BOTUCATU MEDICAL SCHOOL – UNESP SÃO PAULO STATE UNIVERSITY - BRAZIL POSTGRADUATION PROGRAM ON GYNECOLOGY, OBSTETRICS AND MASTOLOGY

Evaluation of Clinical, Ultrasonographic, Hysteroscopic Parameters in the Differentiation of Endometrial Polyps and Cancer of Endometrium Caue Carvalho Modotti, MD, Fisrt year resident OB&GYN SAO PAULO UNIVERSITY (Ribeirão Preto Campus) [email protected]

Evaluation of Clinical, Ultrasonographic, Hysteroscopic Parameters in the Differentiation of Endometrial Polyps and Cancer of Endometrium _ __________________________________________________________________

Clinical features Diagnosis Risk factors for malignant degeneration Main Result _

Conclusion

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Post Graduation Program in Gynecology, Obstetrics and Mastology - Botucatu Medical School Paulo State University – UNESP

São

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Endometrial Polyps

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Intrauterine Overgrowth consist of glands, stroma and blood vessels

Basa

lis la

ye r

Dias R, et al. Femina. 1998; 26(7): 579-81. Miranda SMN, et al. Rev Bras Ginecol Obstet. 2010; 32(7): 327-33.

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Endometrial Polyps

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CLINICAL FEATURES

ASYMPTOMATIC EVEN TO 80% - Incidental diagnosis by routine TVUS

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__________________________________________________________________ Dreisler E, et al. Ultrasound Obstet Gynecol. 2009; 33(1): 102-8. Salim S, et al. J Minim Invasive Gynecol. 2011; 18(5): 569-81.

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Endometrial Polyps

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CLINICAL FEATURES

Abnormal Uterine Bleeding – Approximately 68% of endometrial polyps Premenopausal – 39% of all abnormal vaginal bleeding 64% to 88% of endometrial polyps menorrhagia irregular menses postcoital bleeding intermenstrual bleeding Postmenopausal – 21% to 28% of all postmenopausal bleeding _

__________________________________________________________________ Dreisler E, et al. Ultrasound Obstet Gynecol. 2009; 33(1): 102-8. Salim S, et al. J Minim Invasive Gynecol. 2011; 18(5): 569-81.

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Endometrial Polyps

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DIAGNOSIS

Transvaginal Ultrasonography Sensitivity – 91% (19%-100%) Specificity – 90% (53%-100%) PPV – 86% (70%-100%) NPV – 90% (87%-97%) _

__________________________________________________________________ Salim S, et al. J Minim Invasive Gynecol. 2011; 18(5): 569-81.

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Endometrial Polyps

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DIAGNOSIS

Saline Infusion Sonography Sensitivity – 95% (58%-100%) Specificity – 92% (35%-100%) PPV – 95% (70%-100%) NPV – 94% (83%-100%) _

__________________________________________________________________ Salim S, et al. J Minim Invasive Gynecol. 2011; 18(5): 569-81.

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Endometrial Polyps

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DIAGNOSIS

Color-Flow or Power Doppler Specificity – 95% NPV – 94%

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__________________________________________________________________ Vuento MH, et al. Br J Obstet Gynaecol. 1999; 106: 14-20. Goldstein SR, et al. Am J Obstet Gynecol. 2002; 186: 669-74. Timmerman D, et al. Ultrasound Obstet Gynecol. 2003; 22: 166-71. Salim S, et al. J Minim Invasive Gynecol. 2011; 18(5): 569-81.

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Endometrial Polyps

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DIAGNOSIS

Diagnostic Hysteroscopy Sensitivity – 90% (58%-99%) Specificity – 93% (87%-100%) PPV – 96% (21%-100%) NPV – 93% (66%-99%)

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__________________________________________________________________ Salim S, et al. J Minim Invasive Gynecol. 2011; 18(5): 569-81.

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Endometrial Polyps

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ENDOMETRIAL POLYPS AND MALIGNANT DEGENERATION Endometrial polyps with atypia - 1.3% to 3.3% ATYPICAL LEVELS EVEN TO 23% Adenocarcinoma of endometrial polyps - 0% to 4.8% MALIGNANCY LEVELS EVEN TO 13%

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__________________________________________________________________ Bakour SH, et al. Acta Obstet Gynecol Scand. 2000; 79(4): 317-20. Savelli L, et al. Am J Obstet Gynecol. 2003; 188(4): 927-31. Ben-Arie A, et al. Eur J Obstet Gynecol Reprod Biol. 2004; 115(2): 206-10. Shushan A, et al. Gynecol Obstet Invest. 2004; 58(4): 212-5. Epstein E. Acta Obstet Gynecol Scand. 2004; 83: 89-95. Hileeto D, et al. World J Surg Oncol. 2005; 3(1): 8.

