Management of Endometrial Intraepithelial Neoplasia or Atypical Endometrial Hyperplasia: ACOG Clinical Consensus No. 5

Surgical Management of Endometrial Intraepithelial Neoplasia at Military Treatment Facilities: A Multicenter Retrospective Study

INTRODUCTION

Endometrial intraepithelial neoplasia (EIN), also known as atypical endometrial hyperplasia (AEH), is a precursor lesion of endometrial carcinoma (EC). In endometrial cancer patients, lymph node assessment with biopsy during hysterectomy is part of surgical staging. However, routine lymph node assessment for EIN is inconsistently utilized. This study aims to investigate the surgical management of EIN in the military to inform best-practice guidelines tailored for the Military Health System to avoid delays in care, manage cost, ensure military readiness and optimize clinical outcome.

MATERIALS AND METHODS

We performed a retrospective chart review of patients with EIN treated at 2 military treatment facilities over a 10-year period between July 1, 2013 and July 1, 2023. Pathology reports were queried to identify patients with a preoperative diagnosis of EIN. Patients not surgically managed were excluded. Statistical analysis was performed using chi-squared test and Wilcoxon rank-sum test. Independent associations were investigated using logistic regression modeling.

RESULTS

There were 95 evaluable patients with an EIN diagnosis, including 43 (45.3%) patients upstaged to EC based on final pathology (95% CI: 35.0-55.8). Older patients diagnosed with EIN ≥65 years old and those with endometrial thickness ≥15 mm exhibited the highest risk for upstaging EIN to an EC diagnosis. Of the 50 patients who underwent lymph node assessment, none had positive lymph nodes. Patients diagnosed with EIN via hysteroscopy vs. an endometrial biopsy had the lowest risk of being upstaged to EC.

CONCLUSIONS

Upstaging from EIN to EC occurred in 45.3% of the 95 patients emphasizing the value of performing surgicopathologic staging in this setting. In contrast, none of the 50 EIN patients who underwent lymph node resection had positive lymph nodes indicating morbidity risk with low likelihood of clinical benefit. We identified risk factors for upstaging to EC, including age ≥65 years and endometrial thickness ≥15 mm, and confirmed the diagnostic superiority of hysteroscopy. These findings have informed clinical practice guideline recommendations for the surgical management of EIN in the Military Health System.

Examining the Association of Body Mass Index and Complications When Including Sentinel Lymph Node Biopsy in Minimally Invasive Surgery for Endometrial Intraepithelial Neoplasia

Objective: We aimed to study the association of patient's body mass index (BMI) with postoperative complications in patients surgically treated for endometrial intraepithelial neoplasia, with and without sentinel lymph node biopsy. Methods: A cohort study using the prospective National Surgical Quality Improvement Program database. Women with endometrial intraepithelial neoplasia on postoperative pathology who underwent minimally invasive hysterectomy from January 2012 to December 2020 were included. The cohort was dichotomized based on the performance of sentinel lymph node biopsy. We analyzed postoperative complications based on the World Health Organization (WHO) categories of BMI. Results: A total of 4428 patients met the inclusion criteria. Of those, 584 (13.2%) had sentinel lymph node biopsy. Overall, 76.5% of patients (n = 3389) were obese (BMI > 30.0), with 1840 (41.6%) patients of BMI ≥ 40.0. The rate of any complications was 6.0% (n = 264), major complications 2.3% (n = 101), and minor complications 4.2% (n = 187). When comparing the rate of any complications between patients who had sentinel lymph node biopsy vs. those without a sentinel lymph node biopsy procedure, stratified by BMI category, there was no association between sentinel lymph node biopsy performance and any complications in any of the BMI categories. In a multivariable binary regression analysis, BMI and the performance of sentinel lymph node biopsy were not independently associated with any complication [adjusted odds ratio (aORs) 1.001, 95% confidence interval (CI) (0.98-1.01), and aORs 1.1, 95% CI (0.82-1.65), respectively]. In an analysis of the cohort of patients who underwent sentinel lymph node biopsy, there was no association between the rates of any major or minor complications with BMI categories or obesity. ROC analyses for the association between BMI and occurrence of any major or minor complications had a low performance. Conclusions: In minimally invasive surgery for endometrial intraepithelial neoplasia, there is no association between body mass index and increased risk for postoperative complications when performing hysterectomy with sentinel lymph node biopsy versus hysterectomy alone.

Prospective evaluation of 92 protein biomarkers for early detection of endometrial cancer

The human epididymis protein 4 (HE4) remains the best available endometrial cancer (EC) biomarker; however, its discrimination between cases and cancer-free individuals is limited and might be improved when combined with other protein markers. We evaluated the discrimination capacity of 92 proteins as potential early detection biomarkers for EC in nested case-control studies in the European Prospective Investigation into Cancer and Nutrition (EPIC) (63 cases, 123 controls) and Janus (75 cases, 146 controls) cohorts, evaluating blood samples taken ≤2 years prior to diagnosis. Proteins were measured with the Olink Target 96 Oncology II panel assays. Areas under the receiver operating characteristic curves (AUCs) were calculated using logistic regression. The discrimination between cases and controls of top-performing proteins was modest (EPIC: HE4, CA125, CAIX, and S100A4; Janus: HE4, CA125, FURIN, CXCL13, and IL6; AUC range: 0.65 [S100A4], 0.76 [HE4, EPIC] within 0 to <12 months of blood collection) and decreased as the time between blood draw and cancer diagnosis increased (12-24 months AUC range: 0.49 [S100A4], 0.69 [CA125, Janus]). The combination of these other markers with HE4 did not improve discrimination. HE4 and other candidate proteins had limited discrimination between EC cases and controls and hence do not appear to be useful for early detection of this disease in women at average population risk.

