Endometrial sampling techniques in the diagnosis of abnormal uterine bleeding

A study evaluating liquid-based endometrial cytology test and transvaginal ultrasonography as a screening tool for endometrial cancer in 570 postmenopausal women

OBJECTIVE

To evaluate the combination of transvaginal ultrasonography (TVS) and endometrial cytology test (ECT) as a potential diagnostic strategy for endometrial cancer and endometrial precancerous lesions in postmenopausal patients.

METHODS

570 postmenopausal patients admitted in our hospital due to abnormal bleeding or other symptoms and/or with endometrium thickness over 5 mm on ultrasound. The endometrial thickness was evaluated by TVS. Following obtainment with written consent, all patients underwent ECT, hysteroscopy and then dilatation and curettage (D&C). Cytological sampling was conducted by scratching the uterus cavity using SAP-1 and the samples were prepared as liquid-based smear using SurePath technology. The samples were stained using Papanicolaou method. The correlation between cytological diagnosis and TVS results with the D&C histological diagnosis was analyzed. The WHO classification was used for diagnosis.

RESULTS

Sensitivity of ECT, TVS, ECT or TVS positive, ECT and TVS positive to diagnose atypical hyperplasia or worse were estimated at 80.7%, 86.8%, 97.4%, 70.2%, specificity at 94.7%, 20.4%, 17.5%, 88.4%, positive predictive value at 58.2%, 21.1%, 22.8%, 60.2%, negative predictive value at 94.4%, 86.1%, 96.4%, 92.2%, and accuracy at 84.6%, 33.7%, 33.5%, 84.7%, respectively.

CONCLUSIONS

Transvaginal ultrasonography and Endometrial cytology test may be regarded as a effective first-line method in endometrial pathology detection in postmenopausal women.

Endometrial biopsy under direct hysteroscopic visualisation versus blind endometrial sampling for the diagnosis of endometrial hyperplasia and cancer: Systematic review and meta-analysis

Background: Endometrial cancer is the most common gynaecological neoplasia in western countries. Diagnosis of endometrial cancer requires an endometrial biopsy. A good quality endometrial biopsy allows not only the identification of the pathology, but also preoperative histologic subtype classification. Endometrial biopsy can be performed under direct hysteroscopic visualisation, but also using blind sampling techniques Objectives: To compare endometrial biopsy performed under direct hysteroscopic visualisation versus blind sampling for the diagnosis of endometrial hyperplasia and cancer. Materials and Methods: Systematic review and meta-analysis. Electronic databases were searched from their inception until March 2022.We included all studies comparing endometrial biopsy performed under direct hysteroscopic visualisation versus blind endometrial sampling. Main outcome measures: Sample adequacy, failure rate to detect endometrial cancer or endometrial hyperplasia, and rate of detection of endometrial cancer. The summary measures were reported as relative risk (RR) with 95% of confidence interval (CI). Results: Four studies with a total of 1,295 patients were included. Endometrial biopsy under direct hysteroscopic visualisation was associated with a significantly higher rate of sample adequacy (RR 1.13, 95% CI 1.10 to 1.17), and significantly lower risk of failure to detect endometrial cancer or endometrial hyperplasia (RR 0.16, 95% CI 0.03 to 0.92) compared to blind endometrial sampling. However, there was no significant difference between endometrial biopsies taken under direct hysteroscopic visualisation or blindly, with or without a preceding diagnostic hysteroscopy, in the rate of detection of endometrial cancer (RR 0.18, 95% CI 0.03 to 1.06). Conclusion: Hysteroscopic endometrial biopsy under direct visualisation is associated with significantly higher rate of sample adequacy and is comparable to blind endometrial sampling for the diagnosis of endometrial cancer and precancer. What is new? Hysteroscopic endometrial biopsy under direct visualisation would be expected to reduce diagnostic failure for endometrial cancer compared to blind endometrial sampling.

