Stage II endometrial cancer: The diagnostic power of hysteroscopic excisional biopsy and MRI in the pre-operative cervical stroma assessment.

INTRODUCTION/BACKGROUND: Stage II Endometrial cancer (EC) accounts only for 12% of cases. Recent evidences redraw the weight of radicality in this stage as it would seem to have no impact on survival outcomes claiming for radicality when free surgical margins are not ensured to be achieved by simple hysterectomy. Thus, an accurate pre-operative evaluation might be crucial. This study aims to estimate the diagnostic power of Hysteroscopic excisional biopsy (HEB) of cervical stroma alone and combined with Magnetic resonance imaging (MRI) to predict the stage and concealed parametrial invasion in patients with preoperative stage II EC. METHODOLOGY: From January 2019 to November 2023, all patients evaluated at the Department of Gynaecology Oncology of Humanitas, Istituto Clinico Catanese, Catania, Italy, with a diagnosis of EC and evidence of cervical stromal diffusion on preoperative MRI and/or office hysteroscopy evaluation, considered suitable for laparoscopic modified type B hysterectomy, were consecutively included in the study. These underwent endometrial and cervical hysteroscopy excisional biopsy (HEB) for histological evaluation before definitive surgery. The data obtained were compared with the definitive histological examination (reference standard). RESULTS: Sixteen patients met the including/excluding criteria and were considered into the study. Stage II endometrial cancer were confirmed in 3 cases (18.7%). We reported 2 (12,5%) parametrial involvement (IIIB), 4 (25%) cases of lymph nodes metastasis (IIIc), 7 (43,7%) cases of I stage. MRI had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy (95% CIs) of 71%, 44%, 50%, 66% and 56.2 % respectively. HEB showed sensitivity, specificity, PPV, NPV and accuracy (95 % CI) of 85 %, 89 %, 85 %, 88 % and 87 % respectively. Comparing HEB + MRI to HEB alone, no statistical differences were noted in all fields. Considering parametrial invasion, MRI had better sensitivity but there were no statistical differences to HEB in other fields, showing both a worthy NPV. CONCLUSION: HEB was accurate in all fields for cervical stroma assessment and had a fine NPV to exclude massive cervical involvement up to parametrial. Considering the new FIGO staging a preoperative molecular and histological evaluation of the cervical stroma may be useful. Operative hysteroscopy seems to be a feasible and accurate method for this purpose.

Risk factors for developing multiple malignancies in patients with endometrial cancer.

OBJECTIVE: The purposes of this study were to investigate the clinical and pathologic characteristics of patients with endometrial cancer (EC) and associated breast, colorectal, or ovarian cancer, and to define the risk of developing an associated malignancy during follow-up after EC treatment. METHODS/MATERIALS: During a 13-year period, 1028 women had a hysterectomy for EC at our institution and available clinical information. An associated malignancy was defined as diagnosis of another malignant disease before or at the time of operation for EC or during follow-up. RESULTS: Of these 1028 patients, 208 (20%) had a history of another malignancy besides EC. Most frequent were carcinomas of the breast (10%), colon-rectum (3%), and ovary (4%). Patients with a family history of hereditary nonpolyposis colorectal cancer (HNPCC)-related cancers and presence of EC in the lower uterine segment (LUS) had a higher risk of developing colorectal cancer within 5 years after hysterectomy (2% and 6%, respectively). After multivariate analysis, only LUS involvement remained significantly associated with this risk. Patients with EC and associated ovarian cancer were more likely to be younger and have superficially invasive EC, family history of HNPCC-related tumors, and family history of breast or ovarian cancer. After multivariate analysis, only age younger than 50 years (odds ratio [OR], 4.27; 95% confidence interval [CI], 1.49-12.21) and family history of breast or ovarian cancer (OR, 3.95; 95% CI, 1.60-9.72) were significantly related to risk of having ovarian cancer associated with EC. No significant risk factors were identified for development of an associated breast cancer after EC. CONCLUSIONS: Young age, family history of malignancy, and LUS involvement may indicate the need for more intensive preventive strategies for colorectal cancer and for evaluating the risk of synchronous ovarian cancer in patients with EC.