Hysteroscopic view with targeted biopsy in the assessment of endometrial carcinoma. What is the rate of underestimatated diagnosis? The results of a multicenter Italian trial

Abstract

Abstract Objective In the last two decades, many reports demonstrated the unreliability of endometrial biopsy pathology showing an AH (atypical hyperplasia) to exclude a synchronous EEC (endometrioid endometrial carcinoma), with an underestimation of EEC in up to 50% of women. Hysteroscopy is now considered the standard diagnostic tool for endometrial pathology. However, a recent meta-analysis showed that hysteroscopically guided biopsy provides a high rate of failure with respect to dilatation and curettage (D&C) and endometrial resection, in underestimating AH instead of concurrent EC. The aim of this study was to assess the sensitivity of hysteroscopy view and hysteroscopic sampling in diagnosing EEC. Materials and methods A multicenter, retrospective, observational trial was conducted between January 2012 and December 2018 in 14 Italian gynecological units (university-affiliated or public hospitals). Eligible patients were identified as those women in whom either a pathologic report of EEC was found on hysterectomy specimen and a preoperative hysteroscopy assessment with endometrial biopsy targeted under vision had been performed. As primary outcome, we calculated the sensitivity of hysteroscopy view and biopsy pathology on hysteroscopically driven sampling in the diagnostic workup of EC. Results Nine hundred forty-eight patients (age 65.83 ± 10.43) resulted eligible for analysis. Hysteroscopy view showed a sensitivity of 54.2%, a specificity of 47.2%, and an accuracy of 54% in the diagnosis of EC. Moreover, hysteroscopic view was significantly able to distinguish carcinoma from hyperplasia (p < 0.001). We evidenced an important difference of the results comparing the centers involved. Hysteroscopy-driven biopsy presented a sensitivity of 76.2%, a specificity of 52.8%, and an accuracy of 75.3%. AH pathology was reported in 19% of the cases. Conclusion Our study showed that EEC diagnosis via hysteroscopy diagnosis could be improved through the implementation of operator training. Hysteroscopy-driven biopsies have excellent sensitivity and accuracy in the diagnosis of EEC, and the advantages of using hysteroscopy for making a diagnosis can improve the management of the patients with EEC. While it seems reasonable that hysteroscopy is the preferred technique for diagnosing and treating a benign pathology of the uterus, it could play a major role even in the diagnosis of a malignancy.