estrogen treatment (142 genes). Upon focusing on regulation of proliferation, we found that tamoxifen-induced endometrial proliferation is largely accomplished by using the same set of genes as are regulated by estradiol. So, as far as regulation of proliferation goes, tamoxifen seems to act as estrogen agonist. Furthermore, tamoxifen-specific gene regulation may explain why tamoxifen-induced endometrial tumors behave more aggressively than sporadic endometrial tumors.

Uterine effects of tamoxifen: a prospective study

The purpose of the study was to evaluate tamoxifen-associated changes in the vagina and uterus in postmenopausal breast cancer patients. Between June 1994 and December 1998, 45 patients enrolled in a prospective study before commencing tamoxifen therapy. Patients with endometrial thickness >5 mm or neoplasia were excluded. Transvaginal ultrasonography, vaginal maturation indexes (VMI), and endometrial biopsy were performed at baseline and repeated at 6 months (n= 42), 1 year (n= 39), 2 years (n= 32), 3 years (n= 26), 4 years (n= 19), and 5 years (n= 15). For the 39 patients followed for 1 year, VMI (% parabasal/intermediate/superficial) was 21/71/8 at baseline compared with 1/90/9 at 1 year (P value = 0.0008/0.001/0.78). At baseline, mean endometrial thickness and uterine volume were 2.6 mm and 64 cm(3), respectively, compared with 5.8 mm and 84 cm(3) at 1 year (P= 0.0002, 0.002). At baseline, 80% of patients had atrophic endometrium and 9% proliferative endometrium compared with 61% and 26% at 1 year, respectively (P= 0.04). No cases of endometrial hyperplasia or adenocarcinoma were detected. Findings observed at 6 months persisted through 5 years of follow-up. Tamoxifen exerts a weak estrogenic effect on the vagina and uterus in highly prescreened postmenopausal women without preexisting endometrial pathology.

Aromatase inhibitors reverse tamoxifen induced endometrial ultrasonographic changes in postmenopausal breast cancer patients

OBJECTIVE

Aromatase inhibitors may decrease endometrial thickness in breast cancer patients previously having short-term tamoxifen treatment. There is a necessity to find out if aromatase inhibitors can also decrease endometrial thickness in patients previously treated with long-term tamoxifen treatment.

METHODS

Prospective comparison of the last ultrasonographic endometrial thickness measurement taken before discontinuation of long-term tamoxifen treatment in 36 postmenopausal breast cancer patients, with further measurements, performed following aromatase inhibitors administration.

RESULTS

There was a significant decrement of endometrial thickness, following 36.2 +/- 16.8 months of tamoxifen treatment, from a mean value of 9.1 +/- 5.8 mm, measured at the last ultrasonographic measurement performed before discontinuation of tamoxifen treatment, down to a mean value of 6.0 +/- 5.0 mm, measured following 5.8 +/- 5.8 months of aromatase inhibitors therapy (P = 0.001). A second ultrasonographic measurement performed in 8 patients following of additional 7.5 +/- 4.0 months of aromatase inhibitors treatment revealed further decrement of mean endometrial thickness to 4.8 +/- 2.1 mm (P = 0.002 compared to baseline). In 28 patients (77.8%), endometrial thickness was reduced following the administration of aromatase inhibitors, in four patients (11.1%) there was no change in endometrial thickness and four (11.1%) patients demonstrated an increase of endometrial thickness.

CONCLUSIONS

Aromatase inhibitors may reverse endometrial thickening induced by long-term tamoxifen treatment in postmenopausal breast cancer patients.

Changes in the sonographic appearance of the uterus after discontinuation of tamoxifen therapy

OBJECTIVE

The purpose of this study was to assess the duration of sonographically detected changes in the endometrium of women with a history of tamoxifen use.

METHODS

Patients with breast cancer who had a history of tamoxifen use and documented pelvic sonographic studies were identified by means of clinic databases in both the Section of Gynecological Oncology and the Section of Obstetrical and Gynecological Ultrasound, University of Chicago, between January 1, 1996, and March 30, 2004. Of the 99 patients who met study criteria, 34 had discontinued tamoxifen use before the sonographic evaluation. Each patient's age, gravity and parity, weight, ethnicity, duration and dose of drug use, interval from drug discontinuation until sonographic evaluation, and uterine pathologic findings were reviewed. Endometrial thickness as assessed by pelvic sonography was examined in relation to duration of tamoxifen use and time from discontinuation of the drug. Statistical analysis was performed with linear regression and mixed effect linear regression models.

RESULTS

Endometrial thickness increased with increasing duration of tamoxifen use at a rate of 0.75 mm/y. The mean endometrial thickness after approximately 5 years of tamoxifen use was 12 mm (range, 6-21 mm). After discontinuation of tamoxifen, endometrial thickness decreased by 1.27 mm/y.

CONCLUSIONS

Endometrial thickness as measured by pelvic ultrasound examination increases with the duration of tamoxifen use. After discontinuation of the drug, the measured thickness decreases but at a very slow rate.

