Clinical utility of liquid-based cytology for the characterization and management of endometrial polyps in postmenopausal age.

The proper management of endometrial polyps still represents a clinical ongoing challenge, especially when they are asymptomatic and occasionally discovered. The aim of this study was to evaluate liquid-based endometrial cytology to manage endometrial polyps in postmenopausal age by its ability to exclude hidden premalignant and malignant changes within polyps. Three hundred fifty-nine consecutive postmenopausal patients who underwent hysteroscopic diagnosis of endometrial polyp over a 3-year period and who were scheduled for surgical removal within the three subsequent months were retrospectively evaluated. Histologic results after resection during operative hysteroscopy or during hysterectomy were compared with liquid-based cytology and endometrial biopsy obtained at the time of diagnostic hysteroscopy. Eight of 359 patients (2.2%) had malignant or premalignant polyps interpreted as benign finding at hysteroscopy. Unsatisfactory samples were higher for endometrial biopsy compared to liquid-based cytology in the whole series and in the subgroup of low-risk asymptomatic patients (P < 0.001). Endometrial biopsy and liquid-based cytology revealed a sensitivity of 62% and 87.5%, respectively and a 100% specificity. Considering the subgroup of low-risk asymptomatic patients, liquid-based cytology disclosed all the five pathologic lesions with a 100% sensitivity and specificity. In conclusion, liquid-based cytology proved to be a useful tool to establish the nature of endometrial polyps in postmenopausal patients. Complete removal of the lesion should be offered to all symptomatic patients and those with established risk factors for endometrial cancer. Conversely, a wait and see attitude should be considered in case of asymptomatic low-risk polyps with typical appearance on hysteroscopy and negative liquid-based cytology.

Can hysteroscopic evaluation of endometrial carcinoma influence therapeutic treatment?

235 cases of primary endometrial adenocarcinoma (AC) (age range, 37-94; mean age, 61 years) were collected during the period 1980-1992. Hysteroscopic examination of both the endometrial cavity and the cervical canal was performed in every patient prior to hysterectomy, and evaluations of cancer extension in the endometrium (focal: 97 pts; partial: 82 pts; massive: 47 pts; unevaluable: 9 pts) and of endocervical involvement (positive: 45 pts) were compared to the histological findings and survival rates. The chi 2 test was used for statistical analysis, and statistical significance was considered where the p value was < 0.05. Endometrial extension was poorly related to the depth of myometrial invasion (M1 = depth of invasion to < 1/2 myometrium, M2 = invasion to > 1/2 myometrium): focal AC: M1 57.8%, M2 42.2%; partial AC: M1 40.2%, M2 59.8%; massive AC: M1 51.1%, M2 48.9%; (p = 0.5). Endocervical involvement was unrelated to endometrial extension. No correlation was found between AC histological grade (G1-G3) and entity of endometrial extension, whereas grade showed a significant correlation with myometrial invasion (G1 M1: 69.1%; G3 M1: 41.0%; p = 0.002) and survival rates (G1 90.4%, G2 88.5%, G3 69.4%; p = 0.01). Five-year survival figures showed no evident correlation with cancer extension (focal AC: 86.5%; partial AC: 87.8%; massive AC: 86.3%; p = 0.9) whereas myometrial invasion showed a statistical significance (M1: 91.4%, M2: 79.7%; p = 0.03). Three patterns of invasion were defined: pushing (P), infiltrative (I) and diffuse (D) isolated cells. There were significant differences between the various growth patterns and survival rates (P 90.7%; I 84.3%; D 45.4%; p = 0.0001). False negative rate of the hysteroscopic diagnosis of cervical involvement was 7.9% (18 cases); however, in 6 of these cases only deep cervical invasion was found.

Pressure lavage under ultrasound guidance: a new approach for outpatient treatment of intrauterine adhesions.

OBJECTIVE: To present pressure lavage under ultrasound guidance (PLUG) as a new therapeutic procedure for selected cases of intrauterine adhesions (IUA). DESIGN: An open clinical investigation with no control group. SETTING: Teaching hospital. PATIENT(S): Seven consecutive patients referred to our department for secondary amenorrhea due to IUA. INTERVENTION(S): A newly developed technique based on sonohysterography was used to monitor the effects of intrauterine injections of saline solution on the continuous accumulation of saline in the uterine cavity for the mechanical disruption of IUA. MAIN OUTCOME MEASURE(S): Lysis of intrauterine adhesions, restoration of menses, and increased pregnancy rate in infertile patients. RESULT(S): Five patients with mild IUA obtained satisfactory lysis of adhesions by the use of the PLUG technique. A second-look hysteroscopy after 1 month showed that filmy adhesions persisted in two patients with moderate IUA. These adhesions were removed successfully during hysteroscopy. Restoration of menses was obtained and has continued in all patients. Two of the three infertile patients became pregnant. CONCLUSION(S): This technique is safe and ideal as an in-office procedure. PLUG allows complete lysis in mild IUA cases, and the need for therapeutic, and possibly follow-up hysteroscopy, can be avoided. In moderate IUA cases, the procedure may represent a useful initial step in reducing the need for operative hysteroscopy.

Intraoperative ultrasound guidance for operative hysteroscopy. A prospective study.

