Outcome and Follow-up of Patients with Endometrial Carcinoma Diagnosed on Operative Hysteroscopic Resection Specimens

Results

During the study period, a total of 6,104 operative hysteroscopies were performed and 29 patients met the inclusion criteria. Median age was 62 years (range=48-72). Twenty-seven (93.1%) patients had a menopausal status. A hormonal replacement treatment was reported in 8 (27.6%) cases. Mean follow-up was 6.44±6.18 years.

All patients consulted for pre- or postmenopausal bleeding. Median duration of operative hysteroscopy was 15 minutes (range=4-60) and median volume of glycine solution used was 2 liters (range=0.3-11). Hysteroscopic procedure performed was a resection of an intrauterine lesion for 5 patients (17.2%), a total endometrectomy for 8 patients (27.6%) and both for 16 patients (55.2%). The pathological results of the lesion resected or total endometrectomy comprised: 21 endometrioïd carcinomas (72.4%), 2 clear-cell adenocarcinomas (6.9%), 4 mucinous adenocarcinomas (13.8%) and 2 papillary serous carcinomas (6.9%). A total of 25/29 (86.2%) type 1 histotypes and 4/29 (13.8%) type 2 histotypes were observed.

Following cancer diagnosis, all patients underwent surgical treatment consisting of a total hysterectomy with a bilateral salpingo-oophorectomy after preoperative imaging (MRI or CT scan). Lymphadenectomy was performed depending on the stage, patient's age and operability (obesity, comorbidities). Mean time between operative hysteroscopy and surgery was 35.3±19.9 days.

FIGO classification status according to the final histopathology report was distributed as follows: 16 stage IA, 7 stage IB, 4 stage II and 2 stage III patients (7). There was only 1/29 positive peritoneal cytology (3.4%) and 1/29 positive pelvic lymph node (3.4%). Peritoneal cytologies and lymphadenectomies performed for stage I and II patients were all negative.

Outcomes of stage IA patients. Post-operative histopathological analysis revealed 16 patients presenting a FIGO stage IA disease: 8 of these tumors were grade 1 (including 7 endometrioid carcinomas and 1 mucinous adenocarcinoma), 5 were grade 2 (including 4 endometrioid carcinomas and 1 mucinous adenocarcinoma). There was one grade 3 (endometrioid carcinoma) and 2 clear-cell carcinomas.

All patients underwent surgery during the initial phase of treatment. A pelvic lymphadenectomy was performed in 8 cases. For both patients with a clear-cell carcinoma a surgical treatment equivalent to ovarian cancer was performed. Seven patients underwent adjuvant radiotherapy. No patient received adjuvant chemotherapy. All patients were alive during the follow-up period, except one patient who died 7 years after initial treatment of gastric cancer.

Outcomes of stage IB patients. All 7 patients presenting with stage 1B endometrial cancer received surgical treatment followed by radiotherapy and brachytherapy. Four of these patients had a grade 1 endometrioid carcinoma and all of them were alive during the follow-up period. One patient had a mucinous adenocarcinoma (grade 1). She died 3.7 years later from another cause (heart failure). One patient had a grade 2 endometrioid carcinoma. She was alive at 1.9 years follow-up. The last patient presented a papillary serous carcinoma (type 2). She died 12 years later of breast cancer.

Outcomes of stage II patients. Treatment and outcomes for stage II patients are detailed in Table I.

Outcomes of stage III patients. There was one stage IIIA and one stage IIIC1 patient. The stage IIIA patient was a non-menopausal patient aged 48 who underwent a 15-min endometrectomy that enabled the diagnosis of a grade 1 endometrioid carcinoma. The preoperative MRI classified her as a presumed stage FIGO IA. Fourteen days later, she underwent a total hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy. The final histopathological analysis revealed a grade 2 endometrioid carcinoma with myometrial invasion >50%, an invasion of the serosa and adnexas, a positive peritoneal cytology and no lymphovascular invasion or nodal involvement. She received chemotherapy and radiotherapy and died two years later from disease. The stage IIIC1 patient, aged 60, underwent a 20-min endometrectomy that enabled the diagnosis of a grade 1 endometrioid adenocarcinoma. The preoperative MRI classified her as a presumed stage FIGO IB. She underwent the same surgical treatment as described for the previous patient 31 days after endometrectomy. Pathological analysis revealed a grade 1 endometriod adenocarcinoma with a myometrial invasion >50%, lymphovascular invasion, 3 metastatic pelvic nodes and a negative peritoneal cytology. She received radiotherapy and brachytherapy and is still alive with no recurrence 19 years later.

Two patients died from endometrial cancer, 1 was stage IIIA and 1 stage II. The stage II patient was a 70-year-old and underwent a polyp resection that lasted 10 minutes. Analysis of hysteroscopic resection products revealed a papillary serous carcinoma. She underwent, 23 days later, a total hysterectomy with bilateral salpingo-oophorectomy, pelvic and aortic lymphadenectomy and an omentectomy. The pathologic results revealed a grade 2 papillary serous carcinoma with myometrial invasion >50%, lymphovascular invasion, isthmus and endocervix invasion. There were 0/12 involved lymph nodes and peritoneal cytology was negative. She received radiotherapy but refused brachytherapy. A recurrence occurred 4 years later consisting of a 7-cm metastatic iliac lymph node. She died from endometrial cancer after a median follow-up of 5 years. Three other patients died of other causes during the follow-up period: stomach cancer, breast cancer and end-stage heart failure.