The ATAC (‘Arimidex’, Tamoxifen, Alone or in Combination) adjuvant breast cancer trial: first results of the endometrial sub-protocol following 2 years of treatment

BACKGROUND

Tamoxifen treatment results in a doubling of the risk of endometrial cancer after 1-2 years of treatment and a quadrupling after 5 years. Anastrozole, a third-generation aromatase inhibitor, with superior efficacy to tamoxifen, may also offer tolerability benefits in terms of effects on the endometrium.

METHODS AND RESULTS

A sub-protocol of the ATAC trial compared the incidence/type of intrauterine changes following treatment with these agents in a subgroup of patients (n = 285) from the main trial. After 2 years anastrozole treatment, endometrial thickness remained </= 5 mm (baseline: 3.0 mm); in patients receiving tamoxifen, endometrial thickness increased by 3.2 mm to 7.0 mm, with a similar trend in the combination group. At baseline, 26/285 patients (9.1%) had endometrial abnormalities, most commonly polyps. After 2 years the number of endometrial abnormalities appeared lower with anastrozole treatment compared with tamoxifen although these differences were not statistically significant (odds ratio: 0.44; 95% confidence interval 0.146, 1.314; P = 0.14). Most abnormalities occurred within the first year of treatment (anastrozole: 4/6; tamoxifen: 7/10; combination: 10/16; total: 21/32). Fewer patients in the anastrozole group (1.4%) required medical intervention (tamoxifen 12.5%; combination 13.6%).

CONCLUSIONS

Fewer endometrial abnormalities occurred during 2 years treatment with anastrozole compared with tamoxifen although statistical significance was not reached in this sub-protocol analysis.

Selective oestrogen receptor modulators in desmoid tumours

Selective oestrogen receptor modulators (SERMs) are compounds with a mixed agonist/antagonist activity on oestrogen receptors. An ideal SERM is a compound with an oestrogen antagonist effect on the breast and uterus but oestrogen agonist effect on bone. Beside tamoxifen, a group of well-investigated SERMs is represented by raloxifene, LY-353381 (SERM3), EM-800 and CP-336156. On an empirical basis, tamoxifen has been used to pharmacologically treat desmoid tumours. Recently, raloxifene, a second-generation SERM, has been used in the treatment of familial adenomatous polyposis patients affected by desmoid tumour. The mechanisms through which these molecules affect desmoid tumour growth appear to be due, in part, to the fact that SERMs may act independently of oestrogen receptors. The knowledge of the molecular basis of SERM action will make the development of novel synthetic compounds with engineered tissue selectivity possible.

The value of transvaginal ultrasonography in the prediction of endometrial pathologies in asymptomatic postmenopausal breast cancer tamoxifen-treated patients

OBJECTIVE

There is no established ultrasonographic endometrial cutoff value for the diagnosis of endometrial pathologies in asymptomatic postmenopausal tamoxifen (TAM)-treated patients. We attempted to seek the most accurate cutoff value.

MATERIALS AND METHODS

Multiple ultrasonographic cutoff points were evaluated by logistic regression analysis based on 279 patients who had transvaginal ultrasonographic examinations followed by endometrial histopathological analysis. Performance characteristics were calculated with correlation to the endometrial histological findings. We also calculated how many endometrial pathologies could have been left undiagnosed and the number of endometrial samplings, with different cutoff values, which could have been avoided.

RESULTS

There was a gradual increase in specificity and a gradual decrease in sensitivity of the ultrasonographic studies with the increase of endometrial thickness. More overall and more various endometrial pathologies were identified with the increase in cutoff values. The best cutoff value appeared to be 15 mm (sensitivity 37.9%, specificity 87.2%, positive predictive value 63.0%, and negative predictive value 70.2%). However, by avoiding performance endometrial sampling up to this cutoff value, 62.2% endometrial pathologies including 48 endometrial polyps, one case of endometrial hyperplasia with atypia, and one case of endometrial cancer may have been left undiagnosed. At the same time, endometrial sampling in 78.5% of cases may have been avoided.

CONCLUSION

In asymptomatic postmenopausal breast cancer tamoxifen-treated patients, the use of wider ultrasonographic endometrial cutoff values could be associated not only with the performance of fewer endometrial samplings, but also with a higher possibility of endometrial pathologies, including endometrial cancers, being left undiagnosed.

The value of sonohysterography in the prediction of endometrial pathologies in asymptomatic postmenopausal breast cancer tamoxifen-treated patients

BACKGROUND

The study evaluated the efficacy of sonohysterography in identifying endometrial pathologies in asymptomatic postmenopausal tamoxifen (TAM)-treated patients by evaluating its performance characteristics.

MATERIALS AND METHODS

Multiple assessments of sonohysterography evaluations of intrauterine mass diameter were evaluated by logistic regression analysis based on overall 85 patients (who had transvaginal ultrasonographic endometrial thickness of >/=8 mm) followed by hysteroscopy and endometrial histological findings. Performance characteristics were calculated with correlation to the endometrial histological findings.

