Does Preoperative Diagnosis of Endometrial Hyperplasia Necessitate Intraoperative Frozen Section Consultation?

Abstract

Background: In women with endometrial hyperplasia, there is a risk for co-existent endometrial cancer when patients are subjected to immediate surgical treatment. Aims: The aim of this study was to investigate the frequency of endometrial cancer and the accuracy of frozen section analysis at the time of hysterectomy among patients with endometrial hyperplasia, to reveal whether or not a preoperative diagnosis of endometrial hyperplasia necessitates frozen section consultation. Study Design: Retrospective cross-sectional study. Methods: A department database review was performed to identify patients who were subjected to hysterectomy with a preoperative diagnosis of endometrial hyperplasia, during the period from 2007 to 2014. Results: The study group included 189 cases. The final pathological examination revealed endometrial cancer in 16 women (8.4%). The risk of cancer in patients with endometrial hyperplasia was 1 of 125 (0.8%) in simple hyperplasia without atypia, 1 of 21 (4.8%) in complex hyperplasia without atypia and 14 of 43 (32.5%) in atypical hyperplasia. Of women with cancer, 2 of 16 (12.5%) had high-risk features. Frozen section analysis was requested in 46 cases. Frozen sections helped to identify six out of 11 cases of endometrial cancer (54.5%). The sensitivity, specificity and positive and negative predictive values of frozen section analysis for the detection of endometrial cancer among women with endometrial hyperplasia were 54.4%, 97.2%, 85.7% and 87.5%, respectively.  Conclusion: Although a significant proportion of patients with atypical endometrial hyperplasia are diagnosed with endometrial cancer following hysterectomy, most of these cases have low-risk features and do not require surgical staging. Additionally, intraoperative frozen section analysis if not helpful for diagnosing concurrent endometrial cancer in patients with endometrial hyperplasia. Therefore, it seems that patients with endometrial hyperplasia can be operated upon in settings with no available method for obtaining frozen sections intraoperatively.

Keywords

• Endometrial hyperplasia, endometrial cancer, frozen sections

References

1. 1. Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murry T, et al. Cancer statistics, 2008. CA Cancer J Clin 2008;58:71-96. [CrossRef]
2. 2. Kurman RJ, McConnell TG. Precursors of endometrial and ovarian carcinoma. Virchows Arch 2010;456:1-12. [CrossRef]
3. 3. Kurman RJ, Kaminski PF, Norris HJ. The behavior of endometrial hyperplasia. A long-term study of “untreated” hyperplasia in 170 patients. Cancer 1985;56:403-12. [CrossRef]
4. 4. Trimble CL, Kauderer J, Zaino R, Silverberg S, Lim PC, Burke JJ 2nd, et al. Concurrent endometrial carcinoma in women with a biopsy diagnosis of atypical endometrial hyperplasia: a Gynecologic Oncology Group study. Cancer 2006;106:812-9. [CrossRef]
5. 5. American College of Obstetricians and Gynecologists. ACOG practice bulletin, clinical management guidelines for obstetrician-gynecologists, number 65, August 2005: management of endometrial cancer. Obstet Gynecol 2005;106:413-25.
6. 6. Creasman WT, Odicino F, Maisonneuve P, Quinn MA, Beller U, Benedet JL. et al. Carcinoma of the corpus uteri. FIGO 26th Annual Report on the Results of Treatment in Gynecological Cancer. Int J Gynaecol Obstet 2006;95(Suppl 1):105-43. [CrossRef]
7. 7. Soliman PT, Frumovitz M, Spannuth W, Greer MJ, Sharma S, Schmeler KM., et al. Lymphadenectomy during endometrial cancer staging: practice patterns among gynecologic oncologists. Gynecol Oncol 2010;119:291-4. [CrossRef]
8. 8. Bogani G, Dowdy SC, Cliby WA, Ghezzi F, Rossetti D, Mariani A. Role of pelvic and para-aortic lymphadenectomy in endometrial cancer: current evidence. J Obstet Gynaecol Res 2014;40:301-11. [CrossRef]

