Endometrial sampling before or after saline contrast sonohysterography in women with postmenopausal bleeding (ESPRESSO trial): A multicenter randomized controlled trial

Diagnostic workup of patients with benign or inconclusive reports on office endometrial biopsy after first episode of postmenopausal blood loss

BACKGROUND

Postmenopausal bleeding carries a risk of endometrial cancer, and office endometrial sampling (OES) is often the first diagnostic approach. Whether further diagnostic procedures such as hysteroscopy or saline infusion sonography (SIS) are required to rule out polyps and malignancies is uncertain. The objective of this study is to evaluate whether clinicians perform further diagnostic tests when OES is benign or inconclusive. Secondary outcomes include the patient characteristics associated with the likelihood of performing further diagnostic tests and the incidence of endometrial intraepithelial neoplasia and endometrial malignancy.

METHODS

We performed a multicenter, prospective cohort study, evaluating patients with a first episode of postmenopausal bleeding, with an endometrial thickness of >4 mm on 2D vaginal sonography and a benign or inconclusive result of an OES. Patients who underwent further diagnostic or therapeutic procedures (hysteroscopy or SIS) were compared to patients who did not. Univariate and multivariate analyses were performed to identify predictive factors for additional diagnostic procedures and the diagnosis of endometrial malignancy.

RESULTS

Of the 350 eligible patients, 197 (56 %) underwent further diagnostic procedures. These patients had a thicker endometrium (median 8.6 mm vs. 6.0 mm; p < 0.001), more frequent suspicion of intracavitary abnormalities (34.0 % vs. 14.4 %; p < 0.001), and more frequent insufficient aspiration samples (20.8 % vs. 11.8 %; p = 0.025) compared to patients who received expectant management. Multivariate regression analysis confirmed these findings. The underlying risk of malignancy was 2.7 % with benign samples and 6.8 % with insufficient samples. Overall, malignancy incidence was higher in those who underwent further diagnostic workup (p = 0.04).

CONCLUSION

In this prospective study, just over half of patients underwent further diagnostic procedures. Endometrial thickness, suspicion of intracavitary abnormality or an insufficient endometrial sample were predictive for further diagnostic workup. The incidence of malignancy was higher in patients who underwent diagnostic workup, which argues for a risk-based strategy in clinical decision-making.

REGISTRATION

Central study approval was obtained at the Erasmus MC (MEC 2015-740). The study was registered in the Dutch trial register (www.onderzoekmetmensen.nl, NL7608).

Current challenges and emerging tools in endometrial cancer diagnosis

The diagnostic process of endometrial cancer includes imaging methods such as trans-vaginal ultrasound, along with procedures to obtain endometrial tissue for histologic evaluation. Common techniques for tissue sampling include Pipelle endometrial biopsy, hysteroscopy, and dilation and curettage, which are used to confirm the diagnosis, determine tumor histology, grade, and molecular profile. However, diagnostic algorithms for endometrial cancer differ significantly across countries, influenced by local resources, protocols, and the availability of diagnostic methods. These variations include differences in the endometrial thickness threshold for recommending a biopsy and the choice of the initial diagnostic test. Moreover, patients often have multiple tests and appointments before a definitive diagnosis, although only 5%-10% of women with post-menopausal bleeding are diagnosed with endometrial cancer. Current diagnostic techniques have limitations. Pipelle endometrial biopsy has a significant false-negative rate (10%-20%) and may fail to provide adequate diagnostic material in up to 30% of cases. Hysteroscopy, while useful, is associated with pain in up to 65% of patients and can delay diagnosis because of limited availability. Dilation and curettage is an invasive procedure requiring general anesthesia and has a higher complication rate. In response to these challenges, there is growing interest in developing new diagnostic tools that are less invasive and provide 1-step diagnoses, including liquid biopsies from urine, blood, cervico-vaginal and endometrial fluid samples by means of genomics and proteomics. This review will examine the current diagnostic algorithms in European and American guidelines, evaluate the sensitivity, specificity, and accuracy of current techniques, and explore new diagnostic tools under development.

The effects of Saline Infusion Sonography on the histological quality of endometrial sampling in women with postmenopausal bleeding

BACKGROUND

The aim of this study is to analyze the histopathological features of endometrial samples obtained by aspiration when performed before or after the saline contrast sonohysterography in women with postmenopausal bleeding and a thickened endometrium. Hypothetically, the saline infusion could disrupt the tissue and therefore affect the quality of the sample. Furthermore, we want to determine which histological features have impact on the quality of the endometrial sample.

METHODS

We performed a randomized controlled trial (ESPRESSO trial) in which we analyzed the aspiration samples in two groups. Women were allocated either to saline contrast sonohysterography and subsequent endometrial sampling (SCSH-Sampling group) or to the opposite order (Sampling-SCSH group). Dedicated gyneco-pathologists retrospectively assessed the specimens and recorded the type (blood, mucus, epithelium, intact glands, stroma and tissue context) and quantity (on a scale of 0-3) of material that was found in the specimens.

RESULTS

This analysis consisted of 197 samples, with 101 women in the SCSH-Sampling group and 96 women in the Sampling-SCSH group. No significant differences were found in the histological features between the two groups. All significant histological features differed significantly in the sufficient samples compared to the insufficient samples: higher amounts of blood, more endometrial epithelium, presence of intact endometrial glands, better stroma and tissue context. Oppositely, a significantly higher amount of mucus was found in the insufficient samples.

CONCLUSION

This study shows that the histological features of the endometrial sample were not affected by the saline contrast sonohysterography, when performed prior to the tissue sampling. Trial registration ESPRESSO TRIAL, NTR5690, registered 16 February 2016, https://trialsearch.who.int/Trial2.aspx?TrialID=NTR5690 .

Endometrial sampling before or after saline contrast sonohysterography in women with postmenopausal bleeding (ESPRESSO trial): A multicenter randomized controlled trial

INTRODUCTION

The aim of this study is to evaluate the quality of the endometrial sample obtained by office endometrial aspiration when performed before or after saline contrast sonohysterography (SCSH) in women with postmenopausal bleeding and a thickened endometrium. To conduct a complete, minimally invasive and cost-effective diagnostic workup in women with postmenopausal bleeding and a thickened endometrium, ideally both the office endometrial sampling and SCSH are performed. However, it is not known whether both tests affect each other when performed one after another.

MATERIAL AND METHODS

Women with postmenopausal bleeding and an endometrial thickness >4 mm were eligible. Women were randomized into two groups: one group received endometrial aspiration before SCSH, the other group received SCSH before endometrial aspiration. The primary outcome was the proportion of sufficient endometrial samples. Reliability of the SCSH images and pain during procedures were secondary outcomes.

RESULTS

During the inclusion period, 513 eligible women with postmenopausal bleeding visited the participating hospitals, 293 of whom received information about the study. Of these women, 232 (79%) agreed to participate. In the SCSH-aspiration group, 65 women (59%) had a sufficient endometrial sample compared with 70 (67%) in the aspiration-SCSH group (odds ratio 1.46, 95% CI 0.83-2.54, P = .19). The proportion of reliable sonographic images was significantly higher in the SCSH-aspiration group (n = 88, 87%) compared with the aspiration-SCSH group (n = 71, 74%) (OR 2.38, 95% CI 1.38-4.99, P = .02) in the per protocol analysis.

CONCLUSIONS

This study shows that the quality of an endometrial sample in women with postmenopausal bleeding is not affected by SCSH. Both procedures can be performed in one outpatient visit to perform an optimal diagnostic workup.