RESULTS

The mean endometrial thickness was 14.6 +/- 6.2 mm, and the mean intrauterine mass diameter detected by SIS was 11.6 +/- 10.4 mm. There was a gradual decrease in sensitivity and gradual increase in specificity of the SIS studies with the increase in intrauterine mass diameter. False-negative and false-positive of SIS were 2.4% and 8.2%, respectively. ROC curve analysis of intrauterine mass revealed 5 mm as the best accurate cutoff value for the diagnosis of endometrial pathologies, with a sensitivity of 74.1%, specificity of 93.0%, and positive predictive value of 88.3% and negative predictive value of 84.2%. The risk of endometrial pathology was elevated by 1.37-fold, with any additional millimeter of diameter of the intrauterine mass. The mean diameter of the intrauterine mass gradually increased the greater the severity of the histological findings.

CONCLUSIONS

Sonohysterography improves the accuracy of diagnosis of intrauterine mass in asymptomatic postmenopausal tamoxifen-treated patients. The size of the intrauterine mass correlates with the severity of the endometrial pathology.

Endometrial pathologies associated with postmenopausal tamoxifen treatment

OBJECTIVE

To evaluate various endometrial pathologies described in association with postmenopausal tamoxifen treatment, as well as the clinical aspects of these endometrial pathologies.

METHODS

A search was made in PUB MED for all studies published in English, up to the end of 2003, reporting on endometrial pathologies in association with postmenopausal tamoxifen treatment. Overall 106 studies were available, and all are included in this review. The types of studies included were mostly randomized clinical trials, non-randomized cohort studies, prospective and retrospective case controlled studies.

RESULTS

Endometrial polyps represent the most common endometrial pathology associated with postmenopausal tamoxifen exposure. A high rate of malignancy was reported in these polyps. Endometrial hyperplasia, endometrial polyps, endometrial cancer and malignant mixed mesodermal tumors and sarcoma are more commonly diagnosed in postmenopausal breast cancer tamoxifen-treated patients as compared to non-treated patients. Long-term tamoxifen users are more likely to succumb to endometrial cancer and endometrial sarcomas than non-users, due to the unfavorable histology of the endometrial malignancy, and an advanced stage of diagnosis.

CONCLUSIONS

The clinician should be alerted to these pathologies, which, in some cases, may potentially increase the mortality of these patients. Consequently, it is suggested that their supervision is of importance, especially if the patients experience any gynecological symptoms, including pelvic pain or pressure.

The effects of tamoxifen on the female genital tract

Tamoxifen is an effective and relatively non-toxic compound used in palliative and adjuvant treatment of breast cancer. More recently its preventive role in breast cancer has also been demonstrated. However, tamoxifen use is related to some increase in the risk of endometrial cancer and to a significant rise in the incidence of benign endometrial pathologies. The activity of tamoxifen against breast cancer is mainly achieved by blocking the oestrogen receptor, whereas the effect of this compound on the female genital tract is mostly related to its agonistic properties. Despite numerous studies no effective methods of tamoxifen-user surveillance have been developed and currently no active screening for endometrial cancer, apart from yearly gynaecological examination, is recommended in these patients. In other parts of the genital tract, tamoxifen increases the risk of some benign conditions and may cause difficulties in the interpretation of cervical smears. Further studies are warranted to develop more effective surveillance and methods decreasing the detrimental effects of tamoxifen on the female genital tract.

Recurrent endometrial polyps in postmenopausal breast cancer patients on tamoxifen

OBJECTIVES

Endometrial polyps are the most common endometrial pathology described in association with postmenopausal tamoxifen exposure, with an incidence of up to 10.7% of malignancy. Some women tend to develop recurrent polyps. However, no one has yet described any risk factors for the development of recurrent endometrial polyps in postmenopausal breast cancer tamoxifen-treated patients.

METHODS

We compared various clinical features of 64 postmenopausal breast cancer tamoxifen-treated patients with a primary endometrial polyp (Group I), with those of 27 similar patients with recurrent polyps (Group 2).

RESULTS

Previous exposure to hormone replacement therapy was significantly more common and duration of tamoxifen treatment, up to the diagnosis of primary endometrial polyp, was significantly shorter in Group II patients (P = 0.0217 and P = 0.0148, respectively). Logistic regression analysis revealed that the combination of shorter tamoxifen exposure before the diagnosis of primary polyp, lower parity, lower menopausal age at the diagnosis of primary polyp, and higher years of tamoxifen treatment was found to increase significantly the risk of developing recurrent endometrial polyps. Any additional year of tamoxifen treatment may increase by fivefold the risk of developing recurrent polyps. There was no significant difference in ultrasonographic endometrial thickness measured before resection of the primary polyps in both groups and before the resection of recurrent polyps in Group II.

