Ultrasonographic evaluation of endometrial stripe thickness is insufficient to rule out uterine serous carcinoma.

PURPOSE: Uterine serous carcinoma (USC) is a rare endometrial cancer representing less than 10% of uterine cancers but contributing to up to 50% of the mortality. Delay in diagnosis with this high-grade histology can have significant clinical impact. USC is known to arise in a background of endometrial atrophy. We investigated endometrial stripe (EMS) thickness in USC to evaluate current guidelines for postmenopausal bleeding in the context of this histology. METHODS: Retrospective chart review was conducted using ICD-9 and ICD-10 codes over an 18-year period. We included 139 patients with USC and compared characteristics of patients with EMS ≤ 4 mm and EMS > 4 mm. Chi-square or Fisher's exact tests were used to compare proportions and two-tailed t-tests to compare means. A p-value of < 0.05 was considered statistically significant. RESULTS: Most patients were white, obese, and multiparous. Thirty-two (23%) had an EMS ≤ 4 mm; 107 (77%) had an EMS > 4 mm. There were no statistically significant differences in age at diagnosis or presenting symptoms between groups, and postmenopausal bleeding was the most common symptom in each group. CONCLUSION: Nearly 25% of patients with USC initially evaluated with transvaginal ultrasound were found to have an EMS ≤ 4 mm. If transvaginal ultrasound is used to triage these patients, one in four women will potentially experience a delay in diagnosis that may impact their prognosis.

Success Rates of Sentinel Lymph Node Mapping for Endometrial Cancer in Patients with Body Mass Index < 45 Compared with Body Mass Index ≥ 45.

STUDY OBJECTIVE: The objective is to evaluate the rate of sentinel lymph node (SLN) mapping in patients with body mass index (BMI [kg/m2]) BMI ≥ 45 compared with < 45. DESIGN: A retrospective chart review. SETTING: Three urban referral-based settings-1 academic and 2 community based. PATIENTS: Patients age ≥ 18 years, with endometrial intraepithelial neoplasia or clinical stage 1 endometrial cancer who underwent robot-assisted total laparoscopic hysterectomy with attempted SLN mapping between January 2015 and December 2021. INTERVENTIONS: Robot-assisted total laparoscopic hysterectomy with attempted SLN mapping. MEASUREMENTS AND MAIN RESULTS: A total of 933 subjects were included: 795 (85.2%) with BMI < 45 and 138 (14.8%) with BMI ≥ 45. Comparing the BMI < 45 with BMI ≥ 45 group, bilateral mapping was successful in 541 (68.1%) vs 63 (45.7%), respectively. Unilateral mapping was successful in 162 (20.4%) vs 33 (23.9%), respectively. Failure to map occurred in 92 (11.6%) vs 42 (30.4%) (p <.001), respectively. Exploratory analysis also suggested an inverse relationship between success rate of bilateral SLN mapping and BMI, with patients with BMI < 20 having bilateral SLN mapping rates of 86.5% and patients with BMI ≥ 61 having rates of 20.0%. The steepest decline in bilateral SLN mapping rates was from BMI group 46 to 50 compared to 51 to 55, at 55.4% to 37.5%, respectively. Adjusted odds ratio (compared with those with BMI < 30) for those in the BMI 30 to 44 group was 0.36 (95% confidence interval 0.21-0.60) and for those in the BMI ≥ 45 group was 0.10 (95% confidence interval 0.06-0.19). CONCLUSION: There is a statistically significant lower rate of SLN mapping in patients with a BMI ≥ 45 than BMI < 45. Understanding the success of SLN mapping in patients with morbid obesity is essential for preoperative counseling, surgical planning, and developing a risk-appropriate postoperative treatment plan.

Cervical Cancer Screening in Postmenopausal Women: Is It Time to Move Toward Primary High-Risk Human Papillomavirus Screening?

Background: Cervical cytology in postmenopausal women is challenging due to physiologic changes of the hypoestrogenic state. Misinterpretation of an atrophic smear as atypical squamous cells of uncertain significance (ASCUS) is one of the most common errors. We hypothesize that high-risk human papillomavirus (hrHPV) testing may be more accurate with fewer false positive results than co-testing of hrHPV and cervical cytology for predicting clinically significant cervical dysplasia in postmenopausal women. Materials and Methods: We conducted a retrospective analysis of 924 postmenopausal and 543 premenopausal women with cervical Pap smears and hrHPV testing. Index Pap smear diagnoses (ASCUS or greater vs. negative for intraepithelial lesion) and hrHPV testing results were compared with documented 5-year clinical outcomes to evaluate sensitivity and specificity of hrHPV compared with co-testing. Proportions of demographic factors were compared between postmenopausal women who demonstrated hrHPV clearance versus persistence. Results: The prevalence of hrHPV in premenopausal and postmenopausal women was 41.6% and 11.5%, respectively. The specificity of hrHPV testing (89.6% [87.4-91.5]) was significantly greater compared with co-testing (67.4% [64.2-70.4]) (p < 0.05). A greater proportion of women with persistent hrHPV developed cervical intraepithelial lesion 2 or greater (CIN2+) compared with women who cleared hrHPV (p = 0.012). No risk factors for hrHPV persistence in postmenopausal women were identified. Conclusion: Our data suggest that hrHPV testing may be more accurate than co-testing in postmenopausal women and that cytology does not add clinical value in this population. CIN2+ was more common among women with persistent hrHPV than those who cleared hrHPV, but no risk factors for persistence were identified in this study.