Hysteroscopy-Guided Endometrial Sampling Diagnostic Performance in Endometrial Intraepithelial Neoplasia Patients

OBJECTIVE

To compare the diagnostic performance of hysteroscopy-guided versus blind sampling in detecting concurrent endometrial carcinoma in patients with endometrial intraepithelial neoplasia and to identify factors associated with missing cancer diagnosis.

DESIGN

This is a retrospective cohort study.

SETTING

Integrated academic and community healthcare system in Minnesota and Wisconsin, USA, January 1, 2018, and January 1, 2023 PARTICIPANTS: This included 151 patients diagnosed with endometrial intraepithelial neoplasia during endometrial sampling who underwent a hysterectomy within three months. Patients with concurrent cancer diagnoses were excluded.

INTERVENTIONS

Patients diagnosed with endometrial intraepithelial neoplasia using hysteroscopy-directed biopsy were compared to those diagnosed with blind-sampling methods using the pathology results of the subsequent hysterectomy specimen as the gold standard comparator to analyze rates of missed endometrial cancer diagnosis.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was a reduced risk of unanticipated concurrent endometrial cancer on the final hysterectomy pathology result for patients diagnosed with endometrial intraepithelial hyperplasia via a hysteroscopy-directed biopsy (OR=0.44, 95% CI=0.20-0.95, p = 0.033). In multivariate analysis, body mass index ≥30 and patient age >60 were associated with an elevated risk of endometrial cancer on final pathology (OR=4.17, 95% CI=1.51-11.51, p = 0.004; OR=5.56, 95% CI=1.22-35.21, p<0.001), respectively, and diabetes mellitus was the only independent variable associated with a higher risk of endometrial intraepithelial neoplasia on final hysterectomy pathology (OR=7.01, 95% CI=1.40-35.04, p = 0.018). Age, BMI, and endometrial thickness on pre-biopsy ultrasound were not associated with an increased risk of overlooking concurrent endometrial carcinoma on final hysterectomy pathology on univariate and multivariate analyses.

CONCLUSION

Hysteroscopy-directed biopsy may reduce the risk of missing a concurrent endometrial malignancy during endometrial sampling in women with endometrial Intraepithelial neoplasia. The results affirm the superior diagnostic accuracy of hysteroscopy-directed endometrial evaluation.

Weight Management for Fertility-Preservation Therapy in Endometrial Cancer: Opportunities and Challenges

PURPOSE OF REVIEW

Obesity is increasingly recognized as a significant factor impacting the outcomes of fertility-preserving therapies for endometrial cancer (EC). This review explores the effects of glycolipid metabolism on EC and its relationship with body weight. We will examine how excess body weight influences the effectiveness of fertility-preserving treatments and discuss potential mechanisms for effective weight management. Additionally, the review highlights the importance of comprehensive weight management as an adjunct strategy to enhance the efficacy of fertility-preserving interventions, providing insights into how to integrate metabolic health into clinical treatment protocols.

RECENT FINDINGS

Weight management can modify the tumor microenvironment by depriving the tumor of nutrients, whereas exercise can enhance immunity, potentially leading to tumor cell death. In addition, progesterone therapy may impede the proliferation of EC cells. Comprehensive weight management can serve as an essential adjuvant treatment for patients undergoing fertility-preserving therapies for EC. In this review, we highlight that comprehensive weight management can serve as a crucial adjuvant treatment for patients undergoing fertility-preserving therapies for endometrial cancer. Targeting glycolipid metabolism and addressing adiposity can improve hormonal balance, reduce inflammation, and enhance fertility outcomes. Further research is necessary to establish specific protocols and evaluate the effectiveness of these strategies in clinical practice.

Sentinel Lymph Node in Endometrial Hyperplasia: State of the Art and Future Perspectives

Background/Objectives: Endometrial hyperplasia is a uterine pathology characterized by the abnormal proliferation of endometrial glands, resulting in an increased gland-to-stroma ratio. Complex atypical hyperplasia represents the primary precursor to endometrial cancer. Given the high risk of progression to endometrial adenocarcinoma, the accurate diagnosis and classification of endometrial hyperplasia are crucial. Since the treatment for atypical endometrial hyperplasia is the same as that for early-stage endometrial cancer (i.e., total hysterectomy and bilateral salpingo-oophorectomy), researchers have questioned whether sentinel lymph node mapping could also have a prognostic role in atypical endometrial hyperplasia. Methods: A literature search was conducted in PubMed and Scopus from 2014 to 2025. Of the 65 papers found, 31 relevant articles were selected based on inclusion criteria, focusing on sentinel lymph node staging in patients with atypical endometrial hyperplasia. This review aims to assess whether sentinel lymph node mapping can be routinely used for prognostic and therapeutic purposes in clinical practice. Results: Sentinel lymph node biopsy represents a promising diagnostic technique for patients with atypical endometrial hyperplasia, reducing the need for invasive procedures and postoperative risks. However, its application requires advanced surgical skills and access to specific technologies, raising ethical and financial concerns, while future studies could improve patient selection and the reliability of the procedure through technological innovations. Conclusions: Sentinel lymph node biopsy is a safe and effective method for staging early-stage endometrial cancer and atypical hyperplasia, with low metastasis rates, but future research should focus on identifying patients who would benefit most from this procedure, considering its costs and required expertise.

Prevalence of occult endometrial carcinoma in patients with endometrial intraepithelial neoplasia who underwent hysterectomy

OBJECTIVES

To determine the prevalence of occult endometrial carcinoma in patients with endometrial intraepithelial neoplasia (EIN) post-hysterectomy and identify pre-hysterectomy risk factors predictive of occult carcinoma.

