Endometrial cancer is the most common gynecologic malignancy in the USA, accounting for 3.6% of all cancers (incidence rate of 26.1/100,000 women) and generally affecting postmenopausal women, with a median age at diagnosis of 62 years [
24]. Diagnostic hysteroscopy is an accurate and less invasive method for the evaluation of common gynecological disorders, such as premenopausal or postmenopausal abnormal uterine bleeding (AUB), endometrial hyperplasia, endometrial cancer, and infertility [
22]. A systematic quantitative review by Clark showed that the overall sensitivity and specificity of hysteroscopy for endometrial cancer were 86.4 and 99.2%, respectively [
25]. We performed a retrospective study on 948 patients who underwent hysterectomy and had ECC confirmed after a selective endometrial biopsy was accomplished under hysteroscopic guidance in 14 public hospitals. We showed that the hysteroscopy view had good sensitivity and an accuracy of around 54% in the diagnosis of EEC (Table
2). Moreover, the hysteroscopic view was able to significantly differentiate EEC and endometrial hyperplasia (Table
4). Interestingly, the operator opinion regarding the hysteroscopic findings had great variability in the different centers (correct diagnosis range, 91-14%), which could explain the results (Fig.
1). These data emphasize the need for continuous training in referral centers to optimize and improve the ability to correctly define the diagnosis related to the vision [
26]. The second aim of our study was to evaluate hysteroscopic sampling in either diagnosing or excluding EEC. Many reports have debated the unreliability of endometrial biopsy pathology. In cases showing an AH, the possibility of underestimating an EEC is as high as 50% [
8‐
11]. This high rate of unrecognized endometrial cancers is firstly due to the difficulty in distinguishing between AH and EEC on endometrial biopsy specimens. The pathologic criteria defined by the World Health Organization (WHO) classification system are highly subject to individual interpretation, resulting in poor inter-observer reproducibility [
27]. Secondly, various techniques for endometrial biopsy, such as blind office-based procedures, hysteroscopy sampling, and dilatation and curettage (D&C), showed varied accuracy at differentiating between AH and EEC [
28,
29]. Hysteroscopy can provide direct visualization of the endometrial cavity, thereby allowing a targeted biopsy or excision of the lesions identified during the procedure [
18]. The progress of techniques and technology, when combined with improvements in understanding endometrial endoscopic imaging, have enabled hysteroscopy to supply the pathologist with biopsies that are reliably fashioned under the targeted vision [
19,
20,
29]. Nevertheless, a recent meta-analysis has shown different results, evidencing poor diagnostic performance of the targeted biopsy with hysteroscopy compared to endometrial resection in the diagnosis of EEC [
16]. By contrast, in our series, we showed that a hysteroscopic-driven histology had good sensitivity and accuracy of > 75% in correctly diagnosing EEC. The use of hysteroscopy-driven biopsy underestimated the disease in only 194 cases (a diagnosis of normal endometrium or non-atypical hyperplasia in 9 cases [0.9%] and AH in 185 cases [19.5%]) (Table
2). Notably, in 40 cases in which the biopsy pathology underestimated EEC with a diagnosis of AH, hysterscopic diagnosis identified the cancer. We did not find a significant difference between hysteroscopic (micro-scissors or electrodes) and resectoscopic techniques in obtaining samples for histology, confirming that the key factor is likely not the chosen biopsy technique but rather hysteroscopic guidance in terms of target selection (Table
4). Moreover, in accordance with previous results, we evidenced that the operating room setting was significantly more associated with a correct diagnosis compared to an office setting. This finding is likely related to the possibility of obtaining more material for the pathologist, which may be limited in an office setting due to the time required and possible pain for the patient. Staging at surgery evidenced a good prognosis in most cases with a biopsy diagnosis of AH (stage I Figo in 97%) (Table
5).
Table 2
Hysteroscopy view diagnosis and biopsy pathology results obtained by hysteroscopy-guided sampling in 948 eligible women undergoing hysterectomy due to endometrioid EC
Hysteroscopy view Normal Polyp Hyperplasia Carcinoma Other | 11 172 219 514 32 | 1.16 18.14 23.10 54.21 3.37 |
Biopsy pathology Normal endometrium Non-atypical hyperplasia Atypical Hyperplasia Endometrioid carcinoma Serous Clear cell carcinoma Insufficient tissue | 3 6 185 722 10 3 15 | 0.31 0.63 19.51 76.16 1.05 0.31 1.58 |
In conclusion, our study supports the choice of diagnostic hysteroscopy and hysteroscopic-driven biopsy in the diagnosis of EEC. This approach can result in excellent performance when hysteroscopy and pathology diagnoses are combined to limit the possibility of undertreating patients with endometrioid carcinoma.