Uterine bioimpedance combined with artificial intelligence as a means of cancer detection

This study hypothesised that benign and tumour-bearing uterine tissue could be differentiated by their unique electrical bioimpedance patterns, with the aid of artificial intelligence. Twenty whole, ex-vivo uterine specimens were obtained at the time of hysterectomy. A total of 11 benign and 9 malignant specimens were studied. A uterine bioimpedance probe was designed to measure the tissue between the endometrial and serosal layers of the uterus. The impedance data was then analysed with multiple instance learning and principal component analysis, forms of artificial intelligence. Final pathology results for the specimens included uterine sarcoma, adenocarcinoma, carcinosarcoma, and high-grade serous carcinoma. The analysis correctly identified 78% (7/9) of the malignant specimens and 82% (9/11) of the benign specimens. The overall accuracy of our analysis was 80%. Our results demonstrate distinction between electrical impedance properties of malignant and benign uterine specimens. Bioimpedance and artificial intelligence may have potential implications in risk assessment of patients and may subsequently guide surgical decision-making regarding route of organ removal.

Comparison between Different Diagnostic Strategies in Low-Risk Reproductive Age and Pre-Menopausal Women Presenting Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) is a common symptom in the female population, with an estimated prevalence of 10 to 30% in fertile age and up to 90% in perimenopausal women. In most cases, AUB is due to a benign cause. However, it can also be a symptom of atypical endometrial hyperplasia or endometrial cancer, a more common disease during menopause which can also affect women in their reproductive age. Considering the high prevalence of this symptom an appropriate diagnostic algorithm is needed. Concerns about the risks, pain, and stress associated with an endometrial biopsy and its impact on the healthcare system make the choice of AUB diagnostic strategy extremely relevant. Even if the scientific community agrees on the definition of AUB, International Guidelines show some differences in the management of women of reproductive age with AUB, especially regarding the age cut-off as an independent indication for endometrial biopsy. This study compared different diagnostic strategies to identify a diagnostic pathway with high sensitivity and specificity but low impact on the health system's resources. The analysis was based on three diagnostic algorithms defined as part of the guidelines of leading scientific societies. Women of reproductive age with AUB (n = 625) and without risk of endometrial cancer were included in the study. Results showed that the best criterion to investigate AUB in women at low risk of endometrial cancer is not age cut-off but the presence or absence of focal endometrial pathology at the ultrasound and the response to the progestin therapy. This approach makes it possible to perform fewer outpatient hysteroscopic biopsies without excluding positive cases from the examination.

Accuracy of Karman endometrial aspiration in comparison to conventional D and C in women with AUB at tertiary care hospital in North West Rajasthan

Background:

Approximately 33% of all gynaecological consultations are associated with abnormal vaginal bleeding, and this proportion increases to 70% in the peri and postmenopausal years.

Aims and Objective:

To compare the diagnostic accuracy of Karman's cannula endometrial aspiration histopathology versus dilatation and curettage in patients with abnormal uterine bleeding.

Methodology:

In total 100 women of all age groups with a clinical diagnosis of AUB were included in this prospective comparative study. Endometrial aspiration with Karman cannula was performed in the operation theatre prior to curettage to maintain synchronization during sampling.

Results:

In our study, no significant difference was observed between Karman and D and C regarding sample adequacy (P = 0.07), HPE findings (P = 1) and concordance rate with hysterectomy specimen (P = 1). 95% of the samples obtained by Karman and 98% of those obtained by D and C were adequate. For obtaining an adequate sample by Karman the sensitivity and accuracy was 96.94% and 96% when compared with D and C. Karman and D and C had comparable concordance rates (95% and 95%) with hysterectomy specimen. Karman endometrial sampling is an easy procedure when compared to D and C (P = 0.007). With considering D and C as gold standard Karman endometrial sampling demonstrated 100% accuracy for diagnosing adenocarcinoma, endometrial hyperplasia.