METHODS

This retrospective study included patients diagnosed with EIN between 2007 and 2021 who underwent hysterectomy as primary treatment. An expert gynecologic pathologist reviewed pathological slides. Data collected from medical records included demographic and gynecologic information, sonographic findings, and surgical and pathological outcomes. The prevalence of occult endometrial carcinoma was calculated. Descriptive statistics evaluated carcinoma incidence, and logistic regression analysis identified independent risk factors.

RESULTS

A total of 113 patients were evaluated. The median time to hysterectomy was 9.1 weeks (range 5.8-12.8 weeks). Post-hysterectomy, 36 patients (31.8%) were diagnosed with endometrial carcinoma, all endometrioid type. Of these, 88.9% were stage I per the International Federation of Gynecology and Obstetrics classification system, and 11.1% were at high risk for nodal metastasis. Predictive factors for occult carcinoma included the intraoperative gross lesion size (2 cm or larger and less than 2 cm) and endometrial aspiration. Adjusted odds ratios were 6.723 (95% CI 2.338 to 19.333) for lesions 2 cm or larger, 3.381 (95% CI 1.128 to 10.132) for lesions less than 2 cm, and 2.752 (95% CI 1.092 to 6.936) for endometrial aspiration.

CONCLUSIONS

Occult endometrial carcinoma was identified in 31.8% of patients with a pre-hysterectomy EIN diagnosis. The significant predictors were endometrial aspiration and the presence of a gross lesion during surgery.

Should we prioritise proper surgical staging for patients with Atypical endometrial hyperplasia (AEH)? Experience from a single-institution tertiary care oncology centre

OBJECTIVE

The study aimed to evaluate the incidence of concurrent endometrial cancer (EC) and lymph node positivity in patients with Atypical Endometrial Hyperplasia (AEH) who underwent surgical staging with sentinel lymph node evaluation. It also sought to identify the risk factors associated with detecting concurrent endometrial cancer in patients with a preoperative diagnosis of AEH.

STUDY DESIGN

A retrospective study was conducted at Amrita Institute of Medical Sciences, involving 54 cases of AEH diagnosed on pre-operative biopsy specimens and undergoing staging surgery between January 1, 2015, and December 31, 2020. The study analysed demographic parameters, clinical presentations, pathological features, and clinical outcomes. Categorical variables were expressed in numbers and percentages, normal distribution data were presented as mean, and non-normal distribution data were presented as median and range.

RESULTS

Fifty-four patients diagnosed with AEH underwent surgical staging. The median age was 54 years. Final HistoPathology Report (HPR) showed 48.14 % with AEH and 51.85 % with concurrent EC. Among those with concurrent EC, 96.4 % had type I EC, and one patient was upgraded to type 2 EC. Among them, 17.8 % patients belonged to high-intermediate and high-risk categories. Patients with AEH and concurrent EC were more likely to be diabetic (OR: 3.56, p = 0.04), have a BMI ≥25 kg/m2 (OR: 1.47, p = 0.04), exhibit a thickened endometrial lining of ≥9 mm (OR: 3.13, p = 0.05) on ultrasound, and undergo preoperative biopsy at a non-oncology centre (OR: 8.33, p = 0.001) whereas experiencing heavy menstrual bleeding had a substantially lower likelihood (OR: 0.29, p = 0.01) of developing concurrent EC.

CONCLUSION

The study revealed that more than half of patients undergoing staging surgery for AEH were found to be at risk of having concurrent EC in their final HPR. The research also pointed out that surgical staging can help identify both low-risk and high-risk ECs, which may require additional treatment. Higher BMI, diabetes mellitus, and an endometrial thickness of ≥9 mm were identified as significant risk factors for concurrent EC. Additionally, heavy menstrual bleeding was associated with a decreased risk of concurrent EC.

Long-Term Follow-up of Levonorgestrel Intrauterine Device for Atypical Hyperplasia and Early Endometrial Cancer Reveals Relapse Characterized by Immune Exhaustion

PURPOSE

Nonsurgical treatment options are increasingly needed for endometrial atypical hyperplasia (AH) and endometrioid endometrial cancer (EEC). Despite promising initial response rates, prospective long-term data and determinants for relapse are limited.

MATERIALS AND METHODS

Follow-up data from patients in our prospective phase II trial of levonorgestrel intrauterine device (LIUD) for AH/G1EEC were collected from medical records. Spatial transcriptomics (Nanostring GeoMX digital spatial profiling) with in silico cell type deconvolution and pathway analyses were employed on longitudinal biopsy samples from five patients across pre-treatment, on-treatment, and relapse.

RESULTS

Of 43 participants exhibiting initial response to LIUD, 41 had follow-up data. Sixteen (39%) experienced relapse. Clinical factors associated with shorter response duration included younger age, initial diagnosis of G1EEC, lack of response at 6 months, premenopausal status, and Hispanic ethnicity (P < 0.05), but only 6-month response status remained a significant predictor in a multivariate model (P = 0.023). LIUD increased abundance of NK cells (ΔMCP-counter score = 46.13, FDR = 0.004) and cytotoxic lymphocytes (ΔMCP-counter score = 277.67, FDR = 0.004), as well as lymphocyte cytotoxicity markers PRF1 (log2FC = 1.62, FDR = 0.025) and GZMA (log2FC = 2.47, FDR = 0.008). NK cells were reduced at relapse (ΔMCP-counter score = -55.96, FDR = 0.02). Immune-related pathways (IFNα response and TGFβ signaling) were enriched at relapse (FDR < 0.05). IDO1 expression, reflecting immune exhaustion, was upregulated at relapse (FDR < 0.05).