CONCLUSIONS

Previous use of HRT, shorter duration of tamoxifen exposure, and additional years of tamoxifen treatment may significantly increase the risk of developing recurrent endometrial polyps in postmenopausal breast cancer tamoxifen-treated patients.

Optimal therapy and management of endometrial cancer

Carcinoma of the endometrium is the most common malignancy of the female genital tract. Fortunately, this neoplasm presents with abnormal clinical symptoms in its early stages. The majority of cases will be detected at a curable stage when the neoplasm is still confined to the uterus. Given this fact, surgical removal of the involved organ remains the cornerstone of treatment for this disease. Certain pathologic risk factors for recurrence have been identified and are the basis for which adjuvant therapy is recommended. Controversy in management exists as to the approach and extent of primary surgery as well as the indications for adjuvant therapy. Management of this disease is reviewed.

Significance of secondary ultrasonographic endometrial thickening in postmenopausal tamoxifen-treated women

BACKGROUND

Ultrasonography has a limited value in endometrial assessment for identification of endometrial pathologies in postmenopausal tamoxifen-treated patients.

METHODS

We compared the rate of endometrial pathologies and the mean +/- SD of endometrial thickness diagnosed after the first and second transvaginal ultrasonographic studies performed on 55 postmenopausal tamoxifen-treated patients with secondary endometrial thickening (Group I). This rate was also compared with 46 similar patients without secondary thickening (Group II). We also compared the mean +/- SD of endometrial thickness detected in various ultrasonographic studies, as well as various clinical features.

RESULTS

A significantly higher rate of endometrial pathologies, including two cases of endometrial cancer identified in gynecologically asymptomatic patients (3.6%), was diagnosed in Group I after the second study compared with the first study (52.7% and 9.1%, respectively; P = 0.001) and compared with those diagnosed after the second study in Group II (30.4%; P = 0.03). There was a significant increase (74.7 +/- 115%) in endometrial thickness after the second study compared with the first study performed on Group I (10.7 +/- 5.53 mm and 16.59 +/- 5.53 mm, respectively; P = 0.0001) and a significant difference in endometrial thickness demonstrated in the second study performed on Groups I and II (16.59 +/- 5.53 mm and 11.4 +/- 3.91 mm, respectively; P = 0.001). There were no significant differences in the time elapsed since the diagnosis of breast carcinoma and from the beginning of tamoxifen treatment to the performance of the first ultrasonographic study as well as the time elapsed between the first and second studies performed.

CONCLUSIONS

A significant increase (> 50%) in secondary endometrial thickening, measured ultrasonographically, in postmenopausal tamoxifen-treated patients, is associated with a high rate of endometrial pathologies, including endometrial cancer.

Postmenopausal bleeding: value of imaging

Endovaginal sonography in combination with HSG is an effective screening tool in evaluating patients with postmenopausal bleeding. Endovaginal sonography is highly sensitive for detecting endometrial carcinoma and can identify patients at low risk for endometrial disease obviating the need for endometrial sampling in this subgroup of patients. In patients with abnormal findings at sonography, a detailed morphologic analysis can be used to determine which patients can undergo blind endometrial sampling successfully versus those who would benefit from hysteroscopic guidance. In patients in whom endovaginal sonography and HSG are inadequate, MRI may provide additional information on the appearance of the endometrium, particularly in patients in whom endometrial sampling is difficult (eg, patients with cervical stenosis).

Tamoxifen-induced endometrial changes in postmenopausal women with breast carcinoma

OBJECTIVES

To assess the effects of tamoxifen (TAM) on the endometrium in postmenopausal women.

METHODS

A case control study of postmenopausal women with breast carcinoma, who were undergoing treatment in the Department of Radiotherapy and Surgery at the Christian Medical College Hospital, Vellore, India was done. Thirty-five women who were on tamoxifen (20 mg/day) for a period of at least 6 months formed the study group. Thirty-three women who were not receiving tamoxifen, formed the control group. Subjects in both groups had a pelvic examination and transvaginal sonogram followed by endometrial biopsy.

RESULTS

There was a statistically significant difference in the mean endometrial thickness between the study group and control group (7.8+/-6.4 mm vs. 4.0+/-2.0 mm, respectively) More women in the tamoxifen group had an endometrial thickness of >5 mm but the number of women with polyps or hyperplasia of the endometrium did not differ significantly between the two groups. There were no women with endometrial carcinoma in either group.

CONCLUSION

All patients on tamoxifen need to be evaluated by clinical examination annually. A transvaginal sonogram and endometrial biopsy/hysteroscopy may be performed on patients with abnormal vaginal bleeding, bloody discharge, staining or spotting.

Endometrial disorders in 406 breast cancer patients on tamoxifen: the case for less intensive monitoring

OBJECTIVES

To describe the endometrial appearance in postmenopausal breast cancer patients on tamoxifen and to assess a routine surveillance scheme for endometrial lesions.

