Re: Atypical complex hyperplasia / endometrial cancer
From: Michael J. Wolpmann, MD (elvisdoc@comcast.net)
Fri Feb 21 05:21:28 2003
Recent meta-analysis from the Green Journal which seems to indicate that
d & c may be the best primary diagnostic tool for PMB, as TVUS and even
EMB will miss too many malignancies. Which raises the question, was the
atypia there all along and the EMB by your primary care physician just
missed it? And given the information below, can you trust TVUS to
monitor endometrial thickness in the presence of prior abnormality?
Complex hyperplasia with atypia or worse in PMP and otherwise healthy
patient...would treat with hysterectomy. What is the benefit of keeping
it once nuclear atypia has been identified? Route of removal....LAVH or
TVH with frozen could be quite justified for atypia alone or possibly
even case #2 given other factors but be prepared to open if frozen shows
higher grade or invasion >50%. In light of that, my preference would be
TAH BSO, with washings and possible LND/omentectomy/etc as the safest
course for case 2. Frozen has returned as grade 2 or 3 on what appeared
to be well-differentiated quite a few times for me and necessitates
complete staging.
good luck,
Michael
Review
April 2002
Volume 99, Number 4
Pages 663 - 670
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Endometrial Thickness as a Test for Endometrial Cancer in Women With
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Postmenopausal Vaginal Bleeding
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Ann Tabor>,a Hilary C. Watt,b and Nicholas J. Waldb
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Objective: To assess the value of endometrial thickness measurement as a
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test for endometrial cancer in postmenopausal women with vaginal
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bleeding (symptomatic women).
Data Sources: We conducted a literature search using the MEDLINE
database from 1991 to 1997, and the key words "vaginal ultrasonography"
and "endometrial thickness measurement." The review was limited to
original research reports written in English, concerning symptomatic
women having vaginal ultrasonography before a diagnostic test and not
receiving tamoxifen.
Study Selection: A total of 48 studies were identified. A questionnaire
was sent to the corresponding author of each paper requesting
supplementary information. Data were included in our analysis if the
corresponding author was able to supply information on the median
endometrial thickness in unaffected symptomatic women and the
endometrial thickness values in affected women. Nine studies were thus
included in our meta-analysis, representing 3483 women without
endometrial cancer and 330 women with endometrial cancer.
Tabulation, Integration, and Results: The median endometrial thickness
in women with endometrial cancer was 3.7 times that in unaffected women
at the same center, and with the same menopausal status and same hormone
replacement therapy use category. The detection rate was 63% (95%
confidence interval 58, 69) for a 10% false-positive rate, or 96% (95%
confidence interval 94, 98) for a 50% false-positive rate.
Conclusion: Endometrial thickness measurement in symptomatic women does
not reduce the need for invasive diagnostic testing because 4% of the
endometrial cancers would still be missed with a false-positive rate as
high as 50%.
At Thu, 20 Feb 2003, Dr. Ainsworth wrote:
>
>Two patients this week with similar problems with PMB, different
>outcomes:
>1). I hysteroscoped a patient this week for postmenopausal bleeding and
>the final pathology showed Complex hyperplasia with focal atypia. Her
>history is that her PCP had been giving her unopposed estrogen
>injections for a number of years and he biopsied her last year and found
>complex hyperplasia w/o atypia. He referred her to me this month
>because she had 3-4 episodes of bleeding over the last year. He had
>ignored his previous biopsy findings, at least he failed to act on them.
>When I saw her, the lining was thickened on TVUS and my biopsy also
>showed complex hyperplasia w/o atypia. My recommendation to her is to
>discontinue estrogen, I feel that I completely resected the lining and
>did not miss any underlying cancer. Does anyone feel strongly that she
>should have a hysterectomy? I will probably monitor with TVUS yearly for
>a couple of years.
>
>2) The pathology on another patient I hysteroscoped this week because of
>AGUS showed extensive complex hyperplasia w/focal atypia and focal areas
>of well differentiated adenocarcinoma, adenomyosis with hyperplasia and
>no evidence of stromal invasion. I was sure at the time of the
>hysteroscopy that I was dealing with a cancer, polypoid tissue
>extensively throughout the cavity with atypical vessesl, very friable.
>Obviously she needs a hysterectomy. Would your choice be a)
>TAH/BSO/cell washings/limited node sampling, b) LAVH/BSO with cell
>washings, c)TVH/BSO, or d)refer for Gyn oncology (which means referral
>to a center 2 hours away). She is 71 and in good health. She has been
>on continuous Premarin 0.625 with Prometrium, 100 mg. An endometrial
>biopsy prior to the hysteroscopy showed proliferative endometrium with
>focal metaplasia, TVUS showed 1.1cm thick endometrium.
--
Michael J. Wolpmann, MD, FACOG, FACS
The Women's Centre at Bayside Gynecology
Venice, Florida