OBJECTIVE: To evaluate the efficacy and safety of ultrasound (US) guidance as compared to laparoscopic monitoring during operative hysteroscopy. STUDY DESIGN: Prospective, open study including 81 patients undergoing operative hysteroscopy under US guidance for uterine septum and submucous myoma. Clinical and surgical outcomes were compared with those in an historical control group of 45 patients undergoing the same operation under laparoscopic guidance. RESULTS: US guidance proved satisfactory in all patients, and there were no complications due to insufficient visualization of the pelvic structures; in no case was conversion to laparoscopic guidance required. US scanning was most useful in determining the outer limit of the intramural component of submucous partial intramural myoma, allowing complete resection. During metroplasty, US guidance allowed extension of the resection beyond the normal limit conventionally defined by hysteroscopy; none required reintervention. By comparison, in the control group, a second attempt was required because the operation was insufficiently radical in four patients. CONCLUSION: US guidance was used successfully as the only visual aid for hysteroscopic surgery, comparing favorably with laparoscopy in terms of efficacy and safety.

Levo-norgestrel-nova-T and precancerous lesions of the endometrium.

The authors report the preliminary data on the topical treatment of endometrial hyperplasia by an intrauterine device releasing Levo-norgestrel (LNG-Nova-T), in a series of 31 patients. The patients examined so far by endometrial biopsies performed at predetermined intervals showed a complete histological regression of the hyperplasia, regardless of its pattern.

Liquid-based endometrial cytology: cyto-histological correlation in a population of 917 women.

OBJECTIVE: Liquid-based cytology, because of its capacity to reduce the obscuring factors and to provide thin-layer specimens, represents an opportunity to reevaluate endometrial cytology. In order to assess the utility of the liquid-based method in endometrial diagnosis, we evaluated its accuracy in comparison with histology. METHODS: Nine hundred and seventeen women scheduled for hysteroscopy were enrolled in the study. After providing informed consent, all the women proceeded sequentially to hysteroscopy, endometrial cytology and then biopsy endometrial sampling. RESULTS: Cyto-histological correlations were possible in 519 cases (57%): in 361 (39%) cases the biopsy was inadequate, in 15 (2%) the cytology was inadequate, and in 22 (2%) both were inadequate. At biopsy 25 (3%) women had adenocarcinoma, 5 (1%) had adenomatous atypical hyperplasia and 21 (2%) had simple non atypical hyperplasia. At cytology two adenocarcinomas and one adenomatous atypical hyperplasia were underrated as atypical hyperplasias and as non-atypical hyperplasia; two simple non-atypical hyperplasias were reported as negative; and eight cases were false positive (non-atypical hyperplasia at cytology, negative at biopsy). In our population, the cytology provided sufficient material more often than biopsy (P < 0.04). Sensitivity was estimated at 96%, specificity at 98%, positive predictive value at 86% and negative predictive value at 99%. CONCLUSIONS: We concluded that endometrial cytology may be an efficient diagnostic method. It could be applied to selected patients solely or in association with ultrasonography. The combination of these two noninvasive procedures may improve their diagnostic accuracy and reduce unnecessary hysteroscopies, thereby producing benefits for women and society.

Liquid-based endometrial cytology: its possible value in postmenopausal asymptomatic women.

The incidence of endometrial adenocarcinoma in asymptomatic women is low. Nevertheless, some of these women might require endometrial surveillance. In this study, we evaluated the accuracy of liquid-based endometrial cytology compared to biopsy in asymptomatic postmenopausal women. Three hundred twenty women scheduled for hysteroscopy were enrolled for this study. After hysteroscopy, patients were submitted to endometrial cytology and to biopsy. Two hundred ninety-three (92%) women had sonographically thickened endometrium (>5 mm), 53 (17%) were on tamoxifen, and 16 (5%) were on hormonal substitutive treatment. The evaluation of the biopsies determined that six (2%) women had adenocarcinoma, one (<1%) had adenomatous atypical hyperplasia, and eight (3%) had simple nonatypical hyperplasia. Endometrial cytology evidenced 5 (2%) neoplastic cases, 2 (<1%) hyperplastic with atypia cases, and 25 (8%) hyperplastic without atypia cases. Two hundred twenty-two biopsies (69%) and 17 (5%) cytologies were inadequate. One adenocarcinoma and one simple nonatypical hyperplasia were underrated by cytology resulting, respectively, as atypical hyperplasia and as negative. Four cases were false positive (simple nonatypical hyperplasias on cytology, negative on biopsy). The sensitivity and specificity were estimated, respectively, at 94% and 95%; the positive and negative predictive value were estimated, respectively, at 80% and 99%. Endometrial cytology provided sufficient material more often than biopsy (P < 0.01). We suggest to introduce liquid-based endometrial cytology in the management of some subpopulations of asymptomatic postmenopausal women. Particularly, the combination of liquid-based endometrial cytology and transvaginal sonography may improve their diagnostic accuracy and reduce unnecessary more invasive and expensive procedures.

Hysteroscopy for evaluation of tubal ostium pathology.

A comparison between hysterosalpingography and hysteroscopy in the evaluation of tubal ostium pathology is presented by the authors. They stress in particular the role of hysteroscopy in this evaluation.

Precancerous lesions of the endometrium and medical treatment.

Endometrial hyperplasias, which occur in the premenopausal age and are often induced by anovulatory cycles, are kept under control by progestin therapy. The good results with natural and synthetic progestins suggest that this treatment can be used both in premenopause and postmenopause hyperplasia. The progestin effect on the endometrium appears through a marked pseudodecidual reaction of the stroma and functional atrophy of the glands. These events are reported in the literature as inactive or suppressed endometrium and there is no physiological equivalent.

Hysteroscopy and endometrial biopsy.

The role of hysteroscopy for a complete evaluation of luteal phase is discussed by the authors. They affirm that for a thorough evaluation a hysteroscopy may be usefully performed simultaneously to the endometrial biopsy.