Conclusion:

Endometrial aspiration with Karman cannula is an easy, safe, cost-effective, accurate, convenient method of achieving histopathological diagnosis. It can be done as an outpatient procedure without analgesia and anaesthesia when compared to D and C which is expensive and invasive method and requires hospitalization and general anaesthesia.

The Value of DNA Quantitative Cytology Test for the Screening of Endometrial Cancer

Objective

To evaluate the accuracy, sensitivity, and specificity of DNA quantitative cytology test for the diagnosis of endometrial cancer or precancerous lesions and then discuss the value of DNA quantitative cytology as a screening tool for endometrial cancer.

Methods

The study enrolled 575 patients from September 2013 to January 2017 in Shanghai Minhang Central Hospital. Endometrial hysteroscopy plus dilation and curettage and DNA quantitative cytology tests were conducted as a method for the diagnosis of endometrial cancer. The accuracy, sensitivity, and specificity of this method were calculated according to histopathologic diagnoses which were used as the gold standard for diagnosis confirmation.

Results

For the DNA quantitative cytology diagnosis of endometrial cancer, accuracy was estimated at 85.57%, sensitivity at 87.01%, specificity at 85.34%, positive predictive value (PPV) at 47.86%, and negative predictive value (NPV) at 97.07%. For the DNA quantitative cytology diagnosis of endometrial cancer in menopausal patients: accuracy was estimated at 89.95%, sensitivity at 97.73%, specificity at 87.59%, positive predictive value (PPV) at 70.49%, negative predictive value (NPV) at 99.22%. For the DNA quantitative cytology diagnosis of endometrial cancer in non-menopausal patients, accuracy was estimated at 83.42%, sensitivity at 72.73%, specificity at 84.42%, positive predictive value (PPV) at 30.38%, and negative predictive value (NPV) at 97.07%.

Conclusion

DNA heteroploidy can be tested for the occurrence and the development of endometrial cancer. A small number of non-endometrial cancer cases may also appear DNA heteroploidy, but the number of >5c cells is less than 3. DNA quantitative analysis is a useful tool for the screening of endometrial cancer, worthy of being popularized and applied in endometrial cancer diagnosis.

Endometrial sampling in low-risk patients with abnormal uterine bleeding: a systematic review and meta-synthesis

BACKGROUND

One million women per year seek medical advice for abnormal uterine bleeding (AUB) in the United Kingdom. Many low-risk patients who could be managed exclusively in primary care are referred to hospital based gynaecology services. Performing endometrial sampling (ES) in the community may improve care, reduce the rate of referrals and minimise costs. We aimed to search and synthesise the literature on the effectiveness of ES (Pipelle versus other devices) in managing AUB in low-risk patients.

METHODS

We undertook an electronic literature search in MEDLINE via OvidSP, Scopus, and Web of Science for relevant English-language articles from 1984 to 2016 using a combination of MeSH and keywords. Two reviewers independently pre-selected 317 articles and agreed on 60 articles reporting data from over 7300 patients. Five themes were identified: sample adequacy, test performance, pain and discomfort, cost-effectiveness, and barriers and complications of office ES.

RESULTS

Pipelle seems to perform as well as dilation and curettage and, as well or better than other ES devices in terms of sampling adequacy and sensitivity. It also seems to be better regarding pain/discomfort and costs. However, Pipelle can disrupt the sonographic appearance of the endometrium and may be limited by cervical stenosis, pelvic organ prolapse and endometrial atrophy.

CONCLUSIONS

The current evidence supports the use of Pipelle in the management of low-risk women presenting in the outpatient setting with symptomatic AUB when combined with clinical assessment and ultrasound scanning. However, the implications of its widespread use in primary care are uncertain and more research is required.

Effect of Cervical Lidocaine Gel for Pain Relief in Pipelle Endometrial Sampling

OBJECTIVE

To evaluate the efficacy of cervical lidocaine gel in reducing patient discomfort during Pipelle endometrial sampling.

