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.