Postmenopausal endometrial cancer screening: is there a correlation between transvaginal sonographic measurement of endometrial thickness and body mass index?

OBJECTIVE: The aim of this study was to correlate the body mass index with transvaginal sonographic measurement of endometrial thickness in a cohort of postmenopausal women who were admitted for endometrial cancer surveillance. MATERIAL AND METHODS: Transvaginal sonographic measurement of endometrial thickness was performed in 97 postmenopausal women who attended the gynecology clinic for endometrial cancer screening with no history of hormone replacement therapy and correlated with body mass index. Baseline characteristics including age, years since menopause and body mass index were recorded for each subject. The relationship between transvaginal sonographic endometrial thickness and baseline characteristics was assessed in each. RESULTS: Body mass index was significantly correlated with years since menopause (r = 0.292, p = 0.004) and age (r = 0.243, p = 0.01) but not with endometrial thickness (r = -0.07, p = 0.454). Endometrial thickness versus time since menopause correlation was found to be significant (r = 0.274, p = 0.03) in patients with a body mass index lower than 30. CONCLUSION: The present findings indicate that endometrial thickness does not differ with body mass index in the screening of postmenopausal women for endometrial cancer.     

Is an endometrial thickness of ≥4 mm on transvaginal ultrasound scan an appropriate threshold for investigation of postmenopausal bleeding?

Uterine cancer is the fourth most common cancer in the UK. Transvaginal ultrasound (TVS) provides a reliable means of determining endometrial thickness. There is little consensus as to the optimum endometrial thickness threshold for investigation of endometrial cancer. The aim of our study was to ascertain an appropriate endometrial thickness (ET) while limiting unnecessary investigation. A prospective study of women with postmenopausal bleeding (PMB) referred to the rapid access clinic over a 2-year period was undertaken. The primary investigation was TVS and if the ET was ≥4 mm, an endometrial sampling (Pipelle®) or a hysteroscopy was undertaken. Endometrial cancers were identified from the pathology reporting system and a search of the Northern and Yorkshire Cancer Registry Information Service (NYCRIS). Pre-test/post-test risks of endometrial cancer and numbers needed to test were calculated to determine optimum ET threshold. There were 1045 referrals to the rapid access clinic with a history of PMB. Pre-test risk of endometrial cancer was 6.5 %. Post-test risk was stratified according to ET measurement. The probability of an endometrial cancer at an ET < 4 mm was 0.3 %. Binary logistic regression analysis confirmed a statistically significant linear correlation between ET and the risk of developing endometrial cancer (p < 0.0001). The numbers needed to test in order to diagnose one case of endometrial cancer at 3 mm is 11 when compared with 4 at 10 mm. The authors conclude a threshold of ET ≥ 4 mm ensures the majority of cancers are detected with minimal unnecessary invasive investigation.     

Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding: is it always necessary to perform an endometrial biopsy?

OBJECTIVE: This study was undertaken to evaluate whether it was possible to abstain from performing an endometrial biopsy when endometrial thickness according to transvaginal ultrasonography was /=50 years who were referred because of postmenopausal bleeding or irregular bleeding during hormone replacement therapy. If endometrial thickness was /=5 mm underwent either curettage or endometrial biopsy. RESULTS: One hundred sixty-three women had an endometrial thickness /=5 mm. The corresponding figure when atypical hyperplasia and endometrial metastases were included was 20. 2%. CONCLUSION: If the false-negative rate of endometrial biopsy techniques is taken into account, then the combination of transvaginal ultrasonography and cervical cytologic examination is an adequate form of management for women with postmenopausal bleeding or irregular bleeding during hormone replacement therapy as long as endometrial thickness is 相似文献   

Does size matter? Tumor size and morphology as predictors of nodal status and recurrence in endometrial cancer