CONCLUSIONS

Upfront resistance and relapse after initial response to LIUD for AH/G1EEC impacts nearly half of patients, remaining a major hurdle for nonsurgical treatment of AH/G1EEC. Molecular studies evaluating longitudinal biopsies from a small cohort implicate immune mechanisms at relapse, including reversal of progestin-related immunomodulation and increased immune exhaustion. See related commentary by Johannet and Friedman, p. 5001.

Endometrial Atypical Hyperplasia and Risk of Endometrial Cancer

Endometrial atypical hyperplasia (EAH) is a premalignant condition with a substantial risk of progression to endometrial cancer (EC), with the endometrioid subtype being the most common. EAH is characterized by abnormal endometrial gland proliferation and cellular atypia, often resulting from prolonged unopposed estrogen exposure. This review aims to explore the clinical significance of EAH, its risk of progression to EC, and the current approaches to management. The risk of EAH progressing to EC ranges from 20 to 50%, influenced by factors such as histopathology and genetic mutations including PTEN and KRAS. Key risk factors include obesity, polycystic ovary syndrome, and postmenopausal status. Abnormal uterine bleeding is a hallmark symptom of EAH and early-stage EC, necessitating diagnostic evaluation through endometrial biopsy and transvaginal ultrasonography. Therapeutic management strategies depend on patient risk and fertility considerations. Hormonal therapy, particularly progestins, is the mainstay for fertility preservation, while hysterectomy is preferred for higher-risk patients. Regular monitoring with biopsies is essential for those undergoing conservative treatment. Recent advancements in the management of EAH and EC have shifted towards incorporation of molecular diagnostics and targeted therapies, enabling better risk stratification and individualized care. Biomarkers and minimally invasive surgical techniques are emerging as promising approaches in improving outcomes for women with EAH. This review underscores the importance of early diagnosis and personalized management in preventing the progression of EAH to EC, highlighting current clinical practices and potential future developments in this field.

Weight-loss therapy in patients with obesity with endometrial intraepithelial neoplasia and uterine cancer

OBJECTIVE

Although obesity is an important risk factor for endometrial intraepithelial neoplasia (EIN) and uterine cancer, little is known about the trends in use of weight-loss therapy for patients with obesity with EIN and uterine cancer. We examined the use of weight-loss therapy among patients with obesity with EIN and uterine cancer.

METHODS

The Merative MarketScan Database was used to identify patients aged 18-70 years who were obese and diagnosed with EIN or uterine cancer. The primary treatment for EIN or uterine cancer was categorized as either primary hysterectomy or hormonal therapy. Nutrition counseling, bariatric surgeries, and weight-management medications were identified as weight-loss therapy. We analyzed trends in the use of any weight-loss therapies with Cochran-Armitage tests. A multivariable logistic regression model was developed to examine factors associated with weight-loss therapy use.

RESULTS

Overall, 15,374 patients were identified, including 5561 (36.2%) patients with EIN and obesity, and 9813 (63.8%) patients with uterine cancer and obesity. Weight-loss therapy was utilized within 1 year after diagnosis in 480 (8.6%) patients with EIN and in 802 (8.2%) patients with uterine cancer. Use of any weight-loss therapy after diagnosis of EIN increased from 4.1% in 2009 to 12.6% in 2020 (P < .001), and the use of any weight-loss therapy after diagnosis of uterine cancer increased from 4.9% in 2009 to 11.4% in 2020 (P < .001). In a multivariable regression model, younger age and patients with high comorbidity score were associated with a higher likelihood of using any weight-loss therapy.

CONCLUSIONS

Use of weight-loss therapy has increased, however there is still a significant underuse of this adjunctive therapy in patients with obesity with EIN or uterine cancer.

Uterine-Conserving Treatment Options for Atypical Endometrial Hyperplasia and Early Endometrial Cancer

PURPOSE OF REVIEW

This review aims to synthesize available literature on uterine-conserving treatment options for atypical endometrial hyperplasia and grade 1 endometrial carcinoma while highlighting remaining unanswered questions.

RECENT FINDINGS

The need for uterine-conserving treatment options for atypical endometrial hyperplasia and grade 1 endometrial carcinoma is growing with the increasing number of cases in younger patients or those who cannot undergo surgery. We reviewed the oncological and reproductive outcomes associated with endocrine therapies used for atypical endometrial hyperplasia and grade 1 endometrial carcinoma. The rising prevalence of delayed childbearing, obesity, and diabetes in reproductive-age individuals and of medical comorbidities associated with high surgical risk continues to amplify the demand for uterine-conserving therapies. Appropriate patient selection for such therapies is imperative to maximize likelihood of treatment response. The ideal candidates are patients with atypical endometrial hyperplasia or early-stage, low-grade endometrial cancer with no evidence of myometrial invasion or extrauterine disease. The most accepted conservative therapeutic approach is hormonal therapy with close surveillance, with or without eventual hysterectomy following childbearing or failure of treatment. Further prospective and randomized trials are needed to address optimal patient and treatment selection, as well as the use of molecular profiling for treatment individualization and prognostication.

SIR-EN-New Biomarker for Identifying Patients at Risk of Endometrial Carcinoma in Abnormal Uterine Bleeding at Menopause

OBJECTIVE

This study aimed to evaluate the efficacy of a new biomarker, termed SIR-En, in identifying patients at risk of endometrial carcinoma among those presenting with abnormal uterine bleeding during menopause.

MATERIAL AND METHODS

A retrospective case-control analysis was conducted on 242 women with menopausal abnormal uterine bleeding and endometrial thickness ≥ 4 mm. Peripheral blood samples were collected within 7 days before histological diagnosis. systemic inflammatory reaction (SIR) indices were calculated, including NLR, MLR, PLR, and SII. SIR-En was derived by multiplying SII and endometrial thickness. Statistical analyses, including multivariate linear regression and ROC curve analysis, were performed to assess the diagnostic capability of SIR-En.