9. 9. Valenzuela P, Sanz JM, Keller J. Atypical endometrial hyperplasia: grounds for possible misdiagnosis of endometrial adenocarcinoma. Gynecol Obstet Invest 2003;56:163-7. [CrossRef]
10. 10. Indermaur MD, Shoup B, Tebes S, Lancaster JM. The accuracy of frozen pathology at time of hysterectomy in patients with complex atypical hyperplasia on preoperative biopsy. Am J Obstet Gynecol 2007;196:e40-2. [CrossRef]
11. 11. Lambert B, Muteganya D, Lepage Y, Boivin Y. Complex hyperplasia of the endometrium. Predictive value of curettage vs. hysterectomy specimens. J Reprod Med 1994;39:639-42.
12. 12. Merisio C, Berretta R, De Ioris A, Pultrone DC, Rolla M, Giordano G, et al. Endometrial cancer in patients with preoperative diagnosis of atypical endometrial hyperplasia. Eur J Obstet Gynecol Reprod Biol 2005;122:107-11. [CrossRef]
13. 13. Widra EA, Dunton CJ, McHugh M, Palazzo JP. Endometrial hyperplasia and the risk of carcinoma. Int J Gynecol Cancer 1995;5:233-35. [CrossRef]
14. 14. Costales AB, Schmeler KM, Broaddus R, Soliman PT, Westin SN, Ramirez PT, et al. Clinically significant endometrial cancer risk following a diagnosis of complex atypical hyperplasia. Gynecol Oncol 2014;135:451-4. [CrossRef]
15. 15. Stephan JM, Hansen J, Samuelson M, McDonald M, Chin Y, Bender D, et al. Intra-operative frozen section results reliably predict final pathology in endometrial cancer. Gynecol Oncol 2014;133:499-505. [CrossRef]
16. 16. Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet 2009;105:103- 4. [CrossRef]
17. 17. Mariani A, Webb MJ, Keeney GL, Haddock MG, Calori G, Podratz KC. Low-risk corpus cancer: is lymphadenectomy or radiotherapy necessary? Am J Obstet Gynecol 2000;182:1506-19. [CrossRef]
18. 18. Turan T, Oguz E, Unlubilgin E, Tulunay G, Boran N, Demir OF, et al. Accuracy of frozen-section examination for myometrial invasion and grade in endometrial cancer. Eur J Obstet Gynecol Reprod Biol 2013;167:90-5. [CrossRef]
19. 19. Creasman WT, Morrow CP, Bundy BN, Homesley HD, Graham JE, Heller PB. Surgical pathologic spread patterns of endometrial cancer. A Gynecologic Oncology Group Study. Cancer 1987;60(Suppl 8):2035-41. [CrossRef]
20. 20. Bilgin T, Ozuysal S, Ozan H, Atakan T. Coexisting endometrial cancer in patients with a preoperative diagnosis of atypical endometrial hyperplasia. J Obstet Gynaecol Res 2004;30:205-9. [CrossRef]
21. 21. Morotti M, Menada MV, Moioli M, Sala P, Maffeo I, Abete L, et al. Frozen section pathology at time of hysterectomy accurately predicts endometrial cancer in patients with preoperative diagnosis of atypical endometrial hyperplasia. Gynecol Oncol 2012;125:536-40. [CrossRef]
22. 22. Salman MC, Usubutun A, Dogan NU, Yuce K. The accuracy of frozen section analysis at hysterectomy in patients with atypical endometrial hyperplasia. Clin Exp Obstet Gynecol 2009;36:31- 4.
23. 23. Turan T, Karadag B, Karabuk E, Tulunay G, Ozgul N, Gultekin M, et al. Accuracy of frozen sections for intraoperative diagnosis of complex atypical endometrial hyperplasia. Asian Pac J Cancer Prev 2012;13:1953-6. [CrossRef]