MATERIALS AND METHODS

From September 2012 to January 2013, 137 patients were evaluated with Pipelle endometrial biopsy. For group 1 (77 women), 2% lidocaine gel was applied to the cervical canal 3 min before endometrial sampling. For group 2 (60 women), a placebo gel was applied. The pain experienced by the patients during biopsy was evaluated using a 100 mm visual analog scale.

RESULTS

The pain score was significantly lower during suction curettage (T3) in the group 1 than in the group 2. There was no significant difference between the groups in terms of pain score in other stages of the procedure (2.6±1.3 and 4.5±1.4; p=0.03).

CONCLUSION

Cervical 2% lidocaine gel is simple and effective for decreasing pain associated with Pipelle endometrial biopsy.

Correlation between cytological and histopathological examination of the endometrium in abnormal uterine bleeding

Background:

Abnormal uterine bleeding (AUB) is a common problem for which women seek gynecological consultation. Endometrial aspiration cytology (EAC) is an acceptable and valuable diagnostic procedure for screening the endometrial status.

Materials and Methods:

Endometrial aspiration using a menstrual regulation (MR) syringe and a 4 mm Karman's cannula was performed just prior to D and C in 100 women presenting with AUB. Smears were reviewed for cytomorphological findings and were correlated with the histopathological findings. These findings were categorized as benign endometrium, endometrial hyperplasia, malignancy and inadequate smears.

Results:

Age of the patients ranged from 19 to 70 years. In our study, the accuracy in diagnosing benign conditions of endometrium, hyperplasia, and malignancy on aspiration cytology were 93.88%, 96.94% and 96.84%, respectively.

Conclusions:

Endometrial aspiration is an effective, useful and a minimally invasive procedure. With an experienced cytologist, it can be used routinely for the primary investigation of women with AUB, provided all the points of discrepancies are taken care of.

Role of postmenopausal bleeding pattern and women's age in the prediction of endometrial cancer

BACKGROUND

Women with postmenopausal bleeding should be evaluated efficiently to exclude endometrial carcinoma.

AIMS

To estimate the risk of endometrial cancer using individual case characteristics among women with postmenopausal bleeding in whom the endometrial thickness is >4 mm.

METHODS

Women with postmenopausal bleeding underwent clinical evaluation followed by transvaginal ultrasonography and endometrial biopsy. Clinical evaluation included age, body mass index, duration of menopause, number of bleeding episodes and amount of bleeding.

RESULTS

This study included 142 women, and endometrial carcinoma was found in 18 (12.7%). Older age, higher body mass index, longer duration of menopause, longer lasting bleeding episodes, higher amount of bleeding and recurrent bleeding episodes were the clinical characteristics associated with endometrial cancer. However, multivariate analysis revealed >55 years of age during postmenopausal bleeding, history of recurrent bleeding episodes and bleeding exceeding 5 pads per day in each episode as significant parameters, which predicted the presence of endometrial cancer among women with postmenopausal bleeding.

CONCLUSIONS

Prompt evaluation is required in women with postmenopausal bleeding to exclude endometrial cancer. Transvaginal ultrasonography is a reasonable first-line approach, and invasive sampling is required when ultrasonographic endometrial thickness is above 4 mm. However, about 90% of women with postmenopausal bleeding will finally be found to have a nonmalignant condition. Therefore, women who are at increased cancer risk should further be distinguished. This may be achieved using individual patient characteristics that result in a more accurate evaluation strategy with lower rates of unnecessary invasive procedures.