OBJECTIVE: To determine whether tumor size or morphology is predictive of extrauterine disease and/or recurrence risk in endometrial cancer and therefore guide decisions about the necessity of complete surgical staging and adjuvant therapy. METHODS: All women with surgically treated endometrial carcinoma between 1 January 1990 and 1 January 2000 were eligible. 345 patients were eligible for retrospective chart review. Univariate and multivariate logistic regression models were used to determine the predictors of nodal metastasis and recurrence. RESULTS: As tumor size increased, the risk of nodal metastasis increased. However, a risk of nodal metastasis remained even with small lesions less than or equal to 2 cm (6.3% risk). Patients with tumor size greater than 2 cm had a 26.3% incidence of nodal metastasis. In univariate analysis, the odds ratio (OR) for tumor size as a predictor of extrauterine disease was 1.4 (95% CI 1.2-1.6). In multivariate analysis, tumor size was not statistically significant. Only the lesions greater than or equal to 8 cm confer a risk that approaches previously identified well-known predictors. Tumor size was not found to be a statistically significant predictor of recurrence OR 1.3 (1.0-1.8). CONCLUSIONS: Tumor size correlates with extrauterine disease, but it is not an independent prognostic variable. Although the risk of extrauterine disease increases with tumor size, the risk of nodal metastases remains even for those patients with very small tumors, underscoring the need for routine complete surgical staging. Tumor size does not appear to be an independent predictor of recurrence.     

The use of screening ultrasonography in the evaluation of postmenopausal breast cancer patients on tamoxifen: Is endometrial echo thickness enough?

This study addresses the efficacy of endometrial echo thickness and uterine volume in predicting endometrial histology in postmenopausal breast cancer patients on tamoxifen citrate. Sixty-four post-menopausal women with breast cancer using tamoxifen for at least 6 months were entered in the study. All subjects underwent transabdominal and transvaginal ultrasonography by a board-certified radiologist as well as having an office endometrial biopsy performed by a gynecologist. Twenty of the 64 patients were evaluated on two separate occasions at least 6 months apart. Histologic findings ranged from atrophic or inactive endometrium (N = 29), proliferative endometrium (N = 6), simple hyperplasia without atypia (N = 9), and scant tissue insufficient for diagnosis (N = 20). Endometrial echo averaged 10.6 mm (range: 1.2–25.0 mm), and mean uterine volume was 105 cm³ (range: 12–600 cm³). The correlation between histology and endometrial thickness was not significant (r = 0.12, P = 0.34). However, the correlation between histology and uterine volume was statistically significant (r = 0.31, P = 0.017). Both uterine volume and endometrial thickness were found to increase with duration of therapy but only uterine volume was found to correlate with the length of treatment. This study suggests that tamoxifen has a universal uterotropic effect stimulating myometrial as well as endometrial growth and, in addition, a uterine volume measurement may be more predictive of endometrial histopathology than endometrial thickness in this patient population.     

Tamoxifen and endometrial cancer. Is screening necessary? A review of the literature

Tamoxifen is a selective oestrogen receptor modulator (SERM) with anti-oestrogenic activity in the breast and oestrogenic effects in various tissues such as the endometrium, bone and cardiovascular territory. As adjuvant hormone therapy, it has a clear beneficial effect in patients with breast cancer, reducing relapses, contralateral breast cancer and mortality. Its most important secondary effect is a greater rate of occurrence of endometrial cancer. Although the risk/benefit ratio is clearly positive, the follow-up on these patients is still an issue. In women with metrorrhagia, it is clear that an endometrial sample must be obtained for histological examination and the best procedure today is hysteroscopic-directed biopsy. Nevertheless, the need to screen asymptomatic patients is not universally accepted. The vaginal ultrasound scan gives a great number of false positives. This entails more aggressive and more expensive procedures such as hysteroscopic-directed biopsy, meaning greater expense and more complications. As a result, the cost/benefit ratio is not very favourable. The rate of occurrence of endometrial cancer in 1026 tamoxifen-treated patients with breast cancer in our hospital between 1999 and 2001 was 1.25%. Two cases were diagnosed in asymptomatic patients. In this article, we analyse the literature on the need to screen patients on tamoxifen and about the most appropriate diagnostic protocol.     

MRI,PET/CT and ultrasound in the preoperative staging of endometrial cancer — A multicenter prospective comparative study