STUDY DESIGN

Three hundred and seventeen postmenopausal breast cancer women already on tamoxifen at the start of the study (group I) and 89 breast cancer women assessed before any tamoxifen intake (group II) underwent an initial and then yearly scans with transvaginal ultrasonography, followed by an hysteroscopy and biopsy for women with an endometrium thickened above 8mm. Endometrial thickness was also measured in 823 women with no breast cancer nor tamoxifen intake (group III).

RESULTS

Initial mean endometrial thickness was 8.2mm in group I, 4.4mm in group II and 3.4mm in group III (P<0.001). Eighteen percent endometrial lesions were found in group I and 3.3% in group II. We observed a significant association between endometrial pathology and both cumulated dose and total duration. Polyps were the most frequent and first to appear pathology. Five cancers were detected in group I, and all of them had taken tamoxifen for more than 3 years.

CONCLUSION

Our surveillance scheme could be lightened; an acceptable screening scheme might include a baseline assessment before the start of tamoxifen and, if normal, yearly screening after 3 years of tamoxifen therapy, yearly surveillance for women with an abnormal baseline assessment and immediate investigation for symptomatic women.

Proliferation profile of endometrial polyps in post-menopausal women

OBJECTIVE

To determine whether or not the presence of c-erbB2 over-expression in endometrial polyps affects the percentage of cells positive for Ki-67 proliferation marker.

METHODS

Thirty-five patients with endometrial polyps were submitted to polypectomy by hysteroscopy. Ki-67 and c-erbB2 over-expression were investigated in the polyps by immunohistochemistry.

RESULTS

The presence of c-erbB2 over-expression by immunohistochemistry was observed in 80% of endometrial polyps and was associated with higher proliferation rates as determined by the number of positive Ki-67 cell nuclei. In c-erbB2-negative polyps, the proliferation rates were low.

CONCLUSION

Ki-67 and c-erbB2 over-expression are frequent in endometrial polyps in post-menopausal women.

Risk factors of endometrial polyps resected from postmenopausal patients with breast carcinoma treated with tamoxifen

BACKGROUND

Endometrial polyps are the most common endometrial pathology described in association with postmenopausal tamoxifen exposure. Up to 3% of these polyps may show malignant changes. However, to the authors' knowledge no one has described any risk factor for the development of this pathology in postmenopausal patients with breast carcinoma treated with tamoxifen. OBJECTIVE. The objective of this study was to evaluate whether risk factors can be identified for the development of endometrial polyps in postmenopausal patients with breast carcinoma treated with tamoxifen.

METHODS

The authors reviewed the medical records of 54 postmenopausal patients with breast carcinoma in whom endometrial polyps were resected by hysteroscopy after at least 6 months of tamoxifen treatment (Group I). Demographic characteristics, health habits, risk factors for endometrial carcinoma, and clinical factors related to the primary breast disease were examined. The results were compared with those obtained from 210 similar patients in whom hysteroscopy did not reveal any endometrial pathology (Group II).

RESULTS

Age at menopause was significantly older, duration of breast disease was significantly longer, and body weight was significantly heavier among Group I patients compared with Group II patients (P = 0.0162, P = 0.0026, and P = 0.0364, respectively). Endometrial thickness, measured by transvaginal ultrasonography, was significantly thicker in Group I patients (16.3 +/- 7.2 mm) compared with that detected in Group II patients (11.8 +/- 6.3; P = 0.0001).

CONCLUSIONS

Various factors, such as older age at menopause, longer duration of breast disease, heavier weight, and thicker endometrium may contribute to the prediction of increased risk of development of endometrial polyps in postmenopausal patients with breast carcinoma treated with tamoxifen.

Endometrial evaluation with transvaginal US and hysterosonography in asymptomatic postmenopausal women with breast cancer receiving tamoxifen

PURPOSE

To determine performance characteristics of transvaginal ultrasonography (US) and hysterosonography for diagnosing endometrial abnormality in asymptomatic postmenopausal women with breast cancer receiving tamoxifen.

MATERIALS AND METHODS

The authors prospectively examined 138 women receiving tamoxifen by using transvaginal US, hysterosonography, and office hysteroscopy. The combined hysteroscopic-histopathologic diagnosis was the reference standard. Sensitivity, specificity, positive and negative predictive values, and likelihood ratios of transvaginal US and hysterosonography were calculated.

RESULTS

All 138 women underwent transvaginal US; 104, successful hysterosonography; and 117, successful hysteroscopy. Uterine abnormality was present in 47 (40.2%) of 117 women: 45 with polyps and two with submucosal fibroids. Receiver operating characteristic curve analysis revealed 6 mm to be the optimal endometrial thickness cutoff for diagnosing endometrial abnormalities. When a thickness greater than 6 mm or a focal endometrial finding was considered abnormal, transvaginal US had a sensitivity of 85.1% and a specificity of 55.7%. In 92 women who completed transvaginal US, hysterosonography, and hysteroscopy, hysterosonography was more specific (79.2%; P =.008) but not significantly more sensitive (89.7%; P =.508) than transvaginal US. When women with abnormal transvaginal US findings were further examined with hysterosonography, the sequential combination of transvaginal US and hysterosonography was more specific (77.1%) than transvaginal US alone (P <.001), without a significant decrease in sensitivity (78.7%; P =.25).

