Hysteroscopic Morcellation in Endometrial Cancer Diagnosis: Increased Risk?

Abstract

Study Objective: Operative hysteroscopy requires elevated intrauterine pressures, which could lead to the spread of malignant cells into the peritoneal cavity. Currently, there is a paucity of data analyzing clinical outcomes in endometrial cancer after hysteroscopic morcellation with newer equipment. In this study, we sought to determine whether there are increased rates of positive peritoneal cytology, lymphovascular space invasion, or surgical upstaging in patients undergoing hysteroscopic morcellation compared with alternative endometrial biopsy methods. Design: A retrospective chart review of patients from 2013−2018 was performed. The exclusion criteria included biopsy at outside institution, stage IV endometrial cancer known before biopsy, and missing data regarding biopsy method and histology. Peritoneal cytology results, lymphovascular space invasion, and surgical staging were compared by method of biopsy and histology using chi-square and Kruskal-Wallis tests. Setting: The patients included in this study were accrued from the Karmanos Cancer Insittute in Detroit, Michigan. Patients: A total of 289 patients met the inclusion criteria: 184 patients were classified as low-grade (F ed eration Internationale de Gyn ecologie et d'Obst etrique grades 1 and 2) and 105 as high-grade (F ed eration Internationale de Gyn ecologie et d'Obst etrique grade 3, serous, clear cell, and carcinosarcoma) endometrial cancer. Interventions: Fifty-three patients (18%) underwent hysteroscopy with morcellation. Alternative biopsy methods included hysteroscopy without morcellation, n = 81 (28%); endometrial biopsy, n = 112 (38.7%); and dilation and curettage, n = 43 (15%). Measurements and Main Results: Positive peritoneal cytology was noted in 34 cases (12%) and negative cytology in 165 (57%). Cytology was not performed in 90 cases (31%). When comparing outcomes by histologic subtypes, no difference was seen in peritoneal cytology (p = .704 and .727 for low grade and high grade, respectively), stage (p = .773 and .053 for low grade and high grade, respectively) or lymphovascular space invasion (p = .400 and .142 for low grade and high grade, respectively). Conclusion:Our study demonstrates that hysteroscopy with morcellation is a safe diagnostic method for low-and highgrade endometrial pathologic conditions and does not lead to increased dissemination of malignant cells, lymphovascular space invasion, or upstaging of patients.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma,

“…Whether hysteroscopy might increase the dissemination of tumour cells into the peritoneal cavity is an old debate; actually, the possible spread of malignant endometrial cells into the peritoneal cavity following diagnostic hysteroscopy has been shown not to alter tumour staging and has not been shown to adversely affect the patient’s prognosis ( Chang et al , 2011 ). Tissue removal devices also do not result in increased dissemination of malignant cells into the peritoneal cavity when used as an initial biopsy method in the diagnosis of endometrial carcinoma and are not associated with surgical upstaging of patients compared with conventional endometrial biopsy methods ( Kelly et al , 2021 ). The International Federation of Gynecology and Obstetrics (FIGO) staging system states that the confirmed diagnosis of a positive peritoneal washing does not alter the tumour stage and is recorded separately from the report issued on the staging itself ( Amant et al , 2018 ).…”

Controversy on Positive Peritoneal Cytology of Endometrial Carcinoma

“…Some studies [32] have suggested that the positive and suspicious positive rates of peritoneal cytology in endometrial carcinoma by hysteroscopy are significantly higher than that in diagnostic curettage. Cohort studies [33] have suggested that although hysteroscopy increases the risk of positive peritoneal cytology in early endometrial cancer, it has no significant effect on prognosis. Vilos et al's study [34] showed that the positive rate of peritoneal cytology increased by 30% in patients with serous endometrial carcinoma before hysteroscopy.…”

OS and DFS are affected by different diagnostic methods and hysterectomy procedures in endometrial cancer patients: A single‐center retrospective study

“…However, there is more evidence suggesting that hysteroscopy may not increase the risk of intraperitoneal dissemination of EC cells or affect the survival of women with this disease. For example, one retrospective cohort study found that diagnostic hysteroscopy had no adverse effects on the incidence of positive peritoneal cytology or on prognosis in stage I EC patients 8 . Consistently, other researchers observed this lack of effect on the FIGO stage or prognosis of EC patients after prolonging the time interval between D&C and hysterectomy 9 .…”