RESULTS

Patients were categorized into endometrial hyperplasia (50 patients) and endometrial cancer (192 patients) groups. The SIR-En index was significantly higher in the carcinoma group (8710 vs. 6420; p = 0.003). The ROC curve for SIR-En had an AUC of 0.6351 (95% CI: 0.5579-0.7121). Using Youden's method, the optimal SIR-En cutoff was 13,806, showing a specificity of 0.940 and a positive predictive value of 0.957.

CONCLUSIONS

Combining systemic inflammatory indices with endometrial thickness, the SIR-En index can effectively distinguish between endometrial hyperplasia and carcinoma in menopausal women with abnormal uterine bleeding. Despite the retrospective design, the identified cutoff's high specificity and positive predictive value support its potential utility in clinical practice. Further prospective studies are required to validate these findings and optimize clinical application.

Immunohistochemical Analysis of GATA2 Expression in Endometrium and its Relationship with Hormone Receptor Expression in Benign and Premalignant Endometrial Disorders

The GATA gene family encodes highly conserved zinc-finger transcription factors that facilitate the development and function of multiple organ systems including the uterus. In the endometrium, GATA2 functions in a positive autoregulatory loop with the progesterone receptor (PGR) and colocalizes with PGR on chromatin to promote PGR transcriptional programs. GATA2 also has PGR-independent functions that maintain endometrial cell identity, and GATA2 transcripts reportedly are down-regulated in endometrial disorders including endometriosis. This event is accompanied by a reciprocal increase in GATA6. Here, we applied custom anti-GATA2 monoclonal antibodies and performed GATA2 immunohistochemistry (IHC) on patient endometrial tissues corresponding to proliferative, secretory, inactive, and hormone-treated endometrium, as well as endometriosis and endometrial atypical hyperplasia/endometrioid intraepithelial neoplasia (EAH/EIN). We also performed IHC for the estrogen receptor, PGR, and GATA6 in relevant groups. The results reveal a tight correlation between GATA2 and PGR expression in the glandular and stromal cells of benign endometrium. GATA2 expression is markedly reduced in stromal but not glandular cells in endometriosis and EAH/EIN. This reduction in GATA2 expression does not lead to a detectable increase in GATA6 expression in endometriosis. Although average glandular GATA2 expression was preserved in endometriosis and EAH/EIN cases, its expression was decoupled from PGR, implying that alternative pathways regulate GATA2 levels in these disorders. Our findings indicate that GATA2 dysregulation is a feature of endometriosis and EAH/EIN, and support a model whereby loss of stromal GATA2 in these disorders contributes to their progesterone insensitivity.

A multi-centre randomised controlled trial comparing megestrol acetate to levonorgestrel-intrauterine system in fertility sparing treatment of atypical endometrial hyperplasia

PURPOSE

The objective of the trial was to compare the regression rate of atypical endometrial hyperplasia (AEH) in patients treated with megestrol acetate (MA) vs. levonorgestrel-intrauterine device (LNG-IUS). We also aimed to assess the fertility and pregnancy outcomes in these patients.

METHODS

The study was a phase II multi-centre randomised controlled trial on the use of MA compared to LNG-IUS in the treatment of AEH conducted from January 2020 to January 2024 in Singapore. Women who were diagnosed with AEH and between 21 and 40 years old were included. The patients were randomised to receive either MA (160 mg orally daily) or LNG-IUS. The primary outcomes assessed were the regression rates at 3 months, 6 months and 9 months of treatment. The secondary outcomes assessed were the side effects, patient acceptability and fertility outcomes.

RESULTS

Thirty-six patients completed the trial. The overall regression rate was 88.9% by 9 months. There was no statistically significant difference in the 9-month complete regression rate between MA vs. LNG-IUS. There was also no significant difference in side effects and weight change between both arms. Nineteen patients were actively pursuing fertility after complete regression. There were 8 pregnancies achieved, with resultant 4 live births and 4 miscarriages.

CONCLUSION

Our study confirms a high regression rate of AH with medical treatment. LNG-IUS is a non-inferior treatment compared to megestrol acetate. Successful pregnancy outcomes can be achieved after regression of AEH. Long-term studies of sufficient sample-size are needed to assess for fertility and pregnancy outcomes, risk of recurrence and long-term risk of malignancy.

TRIAL REGISTRATION NUMBER

The study was registered with the Health Science Authority (HSA) (License No.: CTA1900087) on September 5, 2019: https://eservice.hsa.gov.sg/prism/ct_r/enquiry.do?action=loadSpecificDetail . The trial was registered retrospectively on ClinicalTrials.gov (ID: NCT05492487) on April 7, 2022: https://clinicaltrials.gov/study/NCT05492487 .

DNA methylation detection is a significant biomarker for screening endometrial cancer in premenopausal women with abnormal uterine bleeding

OBJECTIVE

The aim of our study was to explore the value of DNA (CDO1m/CELF4m) methylation detection in exfoliated cervical cells collected for screening endometrial cancer in premenopausal women with abnormal uterine bleeding.

METHODS

A total of 296 premenopausal women with abnormal uterine bleeding admitted to the Department of Obstetrics and Gynecology at the Third Xiangya Hospital of Central South University from November 2021 to October 2022 were selected. Clinical characteristics, endometrial thickness measured by transvaginal ultrasound and serum CA125 were collected. Exfoliated cervical cells from the thinPrep cytogic test were collected for DNA (CDO1m/CELF4m) methylation testing. Endometrial tissue was collected under hysteroscopy for pathological diagnosis as the gold standard. A univariate logistic regression model was used to analyze risk factors for endometrial cancer. The receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to measure the diagnostic efficacy of DNA methylation detection in endometrial cancer screening of women with abnormal uterine bleeding.

