Browse Day: November 18, 2007

Endometrial Cancer. Part 4

Ultrasound in the recent years has taken on a new meaning as far as the workup of endometrial cancers. Many times if you have a patient who comes in to your office with postmenopausal bleeding or abnormal bleeding, rather than rushing in and doing a biopsy on her when she’s in your office, you’re just working her up, one of the helpful tools now is an endovaginal ultrasound, it can give you an enormous amount of information, number one, it tell you are there submucosal fibroids, but the biggest piece of information it gives you, particularly in a postmenopausal woman is the thickness of the endometrial stripe and whether or not there are polyps, and particularly in a post menopausal woman, if you get an ultrasound that shows that she has endometrial polyps on your office Pipel and on your D&C, it’s very easy to miss polyps because you can scrape around the polyp, so that can be a piece of information that is very helpful. There are what is seen as the normal, it’s supposed to be less than 5 mm not on hormonal replacement and less than 8 mm if you are on hormonal replacement. Anybody who has an endometrial stripe greater than 8 mm who is post menopausal, that is considered the absolute cutoff and should be consider a thickened endometrial stripe. There has been a recent publication by Brook although the numbers do not look outstanding, this is the quoted reference on thickened endometrial stripes in postmenopausal women, and what this study looked at, is women who are undergoing ultrasound for evaluation of whatever were diagnosed with a thickened endometrial stripe. They divided those patient’s and to those who were symptomatic and those that were asymptomatic to see how sensitive a test endovaginal ultrasonography was in distinguishing patient’s that had a potential malignancy. If you look at the bottom half of the slide, you will notice insufficient and normal amounts of tissue obtained on D&C was about 70% and about 89% of patient’s had normal or insufficient material, so therefore, did not have uterine pathology, which goes back to my original slide. Patient’s who present with postmenopausal bleeding, only approximately 20% will have a malignancy, and this is what this study has panned out.

Now looking at the symptomatic and symptomatic, the big to do about this paper is that they are trying to point out that asymptomatic patient’s, there was no incidence of atypical hyperplasia, if they were asymptomatic and there was no incidence of cancer, and only a very small percentage who had thickened endometrial stripes, actually had atypical hyperplasia, in this study, they felt that simple hyperplasia was not a precursor to cancer. So because 70 to 80% of patient’s who had thickened endometrial stripes had insufficient tissue or normal endometrium as the study went on, they resampled these patient’s in one year, and their philosophy was even on a fraction D&C, you only sample 20% of the tissue, so could it be that in these patient’s who have a thickened endometrial stripe, whether they are symptomatic or asymptomatic, are we really missing pathology? So these patient’s that were in the insufficient and normal group got resampled in one year and of the patient’s who got resampled, there was a small percentage of patient’s who had atypical hyperplasia, 10% and a small percentage that had cancer. Their conclusions where that people who were asymptomatic who had thickened endometrial stripes one endovaginal vaginal ultrasound, none of them had atypical hyperplasia which is considered a precursor to cancer or cancer, so without symptoms, just because you have a thickened endometrial stripe on ultrasound, you should follow the patient’s symptoms, and that is pretty much the philosophy of patient’s who are are on tamoxifen therapy.

Endometrial Cancer. Part 3

The history that is compatible with endometrial cancer is number one, postmenopausal bleeding. I think that is fairly obvious for most gynecologists who have a patient present in their office who say, I am bleeding. There are other causes for postmenopausal bleeding, but the first flag in your head should be, this may be coming from her uterus, therefore we should get an endometrial biopsy. Certainly, there are other sources of postmenopausal bleeding that can be coming from the bladder, the rectum, vagina, atrophy and those sources need to be worked up. Abnormal menses is a much more difficult diagnosis to make, and you have to be very astute to your patient’s menstrual history and really listen, my periods are increasing, they are coming twice a month, I’m spotting in between the month, this is a group of patient’s that you really have to be on the ball to pick up, because this is the group that gets missed, the 25% that are before menopausal or perimenopausal frequently get diagnosed in a later stage of disease, simply because they were told they are perimenopausal, they have been put on progesterone therapy, oral contraceptions and not undergone an endometrial sampling or even a pelvic ultrasound to diagnose whether there is a thickened endometrial stripe or even a suspicious stripe.
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Only 20% of patient’s who present with postmenopausal bleeding will ultimately have a malignancy, however, the older the patient that presents with postmenopausal bleeding, the more likely she is to have an endometrial cancer. The diagnosis of endometrial cancer is simple, we need to get a specimen of the endometrial cavity, the gold standard is a fractional D&C, most of the fractional D&Cs can be avoided by the office biopsy. I tend to use a Randall curette which is the exact same diameter as a Pipel, except it’s metal, so it doesn’t bend, so as far as the discomfort, because of the cervical dilatation, it’s exactly the same as the Pipel, but sometimes in the postmenopausal woman, it’s a little more difficult to get into the cervical os so I find that the Randall Pipel without the teeth works very well. In addition, if you use the Randall Pipel because it’s metal, you can actually sound the uterus and decide how large it is, you can actually feel where you are with your endometrial sample.

The last diagnosis of endometrial cancer is occasionally picked up on an asymptomatic woman which again is very rare to have a patient who has endometrial cancer who is asymptomatic, but it does occur, to pick it up on a Pap smear. If you have 100 patient’s that have endometrial cancer and you took Pap smears from those patient’s, only 20 would have an abnormal Pap smear. Of the 20 that have an abnormal Pap smear, about 80% would be AGUS, meaning atypical glandular cells of undetermined significance, not ASCUS, atypical squamous cells of undetermined significance, if you ever have a patient in your practice that has atypical glandular cells, those patient’s really need to be worked up thoroughly with an endocervical curettage plus an endometrial curettage, but the Pap smear is not designed to pick up endometrial cancer, it designed to pick up precancerous lesions and does a very poor job for screening for endometrial cancer. The office biopsy is 90% accurate, meaning if you can gain access to the endometrial cavity and you have a patient that has endometrial cancer, 90% of the time it will give you the answer that you have a cancer, 10% of the patient’s who truly do have a cancer that you have done the office Pipel or Randall curette, whatever your choice, 10% of those patient’s will be missed. So therefore, it is imperative that patient’s who have abnormal uterine bleeding that you strongly suspect need to be worked up to rule out an endometrial cancer in your office, biopsy comes back negative. For those small percentage of patient’s, the 10%, they really should undergo a formal procedure, a D&C if that’s medically possible. There are other ways of diagnosing endometrial cancer, one of the new advances has been hysteroscopy which is used on conjunction with D&C and I think this is a very nice technique, it can pick up polyps which you can miss on your D&C, you can also look at the endocervical canal, occasionally you can be working somebody up for an endometrial cancer and find out that indeed they had adenocarcinoma of the endocervix and it not from the endometrium, so I think that hysteroscopy does add t the D&C, it’s not absolutely necessary for complete workup of endometrial cancer, it’s just a diagnostic tool. Hysteroscopy is very infrequently used, it’s used in conjunction with ultrasound. It’s a technique where they look with the ultrasound machine at the uterine strip, and they place saline in to see if this is a cancer. If you’re going to go to that extreme, at some point you are still going to have to sample the patient with either an office biopsy or fractional D&C so I’m not sure that the added expense of this test is always indicated.