Clinical Outcome of Atypical Endometrial Hyperplasia Diagnosed on an Endometrial Biopsy

Abstract

The aims of this study were: (1) to review the rate of concurrent endometrial cancer in patients with a preoperative diagnosis of atypical endometrial hyperplasia (AEH); and (2) to determine the features of concurrent endometrial carcinoma and their impact on the subsequent management of AEH. We reviewed a retrospective series of 219 AEHs diagnosed locally in routine practice, over 24 years, and followed by a repeat biopsy or hysterectomy. Another series of 65 cases with a malignant diagnosis on preoperative sampling was included as a control group. Clinicopathologic parameters were obtained. In addition, published data on the risk of malignancy and features of malignant tumors after a diagnosis of AEH were collected and analyzed. This study reported on 2571 patients diagnosed in 31 published studies in addition to the current one. This showed a wide variation in the positive predictive value (PPV) of AEH in detecting endometrial cancer (6% to 63%) with an overall PPV of 37%. This variation is not only based on the differences among studies but also on the degree of atypia [mild/moderate (PPV 13%) or severe (PPV 50%)], the type of subsequent intervention (biopsy vs. hysterectomy), and more importantly the time period of diagnosis (around 20% in studies published before 1990s and up to 40% to 48% in recently published cases). Of the benign outcome cases, nearly 40% to 50% showed AEH with a potential risk of progressing to invasive carcinoma in 25% of cases. Malignant tumors after AEH diagnosis are associated with features of good prognosis with endometrioid morphology, lower grade, and early stage. Although the overall PPV of AEH is 37%, a figure of 40% to 48% is expected in the cases currently diagnosed in routine practice. Providing qualifying criteria for AEH will help identify its different associated risks and therefore should be included in routine pathology reports whenever possible. Unless there is a clinical contraindication, hysterectomy should be performed to treat concurrent carcinoma and to reduce the risk of subsequent carcinoma in nonmalignant cases with residual AEH.

Prevalence of Co-existing Endometrial Carcinoma in Patients with Preoperative Diagnosis of Endometrial Hyperplasia

“…Eddib et al, found out that; the incidence of endometrial cancer in patients undergone hysterectomy after being diagnosed with atypical endometrial hyperplasia was 17% and none of them was observed to have advanced tumour of more than grade 2 or stage 1B [17]. In similar study done by Rakha et al, suggested that patients who undergone hysterectomy due atypical endometrial hyperplasia and diagnosed with endometrial cancer; their tumours are endometrioid in morphology, early staged, low-graded and show good prognosis [18]. Although most of endometrial hyperplasia associated with endometrial cancer have early stage tumours, it may be accompanied by myometrial invasion.…”

“…In endometrial carcinoma the relationship between degree of tumourn and its prognosis is well known for many years and atypical hyperplasia associated with endometrial malignancies are usually low graded and are good prognostic tumours [18]. In our study, patients with postoperative diagnosis of endometrial cancer; 8 cases had grade 1, 6 cases had grade 2 and only one case had grade 3 tumours.…”

Predictive diagnosis of endometrial hyperplasia and personalized therapeutic strategy in women of fertile age

“…When considering management strategies for women who have a biopsy diagnosis of AEH, clinicians and patients should take into account the considerable rate of concurrent carcinoma [12]. Malignant tumors after AEH diagnosis demonstrate features of good prognosis with endometrioid morphology, lower grade, and early stage, although the overall positive predictive value of AEH is expected at 37% to 48% in the current routine practice [13]. …”

Prospective validation of two mathematical models to calculate the risk of endometrial malignancy in patients with postmenopausal bleeding and sonographic endometrial thickness ≥4.5 mm

“…From a clinical point of view, however, this might not be optimal because today patients with endometrial hyperplasia with atypia are usually treated as if they had a malignant diagnosis, i.e. they undergo hysterectomy unless they want to preserve their fertility [21,22]. None of our logistic regression models was constructed to predict hyperplasia with atypia, and therefore, as expected, when we validated them including hyperplasia with atypia in the malignant group, their diagnostic performance deteriorated (Supplementary Fig.…”