CONCLUSION

In asymptomatic postmenopausal women receiving tamoxifen, 6 mm is the optimal endometrial thickness cutoff for diagnosing endometrial abnormalities with transvaginal US. Further examination with hysterosonography can improve specificity by reducing the high false-positive rate of transvaginal US.

Sonohysterography for evaluation of the endometrium in women treated with tamoxifen

OBJECTIVE

This study was performed to evaluate sonohysterography for the diagnosis of endometrial abnormalities in women treated with tamoxifen.

MATERIALS AND METHODS

Fifty sonohysterograms were obtained in 48 consecutive tamoxifen-treated women. All women were postmenopausal and had been undergoing tamoxifen therapy for a mean of 2.6 years. Forty-six sonohysterograms (92%) were completed and four were unsuccessful. Sonohysterogram findings were correlated with prior endometrial biopsy results for 23 sonohysterograms (46%) that were preceded by endometrial biopsy. Sonohysterogram findings were also compared with histopathology results, available for 38 sonohysterograms (76%) that were followed by hysteroscopy with dilatation and curettage.

RESULTS

Sonohysterography revealed 31 endometrial polyps (62%), six thickened endometria (12%), five normal endometria (10%), and four subendometrial cysts (8%). Surgery was avoided when seven sonohysterograms (14%) revealed normal endometria or subendometrial cysts. In the group with histopathologic correlation, 23 of 28 polyps were confirmed and two of five thickened endometria were shown to represent endometrial hyperplasia. Twelve (63%) of 19 sonohysterograms with prior normal endometrial biopsy findings had abnormalities on sonohysterography, including 10 polyps and two thickened endometria.

CONCLUSION

Sonohysterography aids the diagnosis of endometrial abnormalities in tamoxifen-treated women even if prior endometrial biopsies have negative findings. In 14% of cases, visualization of a normal endometrium on sonohysterography obviated surgery.

Indication for histological examination of endometrium in breast carcinoma patients receiving tamoxifen therapy

OBJECTIVE

To investigate the effects of tamoxifen on the uterine endometrium and define the indications for histological examination of endometrium on the thickness of uterine endometrium and on the duration of tamoxifen therapy.

METHODS

The endometrial thickness was measured on the transvaginal ultrasonogram in 40 postmenopausal breast carcinoma patients receiving tamoxifen (tamoxifen group), and control group. Endometrial histological examination was carried out. Receiver operating characteristic (ROC) curve analysis was carried out.

RESULTS

Endometrial thickness in the tamoxifen group was 11.2 +/- 5.1 mm, and that of the control group was 3.8 +/- 2.1 mm. The incidence of endometrial abnormalities in the tamoxifen group was greater than that in control group. The cut off values derived from the ROC curve analysis were 9 mm for endometrial thickness, and 24 months for duration of tamoxifen therapy.

CONCLUSION

The histological examination of endometrium should be carried out if the endometrial thickness is more than 9 mm, or the duration of tamoxifen therapy is more than 24 months even if the patients do not have any symptoms.

Ultrasonographic measurement of endometrial changes following discontinuation of tamoxifen treatment in postmenopausal breast cancer patients

OBJECTIVE

To assess whether there is a decrease in endometrial thickness following discontinuation of tamoxifen treatment as measured by ultrasound.

DESIGN

Prospective study.

SETTING

Department of Obstetrics and Gynaecology, Sapir Medical Centre, Kfar-Saba, Israel.

POPULATION

Fifty-eight postmenopausal women with breast cancer who were treated with tamoxifen.

METHODS

Transvaginal ultrasonographic measurements of endometrial thickness.

MAIN OUTCOME MEASURES

Evaluation of the changes of endometrial thickness and the frequency the endometrium reached a thickness of < or = 5 mm at different time intervals after stopping tamoxifen treatment.

RESULTS

There was a significant decrease in median thickness of the endometrium, within six months after stopping tamoxifen, from 7.75 mm measured at the last ultrasonographic study performed before tamoxifen discontinuation down to 5.2 mm (P = 0.002). There were no further reductions in endometrial thickness, and it remained constantly low in subsequent ultrasonographic studies which were performed at various times up to 30 months following the discontinuation of tamoxifen treatment. While taking tamoxifen, only 25-9% of the women had an endometrial thickness of < or = 5 mm. This proportion doubled in their first six months after stopping.

CONCLUSIONS

Median thickness of endometrial thickness significantly reduced within six months following tamoxifen discontinuation, and remained constantly low thereafter. This finding may support use of ultrasonographic imaging for the measurement of tamoxifen's effect on the endometrium of postmenopausal breast cancer patients.

