Date Published: March 23, 2017
Publisher: Public Library of Science
Author(s): Jiao Chen, Leslie H. Clark, Wei-Min Kong, Zhen Yan, Chao Han, Hui Zhao, Ting-Ting Liu, Tong-Qing Zhang, Dan Song, Si-Meng Jiao, Chunxiao Zhou, Shian-Ying Sung.
Prior studies evaluating the impact of hysteroscopy on outcomes in endometrial cancer have predominantly evaluated type I tumors. We sought to evaluate whether hysteroscopy worsens prognosis in type II endometrial cancer.
A retrospective cohort analysis of 140 patients from two institutions with type II endometrial cancer was performed. Women who underwent either diagnostic hysteroscopy (HSC) or dilation and curettage (D&C) for cancer diagnosis from June 2001 until June 2010 were included. The clinical and pathologic characteristics, including peritoneal cytology results were reviewed. The primary endpoint was disease-specific survival (DSS). The exposure of interest was hysteroscopy. Survival curves were projected using the Kaplan-Meier method and compared using the log-rank test.
There was no difference in age, histology, stage, depth of myometrial invasion, adnexal involvement, or nodal metastasis between HSC and D&C patients. Positive cytology was found in 16/54 (30%) patients following HSC and in 10/86 (12%) following D&C (p = 0.008). Fourteen patients with stage I and II disease had positive peritoneal cytology, with 11/40 (27.5%) patients in the HSC group and 3/59 (5%) patients in the D&C group(p = 0.002). Median DSS was clinically different for the HSC and D&C groups, but statistical significance was not reached (53 versus 63.5 months, p = 0.34). For stage I and II patients, 18/99 (18%) were dead of EC, with a median DSS of 60 months for HSC and 71 months for D&C (p = 0.82). Overall 46 (33%) patients developed a recurrence, with 18/54 (33%) in the HSC group compared to 28/86 (32%) in the D&C group (p = 0.92). There was no difference in recurrence location between groups.
Diagnostic hysteroscopy significantly increased the rate of positive peritoneal cytology at the time of surgical staging in this cohort of patients with type II EC. However, we were unable to detect a difference in prognosis as measured by DSS.
Endometrial cancer (EC) is the most common malignancy of the female genital system, and can be classified into type I and type II tumors. Type I tumors are of endometrioid histology and are the most common type of EC. These tumors are associated with estrogen dependence and favorable prognosis [2–4]. Type II tumors include a variety of histologies such as serous and clear cell carcinomas. These tumors are associated with poor clinical outcomes [3–5]. More recently, carcinosarcoma has also been included in type II tumors as it is considered a metaplastic carcinoma by the 2010 National Comprehensive Cancer Network (NCCN) panel . Compared with type I EC, type II EC behaves more aggressively with a higher incidence of extrauterine disease and increased propensity for recurrence[7,8]. The 5-year survival rate for type II EC is reported to be between 30% and 60% [9–11].
In the present study, we investigated whether HSC to aid in the diagnosis of EC lead to a worse prognosis in women with type II tumors. We found that HSC is associated with an increased rate of positive peritoneal cytology in patients with type II EC (30 versus 12%, p = 0.008), theoretically due to expulsion of malignant cells through the fallopian tubes after uterine distension. Despite this difference in peritoneal cytology, we were unable to detect a difference in prognosis with a median DSS of 53 versus 63.5 months in the HSC and D&C arms, respectively.