RESULTS

Univariate logistic regression analysis showed that age, body mass index (BMI) ≥25 kg/m2, endometrial thickness ≥11 mm, CDO1 methylation (CDO1mΔCt≤8.4), CELF4 methylation (CELF4mΔCt≤8.8), and dual gene methylation (CDO1mΔCt≤8.4 or CELF4mΔCt≤8.8) were independent risk factors for endometrial cancer in women with abnormal uterine bleeding. The odds ratio (OR) values (95% confidence interval (CI) were 0.87 (0.80-0.95), 4.76 (1.89-11.96), 8.41 (3.13-22.59), 64.49 (20.46-203.33), 12.79 (4.91-33.30), and 42.53 (11.90-152.04), respectively. Among these indicators, dual gene methylation had the higher sensitivity and specificity for endometrial cancer screening (85.7% and 87.6%). Moreover, dual gene methylation combined with BMI or endometrial thickness could further improve the screening efficiency of endometrial cancer in women with abnormal uterine bleeding.

CONCLUSIONS

In premenopausal women with abnormal uterine bleeding, the clinical efficacy of DNA (CDO1m/CELF4m) methylation detection in exfoliated cervical cells for endometrial cancer screening was better than that of other noninvasive clinical indicators. In addition, dual gene methylation combined with BMI or endometrial thickness was a good predictor of endometrial cancer screening.

Utilization and Surgical Outcomes of Sentinel Lymph Node Biopsy for Endometrial Intraepithelial Neoplasia

OBJECTIVE

To describe the rate and surgical outcomes of sentinel lymph node (SLN) biopsy in patients with endometrial intraepithelial neoplasia (EIN).

METHODS

We conducted a cohort study that used the prospective American College of Surgeons National Surgical Quality Improvement Program database. Women with EIN on postoperative pathology who underwent minimally invasive hysterectomy from 2012 to 2020 were included. The cohort was dichotomized based on the performance of SLN biopsy. Patients' characteristics, perioperative morbidity, and mortality were compared between patients who underwent SLN biopsy and those who did not. Postoperative complications were defined using the Clavien-Dindo classification system.

RESULTS

Overall, 4,447 patients were included; of those, 586 (13.2%) underwent SLN biopsy. The proportion of SLN biopsy has increased steadily from 0.6% in 2012 to 26.1% in 2020 ( P <.001), with a rate of 16% increase per year. In a multivariable regression that included age, body mass index (BMI), and year of surgery, a more recent year of surgery was independently associated with an increased adjusted odds ratio of undergoing SLN biopsy (1.51, 95% CI, 1.43-1.59). The mean total operative time was longer in the SLN biopsy group (139.50±50.34 minutes vs 131.64±55.95 minutes, P =.001). The rate of any complication was 5.9% compared with 6.7%, the rate of major complications was 2.3% compared with 2.4%, and the rate of minor complications was 4.1% compared with 4.9% for no SLN biopsy and SLN biopsy, respectively. In a single complications analysis, the rate of venous thromboembolism was higher in the SLN biopsy group (four [0.7%] vs four [0.1%], P =.013). In a multivariable regression analysis adjusted for age, BMI, American Society of Anesthesiologists classification, uterus weight, and preoperative hematocrit, the performance of SLN biopsy was not associated with any complications, major complications, or minor complications.

CONCLUSION

The performance of SLN biopsy in EIN is increasing. Sentinel lymph node biopsy for EIN is associated with an increased risk of venous thromboembolism and a negligible increased surgical time.

Chinese guidelines on the management of endometrial hyperplasia

• Endometrial hyperplasia can be classified as either hyperplasia without atypia or atypical hyperplasia. • Abnormal uterine bleeding is the most common symptom of endometrial hyperplasia. Transvaginal ultrasound is recommended for initial imaging to evaluate endometrial hyperplasia (evidence level 2+), while transrectal ultrasound is recommended for virgo patients (evidence level 3). • Endometrial biopsy should be used to confirm diagnosis in patients where endometrial lesions are suspected. Effective histological approaches to make definite diagnoses include diagnostic curettage (evidence level 2++), hysteroscopic-guided biopsy (evidence level 2+) and endometrial aspiration biopsy (evidence level 2-). • Progesterone is the preferred medication for the treatment of endometrial hyperplasia without atypia. Compared to oral progestins, placement of a levonorgestrel-releasing intrauterine system (LNG-IUS) has been associated with higher regression rates, lower recurrence rates and fewer adverse events which can be the initial treatment method. (Meta evidence level 1-, RCT evidence level 2+). Ultrasound and endometrial biopsies should be performed every 6 months during treatment to evaluate its effect and treatment should continue until no pathological changes are observed in two consecutive endometrial biopsies. Hysterectomy is not the preferred choice of treatment for patients with endometrial hyperplasia without atypia. • Minimally invasive hysterectomy is indicated for patients with endometrial atypical hyperplasia (evidence level 1+), bilateral fallopian tubes should also be removed (evidence level 2+). In cases where surgery cannot be tolerated, fertility is desired or the patient is younger than 45 years old, medical therapy is recommended (evidence level 3). LNG-IUS is the preferred medical therapy method (evidence level 2+). Endometrial pathologic evaluation should be performed every 3 months during conservative treatments, with adjustments made to dosages or approaches based on observed response to medication. Treatment should continue until no pathological changes are detected in two consecutive endometrial biopsies (evidence level 2++). There is no indication of sentinel lymph nodes biopsy and/or lymphadenectomy for hyperplasia with or without atypia. • Total hysterectomy is recommended to treat patients with recurrent endometrial atypical hyperplasia (evidence level 3); however, medical conservative therapy may be considered for patients hoping to become pregnant in the future. • Patients with fully regressed disease who would like to become pregnant should be advised to seek assistance through assisted reproductive technologies (evidence level 3). • Long-term follow-up is suggested for patients after endometrial hyperplasia treatment (evidence level 2+). Patient education is imperative for improving medication adherence, increasing regression rates and lowering recurrence rates (evidence level 3).