Limited value of sonohysterography for endometrial screening in asymptomatic, postmenopausal patients treated with tamoxifen

OBJECTIVES

Sonohysterography (SHG) has been proposed as a useful tool for the surveillance of the endometrium in patients receiving tamoxifen. This study aimed to assess the value of SHG in asymptomatic patients who would have been biopsy candidates because of abnormal transvaginal ultrasound (TVUS) results.

METHODS

The study population included postmenopausal breast cancer patients receiving adjuvant tamoxifen who had asymptomatic abnormalities at TVUS (endometrial thickness >/=8 mm or endometrial echo not adequately visualized). SHG was performed with an Aloka SSD 680 system using a 5-MHz vaginal probe, with sterile saline solution as contrast medium.

RESULTS

Forty-one patients entered the study. A regular endometrial echo was identified by SHG in 9 patients (21.9%). Histology was obtained in the remaining 32 patients with positive (n = 27, 65.8%) or unsuccessful (n = 5, 12.2%) SHG. Benign polyps (n = 15, 36.6%) and endometrial atrophy (n = 14, 34.1%) were the most common findings; 3 patients (7.3%) had simple hyperplasia.

CONCLUSIONS

Breast cancer patients with asymptomatic, tamoxifen-associated TVUS abnormalities have little additional benefit from SHG. More than 23 remain candidates for biopsy, which usually yields benign or insignificant findings.

Tamoxifen-induced uterine abnormalities: the role of imaging

Tamoxifen citrate is an orally administered, nonsteroidal antiestrogen agent that is widely used for the treatment of breast cancer and that has recently been found to prevent breast cancer in some high-risk populations. Tamoxifen may, however, cause adverse effects at the uterine level. In this article, the authors review (a) the histopathologic uterine changes associated with tamoxifen therapy, (b) the spectrum of uterine imaging findings in women treated with tamoxifen, and (c) the recommendations of the American College of Obstetrics and Gynecology for women treated with tamoxifen. An algorithm for imaging evaluation of the uterus in women treated with tamoxifen is presented.

Postmenopausal endometrial pathologies with tamoxifen treatment: comparison between hysteroscopic and hysterectomy findings

Histological findings of endometrial specimens collected by hysteroscopy from 261 postmenopausal breast cancer patients with tamoxifen treatment (group I) and from endometrial specimens obtained following hysterectomy from 40 similar patients (group II) were compared. This comparison was performed in order to assess whether endometrial pathologies are more frequently diagnosed in specimens collected by hysterectomy than by those collected during hysteroscopy in such patients. Overall positive endometrial histological findings were significantly more common in group II patients than in group I patients (82.5 and 24.5%, respectively; p < 0.0001). Atrophic endometrium was significantly more common in group I patients than in group II patients (75.5 and 15.0%, respectively; p < 0.0001). All other different endometrial pathologies, except for proliferative endometrium, were significantly more common in group II patients than in group I patients (endometrial hyperplasia = 17.5 and 4.2%, respectively; p < 0.0003; endometrial polyps = 30.0 and 11. 5%, respectively; p < 0.006; endometrial polyps with hyperplasia = 17.5 and 4.2%, respectively; p < 0.0003; endometrial carcinoma = 15. 0 and 0.4%, respectively; p < 0.0001). These findings suggest that in postmenopausal breast cancer patients treated with tamoxifen, the frequency of various endometrial histological findings and of overall positive endometrial histological findings were significantly higher in specimens collected by hysterectomy than in specimens obtained by hysteroscopy.

Malignant endometrial polyps in postmenopausal breast cancer tamoxifen-treated patients

BACKGROUND

Endometrial polyps are the most common endometrial pathology described in association with postmenopausal tamoxifen exposure. It is generally accepted that the occurrence of malignancy in endometrial polyps among healthy women is up to 0.5%. However, no one has yet described the incidence of this malignant transformation among postmenopausal breast cancer tamoxifen-treated patients. Objective. The aim of this study was to study the exact rate of malignant changes in endometrial polyps recovered from postmenopausal breast cancer tamoxifen-treated patients.

METHODS

We reviewed the pathological results and medical records of all postmenopausal breast cancer patients in whom endometrial polyps were recovered following at least 6 months of tamoxifen treatment in our institute. We also looked for the rate of malignant changes in polyps recovered from all healthy postmenopausal controls with endometrial polyps in our institute during the period of the study.

RESULTS

Two (3.0%) of 67 endometrial polyps recovered from postmenopausal breast cancer tamoxifen-treated patients revealed malignant features. None of the clinical variables tested, including risk factors for endometrial cancer, was significantly different between the groups. In the controls only 5 (0.48%) of 1034 polyps were malignant.

CONCLUSION

Up to 3.0% of endometrial polyps recovered from postmenopausal breast cancer tamoxifen-treated patients may show malignant changes. This rate is higher than that found in our controls as well as that reported in the general female population.