ObjectivesThe aim of this prospective multicenter study was to evaluate and compare the diagnostic performance of PET/CT, MRI and transvaginal two-dimensional ultrasound (2DUS) in the preoperative assessment of endometrial cancer (EC).Methods318 consecutive women with EC were included when referred to three Danish tertiary gynecological centers for surgical treatment. Preoperatively they were PET/CT-, MRI-, and 2DUS scanned. The imaging results were compared to the final pathological findings. This study was approved by the National Committee on Health Research Ethics.ResultsFor predicting myometrial invasion, we found sensitivity, specificity, PPV, NPV, and accuracy for PET/CT to be 93%, 49%, 41%, 95% and 61%, for MRI to be 87%, 57%, 44%, 92%, and 66% and for 2DUS to be 71%, 72%, 51%, 86% and 72%. For predicting cervical invasion, the values were 43%, 94%, 69%, 85% and 83%, respectively, for PET/CT, 33%, 95%, 60%, 85%, and 82%, respectively, for MRI, and 29%, 92%, 48%, 82% and 78% for 2DUS. Finally, for lymph node metastases, the values were 74%, 93%, 59%, 96%, and 91% for PET/CT and 59%, 93%, 40%, 97% and 90% for MRI. When comparing the diagnostic performance we found PET/CT, MRI and 2DUS to be comparable in predicting myometrial invasion. For cervical invasion and lymph node metastases, however, PET/CT was the best.ConclusionsNone of the modalities can yet replace surgical staging. However, they all contributed to important knowledge and were, furthermore, able to upstage low-risk patients who would not have been recommended lymph node resection based on histology and grade alone.     

Does immediate postpartum curettage of the endometrium accelerate recovery from preeclampsia–eclampsia? A randomized controlled trial

Objectives

To evaluate the effect of immediate postpartum curettage on rapid resolution of clinical and laboratory indices in pre-eclampsia and eclampsia women.

Methods

A randomized controlled study, comprised of 420 pre-eclamptic or eclamptic women with singleton pregnancy 24 weeks gestation and more. Patients were divided into two groups: 220 patients underwent immediate postpartum curettage and 200 patients as a control group.

Results

The clinical and laboratory prenatal parameters showed no statistical significant differences between both groups. The follow-up for the postnatal clinical and laboratory data showed significant improvement for the mean arterial blood pressure in the curettage group over 6, 12, and 24 h after delivery and significant improvement in the platelet count as well. The average time required for MAP to reach 105 mmHg or less was significantly shorter (P < 0.05) in the curettage group (40 ± 3.15 h) than the control group (86 ± 5.34 h). Two patients in the curettage group developed convulsions versus 11 patients in the control group within the first 24 h after delivery. No maternal mortalities were reported in both groups.

Conclusion

Immediate postpartum curettage is a safe and effective procedure and can accelerate recovery from pre-eclampsia or eclampsia.     

Premenopausal bleeding: When should the endometrium be investigated?—A retrospective non-comparative study of 3006 women

Objective

There is lack of consensus amongst professional organizations as regards the cut-off age for endometrial sampling of premenopausal women presenting with abnormal uterine bleeding (AUB) to exclude endometrial hyperplasia or carcinoma. Therefore we conducted this study to quantify the prevalence of hyperplasia and carcinoma in different age categories in premenopausal women with AUB to identify the appropriate cut-off age for endometrial sampling.

Study design

A retrospective review of the histopathology reports of endometrial samples taken from 3006 women presenting with AUB and aged from ≥30 to ≤50 years at Ipswich Hospital, UK, from 1 January 1998 to 31 December 2007. Women were divided into three subgroups according to age; group 1: 30 to ≤40 (n = 862), group 2: 40 to ≤45 (n = 1035) and group 3: 45 to ≤50 (n = 1109).

Results

Logistic regression revealed that the prevalence of atypical hyperplasia (OR: 3.85; 95% CI: 1.75, 8.49; p = 0.01) and carcinoma (OR: 4.03; 95% CI: 1.54, 10.5; p = 0.04) was significantly higher in women in group 3 when compared to younger women. There was no statistically significant difference as regards simple and complex hyperplasia in the different age categories. All but one of the women (n = 23) who had complex atypical hyperplasia or carcinoma under the age of 45 years, presented with irregular rather than cyclical heavy menstrual bleeding.

Conclusion

Our study, the largest in the literature, suggests using the age 45 years as a cut-off for sampling the endometrium in all women with AUB. However, irregular menstrual bleeding justifies investigating women regardless of their age.     

Evaluation of endometrial steroid receptors and cell mitotic activity in women using copper intrauterine device: Can Cu-T prevent endometrial cancer?

