Study Objective: Although hysteroscopy (HSC) can be used for assessing the uterine cavity in women with suspected endometrial cancer (EC), it remains controversial as a procedure because it can potentially enhance the metastatic spread of cancer cells. Moreover, it is important to assess this hypothesis for type II EC, a more aggressive phenotype that usually presents with endometrial atrophy and has worse prognosis. Thus, we aimed to assess the prevalence of positive peritoneal cytology result in women with type II EC who underwent HSC as a diagnostic tool and to determine the factors associated with patient relapse/survival. Design: Retrospective cohort analysis (2002−2017). Setting: Tertiary, academic hospital. Patients: One hundred twenty-seven women with type II EC. Interventions: Diagnostic HSC (HSC) (n = 43) or dilation/curettage (D&C) (n = 84). Measurements and Main Results: Primary end point was the frequency of positive peritoneal cytology result. Survival curves were projected using the Kaplan-Meier method and compared using the log-rank test. Cox regression analysis with hazard ratio (HR) and 95% confidence intervals (CIs) were calculated to assess the factors related with the disease-free survival (DFS) and the disease-specific survival (DSS). Advanced cancer stage and greater vascular invasion appeared more frequently in the D&C group (p = .008 and p = .04, respectively). Positive peritoneal cytology result was present in 2 of 43 (4.6%) women following HSC and in 9 of 84 (10.7%) following D&C (p = .22). DFS and DSS curves did not statistically differ between the groups. Multivariate analysis for DFS revealed that advanced cancer stage (III and IV) (HR = 4.67; 95% CI, 2.34−9.34; p <.001) and advanced age (HR = 1.08; 95% CI, 1.04−1.13]; p <.001) were the factors associated with relapse. For DSS, advanced age (HR = 1.08; 95% CI, 1.05−1.12; p <.001), cancer stage III/IV (HR = 3.95; 95% CI, 2.18 −7.15; p <.001), and vascular invasion (HR = 2.47; 95% CI, 1.34−4.54; p = .004) increased the risk of mortality. Conclusion: Diagnostic HSC did not increase the rate of positive peritoneal cytology result at the time of surgical staging in this cohort of women with type II EC and is probably as safe as D&C.

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Interventions: Hysteroscopic endometrial resection (HER). Measurements/Results: The median (range) age and BMI were 58 (50-87) years and 29 (21-52) kg/m 2 , respectively. Office biopsy failed in 30 (19.8%), was inadequate in 20 (13.2%), identified non-atypical endometrial hyperplasia (NAH) in 21 (14%), AH in 4 (2.6%) and EC in 2 (1.3%) women. HER in 83 women on HRT identified 3 additional cancers (1 each from proliferative, inadequate, NAH group) and 2 AH from NAH. HER in 68 women without HRT identified 6 additional cancers (3 from failed, 1 from inadequate, 1 from NAH, 1 from AH group) and 5 AH (1 from inadequate, 2 from failed, 2 from NAH). Two women with EC refused hysterectomy and are well at 10 and 15 years. Hysterectomy was performed for EC in 9, AH in 2, persistent bleeding in 1. One woman had repeat HER for benign bleeding and 9 (6%) were lost to follow. At a median of 11.5 (7-20) years, 140/151 (92.7%) women with no bleeding were satisfied with their treatment. Conclusions: HER, performed by experienced surgeons, is feasible, safe, and effective for diagnosis and treatment of benign intrauterine pathology, NAH and selected cases of AH and/or EC in women with PMB with and without HRT.