Long-term transvaginal ultrasonographic endometrial follow-up in postmenopausal breast cancer patients with tamoxifen treatment

OBJECTIVE

The aim of this study was to evaluate changes in transvaginal ultrasonographic endometrial thickness with increased duration of tamoxifen treatment in postmenopausal breast cancer patients.

MATERIAL AND METHODS

In this prospective study we evaluated the changes (mean +/- SD) of endometrial thickness measured by transvaginal ultrasonography in 181 postmenopausal breast cancer patients, according to the duration of tamoxifen treatment. According to our protocol, the ultrasonographic evaluations were performed every 6 months for the first 2 years of the follow-up and every 12 months thereafter. Two such subsequent ultrasonographic evaluations were performed in 181 patients following 35.1 +/- 41.7 months of tamoxifen treatment, three studies in 127 patients following 44.7 +/- 47.98 months of treatment, four studies in 75 following 54.2 +/- 61.7 months of treatment, five studies in 51 patients following 65.3 +/- 74.4 months of treatment, and six studies in 27 patients following 79.5 +/- 98.8 months of treatment.

RESULTS

The measured endometrial thickness detected varied from 8.84 +/- 4.66 to 10.61 +/- 12.35 mm. There were no significant changes in mean +/- SD of endometrial thickness following various durations of tamoxifen treatment.

CONCLUSIONS

Extension of duration of tamoxifen treatment in postmenopausal breast cancer patients up to 79.48 +/- 98.79 consecutive months does not cause a significant increase in transvaginal ultrasonographic endometrial thickness.

A case of simultaneous presence of primary endometrial carcinoma and metastasis of a breast carcinoma to the ovary after 5 years of tamoxifen therapy

We report a case of a 43-year-old woman with the simultaneous presence of a primary uterine endometrial cancer and metastasis of breast cancer to the ovary after 5 years of tamoxifen therapy. Tamoxifen therapy lengthens recurrence-free survival of the patient. However, the risk of endometrial cancer and the possibility of recurrence of breast cancer also must be considered.

Endometrial pathology in postmenopausal tamoxifen treatment: comparison between gynaecologically symptomatic and asymptomatic breast cancer patients

AIMS

To evaluate whether endometrial pathology is more likely to be diagnosed in gynaecologically symptomatic rather than in gynaecologically asymptomatic postmenopausal breast cancer patients with tamoxifen treatment; and to evaluate the possible influence of various clinical factors on the incidence of endometrial pathology.

METHODS

Endometrial histological findings, transvaginal ultrasonographic endometrial thickness, demographic characteristics, health habits, and risk factors for endometrial cancer were compared between 14 gynaecologically symptomatic (group I) and 224 gynaecologically asymptomatic (group II) postmenopausal breast cancer patients with tamoxifen treatment.

RESULTS

Overall, 28.6% of the study population had endometrial pathology. The incidence of overall positive endometrial histological findings was significantly higher in group I than in group II (92.9% v 24.6%, p < 0.0001). Atrophic endometrium was more common in group II than in group I (75.3% v 7.1%, p < 0.0001). Most other endometrial pathology was significantly more common in group I than in group II (endometrial hyperplasia, 35.7% v 5.6%, p < 0.0001; endometrial polyps, 35.7% v 13.4%, p < 0.0111; endometrial carcinoma, 21.5% v 0.9%, p < 0.0001). Endometrial pathology appeared considerably later in the gynaecologically asymptomatic patients than in gynaecologically symptomatic patients (p = 0.0002). Vaginal bleeding or spotting occurred exclusively in group I. The incidence of endometrial pathology in the entire study population was consistent with that reported elsewhere, and higher than that reported for healthy postmenopausal women.

CONCLUSIONS

Endometrial pathology is more likely to be diagnosed in gynaecologically symptomatic postmenopausal breast cancer patients with tamoxifen treatment, and after a shorter duration of time, than in gynaecologically asymptomatic patients.

Association between endometrial cancer and tamoxifen treatment of breast cancer

A retrospective cohort-study in 4109 breast cancer patients was undertaken to determine how tamoxifen affected the risk of endometrial cancer. Data on 1701 tamoxifen-treated women were analysed. Two thousand four hundred and eight non-tamoxifen users served as control group. The occurrence of new primary uterine cancers was assessed by computerized linkage to the Austrian Cancer Registry. Twenty-five women who subsequently developed endometrial cancer were identified. Eight uterine cancers occurred in the tamoxifen group, whereas 17 uterine cancers were found in the control group. The estimate of the relative risk (RR) showed an increased risk to develop endometrial cancer for the tamoxifen group RR 1.136 (95% CI 0.71; 1.80). Analysis of relevant confounding variables did not show any differences in the two groups. In conclusion, this retrospective study demonstrated a non-significant increased risk of endometrial cancer in women receiving tamoxifen as treatment for breast cancer. However, the magnitude of RR and the absolute number of endometrial cancer cases in this long term observation demonstrate clearly that the clinical benefit of tamoxifen therapy greatly outweighs the risk.