Diagnostic Techniques for Endometrial Cancer By:Sara Lotfiyan

We don’t have a standard screening test for endometrial cancer.

Patients for whom screening for endometrial cancer is justified: 1-Postmenopausal women on exogenous estrogens without progestins 2-Women from families with HNPCC 3-Premenopausal women with anovulatory cycles (PCOD)

The ACS did recommended annual screening for women with or at risk for HNPCC.

Abnormal uterine bleeding should alert the clinician to rule out corpus cancer, regardless of the age of the patient: Age < 40 & irregular heavy bleeding Perimenopausal : Sampling of endometrium is more important. Postmenopausal : Any episode of bleeding could be Endometrial Cancer

Techniques Used in the Diagnosis of Endometrial Cancer : 1- Definitive technique 2- Cytologic evaluation 3- Traditional four-quarter biopsy 4- Histologic suction devices 5- Endoscopic techniques 6- Imaging techniques

1- Definitive technique dilatation and curettage 2- Cytologic evaluation 3- Traditional four- quarter biopsy 4- Histologic suction devices 5- Endoscopic techniques 6- Imaging techniques False Negative of D&C : 10%

1- Definitive technique 2- Cytologic evaluation Pap smear Endometrial lavage Endometrial brush 3- Traditional four- quarter biopsy 4- Histologic suction devices 5- Endoscopic techniques 6- Imaging techniques Only 50% of women with endometrial cancer have malignant cells on a Pap smear. Morphologically abnormal endometrial cells : 25% (increase with age) Aspiration or scrapping of endocervical canal : 70 to 85%

1- Definitive technique 2- Cytologic evaluation Pap smear Endometrial lavage Endometrial brush 3- Traditional four-quarter biopsy 4- Histologic suction devices 5- Endoscopic techniques 6- Imaging techniques These require : - special instrumentation - special cytologic skills

1- Definitive technique 2- Cytologic evaluation 3- Traditional four- quarter biopsy Novac curet 4- Histologic suction devices 5- Endoscopic techniques 6- Imaging techniques Because of : Discomfort associated with it’s use It’s limited sampling of the cavity it is no longer used routinly.

1- Definitive technique 2- Cytologic evaluation 3- Traditional four-quarter biopsy 4- Histologic suction devices Vabra aspirator Tis-U-Trap Pipelle or equivalent 5- Endoscopic techniques 6- Imaging techniques The choice should be determined by: The age of the patient The experience of the clinician Anatomic considerations The emotional milieu of the individual patient

The Pipelle is a soft, flexible endometrial suction curet Use tenaculum for stenotic cervices

Stoval et al. : The Pipelle had a 97.5% sensitivity in patients with known endometrial cancer. Guido et al. : The device was less sensitive in polyps & tumors less than 5% of endometrial surface

The Pipelle was the best device with detection rate 99.6% postmenopausal 91% premenopausal sensitive for detection of endometrial hyperplasia : 81% specific (for all devices) > 98%

1- Definitive technique 2- Cytologic evaluation 3- Traditional four-quarter biopsy 4- Histologic suction devices 5- Endoscopic techniques Hysteroscopy Operative hys. 6- Imaging techniques Iosa et al. in 2007 outpatient hysteroscopy found 22 malignancies missed 8 ones

In hysteroscopy The possibility of PERITONEAL SEEDING of endometrial cancer with tumor cells via reflux of the distending medium through the fallopian tube ? Obermair & Zebre studies : Increased risk of possitive peritoneal cytology in patients who underwent hysteroscopy.

1- Definitive technique 2- Cytologic evaluation 3- Traditional four-quarter biopsy 4- Histologic suction devices 5- Endoscopic techniques 6- Imaging techniques Ultrasound (vaginal or abdominal) Computed Tomography Magnetic Resonance Imaging

In transvaginal ultrasound Indman et al. : Sensitivity 96% for abnormal uterine pathology Brooks et al. : 184 normal endometrial stripe biopsy 4 atypical hyperplasia 4 endometrial cancer symptomatic 129 thickened endometrial stripe Only 2 cancers were diagnosed asymptomatic

In transvaginal ultrasound False Negative is 4% False Positive is 50%

Endometrial Biopsy is Recommended when : Postmenopausal bleeding & endometrial stripe thickness >= 5mm All women with persistent abnormal bleeding

Transvaginal sonography + Pipelle biopsy : The sensitivity & specificity in the diagnosis of endometrial carcinoma reach 100%

Patient acceptability : Sonography > Hysteroscopy = biopsy