Levonorgestrel-releasing intrauterine device therapy vs oral progestin treatment for reproductive-aged patients with endometrial intraepithelial neoplasia: a systematic review and meta-analysis

BACKGROUND

We conducted a systematic review and meta-analysis to examine outcomes of patients with endometrial intraepithelial neoplasia treated with oral progestins or a levonorgestrel-releasing intrauterine device (IUD).

METHODS

We conducted a systematic review across 5 databases to examine outcomes of progestational treatment (oral progestins or levonorgestrel-releasing IUD) for patients with endometrial intraepithelial neoplasia. The primary outcome was the best complete response rate within 12 months of primary progestational treatment. Sensitivity analyses were performed by removing studies with extreme effect sizes. Secondary outcomes included the pooled pregnancy rate.

RESULTS

We identified 21 eligible studies, including 824 premenopausal patients with endometrial intraepithelial neoplasia, for our meta-analysis. Among these, 459 patients received oral progestin, and 365 patients received levonorgestrel-releasing IUD as a primary progestational treatment. The pooled best complete response proportion within 12 months was 82% (95% confidence interval [CI] = 69% to 91%) following oral progestin treatment and 95% (95% CI = 81% to 99%) following levonorgestrel-releasing IUD treatment. After removing outlier studies, the pooled proportion was 86% (95% CI = 75% to 92%) for the oral progestin group and 96% (95% CI = 91% to 99%) for the levonorgestrel-releasing IUD group, with reduced heterogeneity. The pooled pregnancy rate was 50% (95% CI = 35% to 65%) after oral progestin and 35% (95% CI = 23% to 49%) after levonorgestrel-releasing IUD treatment.

CONCLUSIONS

This meta-analysis provides data on the effectiveness of oral progestins and levonorgestrel-releasing IUD treatment within 12 months of treatment among premenopausal patients with endometrial intraepithelial neoplasia. Although based on small numbers, the rate of pregnancy after treatment is modest. These data may be beneficial for selecting progestational therapies that allow fertility preservation for patients with endometrial intraepithelial neoplasia.

Treatment outcomes according to various progestin treatment strategies in patients with atypical hyperplasia/endometrial intraepithelial neoplasia - Multicenter retrospective study (KGOG2033)

OBJECTIVE

To investigate pathologic complete response (pCR) and recurrence outcomes using various progestin treatment strategies in patients with atypical hyperplasia/endometrial intraepithelial neoplasia (AH/EIN).

METHODS

Medical records of patients diagnosed with AH/EIN and undergoing follow-up endometrial biopsy after progestin treatment between 2011 and 2020 were retrospectively reviewed. Clinical factors and treatment outcomes were analyzed according to initial progestin treatment (oral progestin [OP], levonorgestrel-releasing intrauterine device [LNG-IUD], and combination), OP dose, and maintenance treatment using Pearson's χ2, Fisher's exact test, and Kaplan-Meier analysis.

RESULTS

Of 124 patients included, 74, 37, and 13 were in the OP, LNG-IUD, and combination groups, respectively. The pCR rate was 79.8% and recurrence rate was 21.2%. The pCR rates within 3 and 6 months were significantly higher in the OP group than in the LNG-IUD group, but were not significantly different within 12 and 24 months. Recurrence rate was significantly higher in the OP group than in the LNG-IUD group. The pCR rate and recurrence rate had no significant differences between the combination group and the other groups. Excluding the LNG-IUD group, 53 and 34 patients received low- and high-dose OP, respectively. The pCR and recurrence rates were comparable between the low- and high-dose OP groups. Maintenance therapy was significantly associated with lower recurrence rate.

CONCLUSIONS

Although OP alone achieved more short-term pCR than the other groups, more recurrences occurred after pCR than LNG-IUD alone. High-dose OP as well as combination of OP and LNG-IUD did not increase pCR or reduce recurrence. Maintenance therapy may reduce the recurrence rate after pCR.

A Case Report of Consecutive Live Birth Twice Through in vitro Fertilization and Embryo Transfer After Endometrial Carcinoma Fertility Preservation Treatment

Preserving fertility is a vital concern for young women diagnosed with endometrial carcinoma. The clinical management of such patients is often disappointing. It is rare to have two consecutive successful pregnancies. We present a child-bearing-age woman who underwent fertility preservation therapy due to endometrial carcinoma. Following fertility preservation therapy, she underwent in vitro fertilization and embryo transfer. After receiving her first fresh embryo transfer, she successfully conceived and gave birth to a healthy child. Two years after the first embryo transfer and regular follow-up, she had another frozen embryo transfer of two cleavage embryos and successfully gave birth to another healthy baby. After the delivery of her second child, she underwent surgical treatment for endometrial carcinoma. For endometrial carcinoma patients who intend to preserve fertility, high-quality long-term follow-up and personalized treatment are necessary.