AIMS: To study changes in endometrial proliferative indices (i.e. cell mitosis and Ki67), endometrial steroid (estrogen and progesterone) receptors, and serum estradiol and progesterone level in women using copper intrauterine device (IUD) after 6 months of use. METHODS: Fifteen healthy women were recruited having no contra indication to IUD or endometrial biopsy. Endometrial biopsies and serum samples were taken on 10/11th day of menstrual cycle at recruitment and after six months. The endometrial samples were subjected to: (i) steroid receptor estimation by immunohistochemistry; (ii) cell mitosis and Ki67 estimation by morphology and proliferative indices. RESULTS: The mean glandular mitotic index was 1.69 +/- (0.39) at first visit and 0.35 +/- (0.15) at second visit after 6 months. Similarly, Ki-67 count in glands was 11.79 +/- (1.59) at first visit and 2.40 +/- (0.54) at second visit. In the stroma, Ki67 decreased from a mean of 0.85 to 0.01 in six months. This suggested statistically significant reduction in proliferation and mitotic activity in endometrial glands and the stroma of women who used Cu-T continuously for a long period.There was a significant reduction of estrogen receptor concentration in glands (from a mean of 51.67 down to 11.67) and the stroma (from a mean of 33.00 to 8.00) over this 6-month period. The observed fall in progesterone receptor counts was less compared to other parameters studied, being marginally significant in stroma (from a mean of 32.00 down to 14.33), but not significant enough in glands (from a mean of 45.00 down to 25.00). No changes were observed in serum hormone levels in these two visits. CONCLUSION: Continuous use of copper intrauterine device causes significant reduction in endometrial mitotic activity as well as estrogen receptor concentration without affecting serum estradiol or progesterone levels. This finding infers that Cu-T may have a protective role against endometrial cancer.     

Can the endometrial thickness as measured by trans-vaginal sonography be used to exclude polyps or hyperplasia in pre-menopausal patients with abnormal uterine bleeding?

BACKGROUND: To combine findings of normal mid-line echoes from TVS (trans-vaginal sonography) with cut-off levels for endometrial thickness, in order to examine the associated risk of abnormalities in the uterine cavity. DESIGN AND SETTING: Two center prospective study at a university clinic and a central hospital in Denmark. PARTICIPANTS: Three hundred and fifty-five pre-menopausal patients with abnormal uterine bleeding, and indications for endometrial sampling or surgery. INTERVENTIONS: The thickness of the endometrium was measured, and the mid-line echoes were evaluated using TVS. The findings from the endometrial sampling, combined with the evaluation of the uterine cavity using operative hysteroscopy (115), hysterectomy (74) or HSE (hysterosonographic examination) (166), were used as the true values. RESULTS: The mean (+/-s.d.) endometrial thickness was significantly different in patients with hyperplasia 11.5 mm (+/-5.0), polyps 11.8 mm (+/-5.1), sub-mucous myomas 7.1 mm (+/-3.4) and in patients without these abnormalities 8.37 (+/-3.9) (p<0.001). Hyperplasia and/or polyps were present in 20% of all patients, and in 8% of 143 patients with an endometrial thickness of < or =7 mm. This proportion did not decrease with lower cut-off levels for endometrial thickness. Receiver operating characteristic (ROC) curves were not optimal for excluding hyperplasia or polyps by endometrial thickness. In 173 cases with a distinct, regular midline echo without echo-dense foci in TVS the proportion of patients with abnormalities was 16% (11-23). This proportion did not decrease with cut-off levels for endometrial thickness. CONCLUSIONS: Using TVS, low levels of endometrial thickness reduced the possibility of abnormalities such as polyps and hyperplasia, but did not exclude them. Low cut-off levels for endometrial thickness did not increase the diagnostic performance in cases with normal sonograms.     

Is levonorgestrel intrauterine system effective for treatment of early endometrial cancer? Report of four cases and review of the literature

BACKGROUND: Intrauterine progesterone therapy potentially provides a simple alternative treatment for women with Stage I Grade I endometrial cancers who are at high risk for surgery. The case histories of four women with early endometrial cancer primarily treated with levonorgestrel intrauterine system (Mirena) are reported and the literature reviewed. CASES: Four women had Stage I grade 1 endometrial adenocarcinoma with positive progesterone receptor. All were assessed to be in American Society of anaesthesiologists risk class IV. After insertion of mirena intrauterine system, one woman (25%) had complete histological regression of disease within 6 months. One of three women who did not respond to treatment subsequently had a vaginal hysterectomy, which showed endometrial cancer with superficial myometrial invasion. CONCLUSION: This report raises doubts about the effectiveness of intrauterine progesterone therapy as a definitive alternative for the treatment of early endometrial cancer.