Evaluation of DNA from the Papanicolaou test to detect ovarian and endometrial cancers

Papanicolaou (Pap) smears have revolutionized the management of patients with cervical cancers by permitting the detection of early, surgically curable tumors and their precursors. In recent years, the traditional Pap smear has been replaced by a liquid-based method, which allows not only cytologic evaluation but also collection of DNA for detection of human papillomavirus, the causative agent of cervical cancer. We reasoned that this routinely collected DNA could be exploited to detect somatic mutations present in rare tumor cells that accumulate in the cervix once shed from endometrial or ovarian cancers. A panel of genes that are commonly mutated in endometrial and ovarian cancers was assembled with new whole-exome sequencing data from 22 endometrial cancers and previously published data on other tumor types. We used this panel to search for mutations in 24 endometrial and 22 ovarian cancers and identified mutations in all 46 samples. With a sensitive massively parallel sequencing method, we were able to identify the same mutations in the DNA from liquid Pap smear specimens in 100% of endometrial cancers (24 of 24) and in 41% of ovarian cancers (9 of 22). Prompted by these findings, we developed a sequence-based method to query mutations in 12 genes in a single liquid Pap smear specimen without previous knowledge of the tumor's genotype. When applied to 14 samples selected from the positive cases described above, the expected tumor-specific mutations were identified. These results demonstrate that DNA from most endometrial and a fraction of ovarian cancers can be detected in a standard liquid-based Pap smear specimen obtained during routine pelvic examination. Although improvements need to be made before applying this test in a routine clinical manner, it represents a promising step toward a broadly applicable screening methodology for the early detection of gynecologic malignancies.

Detection of chromosomal anomalies in endometrial atypical hyperplasia and carcinoma by using fluorescence in situ hybridization

BACKGROUND

Endometrial cancer is the most common pelvic gynecological malignancy. The diagnosis of well-differentiated endometrial adenocarcinoma, atypical hyperplasia, and hyperplasia is often challenging. The authors sought to investigate the utility of chromosomal anomalies for the detection of endometrial hyperplasia and carcinoma using multitarget fluorescence in situ hybridization (FISH).

METHODS

Samples were collected by endometrial Tao brush and processed by liquid-based cytological preparation protocol from consecutive cases to include 50 benign, 50 hyperplasia without atypia, 47 atypical hyperplasia, and 53 endometrial cancers. Each was hybridized using fluorescence-labeled DNA probes to chromosomes 1, 8, and 10. The FISH signals were enumerated in 100 cells per case, and the chromosomal anomalies were correlated with pathologic findings, including histologic diagnoses on matched endometrial tissue samples.

RESULTS

Numeric chromosomal anomalies were found in 0% (0 of 50) of benign, 20% (10 of 50) of hyperplasia, 74% (35 of 47) of atypical hyperplasia, and 87% (46 of 53) of carcinoma specimens. The mean percentage of cells with chromosomal changes was 55% in cancer specimens, which was significantly higher than that in hyperplasia without atypia (13%, P < .0001) and atypical hyperplasia (32%, P = .003). The most frequent chromosomal anomaly was gain of chromosome 1. FISH anomalies had an overall sensitivity of 81% and specificity of 90% for the detection of atypical hyperplasia and/or endometrial carcinoma. There was no association with grade of endometrial carcinoma.

CONCLUSIONS

Multitarget FISH appears to be useful for the differential diagnosis of hyperplasia, atypical hyperplasia, and endometrial adenocarcinoma, with a high level of sensitivity and specificity. It is also a potential tool for the early detection of neoplastic cells in endometrial cytology specimens. Endometrial hyperplasia with FISH-detected chromosomal anomalies may represent a clinically significant subset of cases that warrant close clinical follow-up.

Comparison of the efficacy of intrauterine lidocaine, paracervical block and oral etodolac for decreasing pain in endometrial biopsy

OBJECTIVE

To compare the effectiveness of paracervical block, intrauterine lidocaine and oral etodolac in decreasing the pain caused by pipelle endometrial sampling. A secondary goal of this study was to determine the adverse effects and compare possible effects of these methods on pulse and blood pressure.