Atypical Endometrial Hyperplasia and Concurrent Cancer: A Comprehensive Overview on a Challenging Clinical Condition

The present review regarding atypical endometrial hyperplasia (AEH) focused on the main debated factors regarding this challenging clinical condition: (i) predictive variables of occult endometrial cancer (EC); (ii) the rate of EC underestimation according to different endometrial sampling methods; and (iii) the appropriateness of lymph node status assessment. When cancer is detected, approximately 90% of cases include low-risk EC, although intermediate/high-risk cases have been found in 10-13% of women with cancer. Older age, diabetes, high BMI, and increased endometrial thickness are the most recurrent factors in women with EC. However, the predictive power of these independent variables measured on internal validation sets showed disappointing results. Relative to endometrial sampling methods, hysteroscopic endometrial resection (Hys-res) provided the lowest EC underestimation, ranging between 6 and 11%. Further studies, including larger sample sizes of women undergoing Hys-res, are needed to confirm these findings. These data are urgently needed, especially for female candidates for conservative treatment. Finally, the evaluation of lymph node status measured on 660 of over 20,000 women showed a lymph node positivity of 2.3%. Although there has been an increase in the use of this procedure in AEH in recent years, the present data cannot recommend this option in AEH based on a cost/risk/benefit ratio.

Diagnosis and management of endometrial hyperplasia: A UK national audit of adherence to national guidance 2012-2020

BACKGROUND

Endometrial hyperplasia (EH) is a precusor lesion for endometrial cancer (EC), the commonest gynaecological malignancy in high-income countries. EH is a proliferation of glandular tissue, classified as either non-atypical endometrial hyperplasia (NEH) or, if the cytological features are abnormal, atypical endometrial hyperplasia (AEH). The clinical significance of AEH is that patients face both a high risk of having occult EC and a high risk of progression to EC if untreated. Recommendations on the care of women with EH were introduced by United Kingdom-wide guidance (Green-top Guide No. 67, 2016). National adherence to guidance is unknown. We aimed to describe the care of patients with EH; to compare the patterns of care for those with EH with national guidance to identify opportunities for quality improvement; and to compare patterns of care prior to and following the introduction of national guidance to understand its impact.

METHODS AND FINDINGS

In this UK-wide patient-level clinical audit, we included 3,307 women who received a new histological diagnosis of EH through a gynaecology service between 1 January 2012 and 30 June 2020. We described first-line management, management at 2 years, and surgical characteristics prior to and following national guidance for EH using proportions and 95% confidence intervals (CIs) and compared process measures between time periods using multilevel Poisson regression. Of the 3,307 patients, 1,570 had NEH and 1,511 had AEH between 2012 and 2019. An additional 85 patients had NEH and 141 had AEH during 2020. Prior to national guidance, 9% (95% CI [6%, 15%]) received no initial treatment for NEH compared with 3% (95% CI [1%, 5%]) post-guidance; 31% (95% CI [26%, 36%]) and 48% (95% CI [43% 53%]) received an intrauterine progestogen, respectively, in the same periods. The predominant management of women with AEH did not differ, with 68% (95% CI [61%, 74%]) and 67% (95 CI [63%, 71%]) receiving first-line hysterectomy, respectively. By 2 years, follow-up to histological regression without hysterectomy increased from 38% (95% CI [33%, 43%]) to 52% (95% CI [47%, 58%]) for those with NEH (rate ratio (RR) 1.38, 95% CI [1.18, 1.63] p < 0.001). We observed an increase in the use of total laparoscopic hysterectomy among those with AEH (RR 1.26, 95% CI [1.04, 1.52]). In the later period, 37% (95% CI [29%, 44%]) of women initially diagnosed with AEH who underwent a first-line hysterectomy, received an upgraded diagnosis of EC. Study limitations included retrospective data collection from routine clinical documentation and the inability to comprehensively understand the shared decision-making process where care differed from guidance.

CONCLUSIONS

The care of patients with EH has changed in accordance with national guidance. More women received first-line medical management of NEH and were followed up to histological regression. The follow-up of those with AEH who do not undergo hysterectomy must be improved, given their very high risk of coexistent cancer and high risk of developing cancer.

Sentinel lymph node assessment in patients with atypical endometrial hyperplasia: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to assess the rate of sentinel lymph node (SLN) metastases in patients with a pre-operative diagnosis of atypical hyperplasia/endometrial intra-epithelial neoplasia and endometrial cancer in hysterectomy specimens.

METHODS

A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and the protocol was registered in PROSPERO (CRD42023416769). MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scopus databases were searched from inception until April 2023. The inclusion criteria were patients with a pre-operative diagnosis of atypical hyperplasia/endometrial intra-epithelial neoplasia undergoing hysterectomy who did or did not undergo SLN assessment.

RESULTS

Four studies met the inclusion criteria. All studies were non-randomized studies with a total of 10 217 patients, 1044 in the SLN group and 9173 in the non-nodal assessment group. The unilateral and bilateral detection rate was 89% (I2=27.6%, 2 studies, 342 participants, 304 events) and 79% (I2=89.2%, 2 studies, 342 participants, 271 events), respectively. The rate of involved SLNs was 1.6% (I2=0%, 3 studies, 424 participants, 7 involved SLN) and 3.5% (I2=0%, 3 studies, 197 participants, 7 involved SLN) in patients with a pre-operative diagnosis of atypical hyperplasia/endometrial intra-epithelial neoplasia as the denominator and in those with endometrial cancer in the hysterectomy specimen, respectively. The cancer rate in the hysterectomy specimen was 45% (I2=72.8%, 3 studies, 503 participants, 224 events) and the most frequent endometrial cancer International Federation of Gynecology and Obstetrics 2009 stage was IA in 199 (89.2%) patients. The complication rate was similar between the groups.

CONCLUSION

The rate of SLN metastases in patients with pre-operative atypical hyperplasia/endometrial intra-epithelial neoplasia is less than 2%, suggesting that routine SLN evaluation may not be necessary in this population.