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Endometrial Polyps

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ENDOMETRIAL POLYPS AND MALIGNANT DEGENERATION Risk Factors Advancing Age – Increase in proliferation-regulating protein (p63) Obesity – Increased levels of estrone Hypertension – Uncertain Diabetes – Increase in growth factors (insulin-like IGF-1) Use of tamoxifen – 30% to 60% prevalence _

__________________________________________________________________ Reslova, T, et al. Arch Gynecol Obstet. 1999; 262: 133-9. Nappi L, et al. J Minim Invasive Gynecol. 2009; 16: 157-62. Salim S, et al. J Minim Invasive Gynecol. 2011; 18(5): 569-81.

Evaluation of Clinical, Ultrasonographic, Hysteroscopic Parameters in the Differentiation of Endometrial Polyps and Cancer of Endometrium _

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Materials and methods From January 2010 to December 2011 82 POLYPECTOMIES 20 HYSTERECTOMIES FOR ENDOMETRIAL CANCER

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Endometrial Polyps (n=82)

Endometrial Cancer (n=20)

P

Age

57 (24,75)

63 (42,80)

p=0,013

CIM (kg/m2)

31,5+/-5,9

32,2+/-7,4

p=0,681

Pregnancy n.

3 (0,9)

4 (0,9)

p=0,212

Delivery n.

3 (0,9)

4 (0,9)

p=0,558

Hypertension

50 (61%)

13 (65%)

p>0,05

Diabetes Mellitus

18 (21,9%)

3 (15,0%)

p>0,05

Cholesterol / triglyceride

9 (11,0%)

1 (5%)

p>0,05

Hypothyroidism

4 (4,9%)

1 (5,0%)

p>0,05

Smokers

13 (15,8%)

5 (25,0%)

p>0,05

TH

8 (9,7%)

4 (20,0%)

p>0,05

Breast Cancer

4 (4,9%)

0 (0,0%)

p0,05

Thickened endometrium focal

37 (45,1%)

5 (25,0%)

p>0,05

Endometrial thickness

11,94+/-7,36

14,11+/-8,17

p>0,05

Doppler flow

60 (73,2%)

18 (90,0%)

p>0,05

Resistence index 0,70+/-0,26

0,58+/-0,17

p>0,05

Hydromethry

6 (7,3%)

3 (15,0%)

p>0,05

Cystic areas

19 (23,2%)

6 (30,0%)

p>0,05

Sonographic findings of 82 patients of endometrial polyps and 20 of endometrial cancer

Endometrial Polyps (n=82)

Endometrial Cancer (n=20)

p

Proliferative endometrium

20 (24,4%)

2 (18,2%)

p>0,05

Secretory endometrium

13 (15,8%)

2 (18,2%)

p>0,05

Atrophic endometrium

49 (59,7%)

7 (63,6%)

p>0,05

Hypervascularization + vascular atypia

13 (15,8%)

8 (72,7%)

p>0,05

Focal hypervascularization

23 (28,0%)

2 (18,2%)

p>0,05

Difuse hypervascularization

12 (14,6%)

4 (36,4%)

p>0,05

Vascular atypia

7 (8,5%)

4 (36,4%)

p>0,05

Cervical polyps

18 (21,9%)

4 (36,4%)

p>0,05

Hysteroscopic findings of 82 patients of endometrial polyps and 20 of endometrial cancer

Evaluation of Clinical, Ultrasonographic, Hysteroscopic Parameters in the Differentiation of Endometrial Polyps and Cancer of Endometrium _

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Conclusion Still remains an inability to establish clinical parameters and reliable ultrasound imaging to differentiate endometrial polyps from endometrium cancer. Attention should be given to hysteroscopic exams presenting diffuse endometrial hypervascularization with architetural distortion of the vessels. The recommendation of our service remains the systematic removal of all endometrial polyps. _

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Ribeirao Preto Medical School Sao Paulo University - USP Thank you Obrigado Merci Gracias Grazie Danke спасибо 謝謝 ありがとう

Caue Carvalho Modotti, MD, Fisrt year resident OB&GYN SAO PAULO UNIVERSITY (Ribeirão Preto Campus) [email protected]