MATERIAL AND METHODS

The study was performed between April 2006 and October 2006 in the Obstetrics and Gynecology Department of Van Yüzüncü Yıl University Research Hospital. One-hundred twenty patients were randomized into four groups: 1. Group: Paracervical block was performed with 3 ml 2% prilocaine solution. 2. Group: Five ml of 2% lidocaine solution was instilled through the endocervix into the uterine cavity. 3. Group: Subjects received 400 mg oral etodolac tablet 1-1.5 hour before the procedure. 4. Group: No method of anesthesia was used in the control group. Endometrial sampling was performed with pipelle. Severity of pain during the procedure was scored by the subjects according to the "6-point Verbal Rating Scale (VRS)". Blood pressure and pulse rate were measured before, during and 30 minutes after the procedure.

RESULTS

Pain scores in intrauterine lidocaine group (2(nd) group) were found statistically significantly lower than the other three groups (p<0.05).

CONCLUSION

Intrauterine lidocaine anesthesia technique decreases pain in endometrial sampling with pipelle more efficiently than paracervical block or oral etodolac. While indication of menorrhagia and endometrial thickness more than 5 mm increased pain scores, intrauterine lidocaine application or paracervical block decreased the scores significantly (p<0.05).

Management of abnormal uterine bleeding and the pathology of endometrial hyperplasia

There are no screening tests for endometrial carcinoma, and patients typically present with abnormal uterine bleeding. This article discusses the pathophysiology and clinical work-up of abnormal uterine bleeding, and risk factors for endometrial carcinoma. Atypical complex hyperplasia and the more recently defined endometrial intraepithelial neoplasia are well recognized as precancers. Evolving knowledge of their genetic alterations provides the opportunity to develop molecular markers, so that endometrial diseases may be diagnosed at the precancerous or early invasive stage. Emerging molecular markers also provide the opportunity to develop clinically useful screening tests for the most common malignancy of the female genital tract.

The role of liquid-based cytology associated with curettage in the investigation of endometrial lesions from postmenopausal women

OBJECTIVE

This study investigates the role of liquid-based cytology with ThinPrep technique, in the detection of endometrial lesions, using direct endometrial sampling from postmenopausal women with the Endogyn endometrial device.

METHODS

It was performed on 491 postmenopausal women referred to our clinic for abnormal bleeding or other symptoms and/or a thickness of endometrium >5 mm on ultrasound. Endometrial sampling, dilatation and curettage (D&C) and hysterectomy were performed on all patients. For the diagnosis, the WHO classification scheme was used.

RESULTS

According to our findings a sensitivity of 98.08%, specificity of 100%, positive predictive value of 100%, negative predictive value of 100% and overall accuracy of 98.98% were observed in both endometrial sampling and in D&C.

CONCLUSIONS

Endometrial sampling is complementary to D&C for the diagnosis of endometrial lesions and it is necessary for it to be performed before D&C and/or hysterectomy.

Endometrial cancer epidemiology and prevention in Federation of Bosnia and Herzegovina, B&H

In Federation of Bosnia and Herzegovina during 2002 a total of 67 cases of endometrial cancer (ICD 10th Revision Code C54) were registered among female population older then 15 years (1 per 10,000 population). Nine women were diagnosed with non specific malignant uteri neoplasia (C55)--without clarifying if that was cervix or corpus uteri located cancer, but assumption is that these cancers are actually endometrial cancer. Majority of cases are older then 50 years, 48 of them (71.6%), while 29 (28.4%) are from 15 to 49 years old. During 2000 about 189,000 new endometrial cancer cases were reported with 44,700 endometrial cancer deaths in the World. In this paper we presented geographical distribution of cases registered in FB&H, as well as leading risk factors, protective factors and prevention and possibilities for screening methods.

Gynecologic problems of the perimenopause: evaluation and treatment

The gynecologic problems associated with the perimenopause and detailed in this review represent common and often vexing concerns for women during this transition. By heeding the evidence-based approaches to evaluation and treatment described herein, clinicians can improve the health and lives of their perimenopausal patients.