Stage II endometrial cancer: The diagnostic power of hysteroscopic excisional biopsy and MRI in the pre-operative cervical stroma assessment

Fabio Francesco Ciancio; Giulio Insalaco; Simone Millan; Claudia Randazzo; Federica Grasso; Giuseppina Trombetta; Marianna Gulisano; Maria Teresa Bruno; Gaetano Valenti

doi:10.1016/j.ejogrb.2024.05.015

Stage II endometrial cancer: The diagnostic power of hysteroscopic excisional biopsy and MRI in the pre-operative cervical stroma assessment

Eur J Obstet Gynecol Reprod Biol. 2024 May 13:298:140-145. doi: 10.1016/j.ejogrb.2024.05.015. Online ahead of print.

Authors

Fabio Francesco Ciancio¹, Giulio Insalaco¹, Simone Millan¹, Claudia Randazzo¹, Federica Grasso¹, Giuseppina Trombetta¹, Marianna Gulisano², Maria Teresa Bruno², Gaetano Valenti³

Affiliations

¹ Humanitas, Istituto Clinico Catanese, Unit of Gynaecologic Oncology, Catania, Italy.
² Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.
³ Humanitas, Istituto Clinico Catanese, Unit of Gynaecologic Oncology, Catania, Italy. Electronic address: valenti.gaetano@humanitascatania.it.

PMID: 38756054
DOI: 10.1016/j.ejogrb.2024.05.015

Abstract

Introduction/background: Stage II Endometrial cancer (EC) accounts only for 12% of cases. Recent evidences redraw the weight of radicality in this stage as it would seem to have no impact on survival outcomes claiming for radicality when free surgical margins are not ensured to be achieved by simple hysterectomy. Thus, an accurate pre-operative evaluation might be crucial. This study aims to estimate the diagnostic power of Hysteroscopic excisional biopsy (HEB) of cervical stroma alone and combined with Magnetic resonance imaging (MRI) to predict the stage and concealed parametrial invasion in patients with preoperative stage II EC.

Methodology: From January 2019 to November 2023, all patients evaluated at the Department of Gynaecology Oncology of Humanitas, Istituto Clinico Catanese, Catania, Italy, with a diagnosis of EC and evidence of cervical stromal diffusion on preoperative MRI and/or office hysteroscopy evaluation, considered suitable for laparoscopic modified type B hysterectomy, were consecutively included in the study. These underwent endometrial and cervical hysteroscopy excisional biopsy (HEB) for histological evaluation before definitive surgery. The data obtained were compared with the definitive histological examination (reference standard).

Results: Sixteen patients met the including/excluding criteria and were considered into the study. Stage II endometrial cancer were confirmed in 3 cases (18.7%). We reported 2 (12,5%) parametrial involvement (IIIB), 4 (25%) cases of lymph nodes metastasis (IIIc), 7 (43,7%) cases of I stage. MRI had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy (95% CIs) of 71%, 44%, 50%, 66% and 56.2 % respectively. HEB showed sensitivity, specificity, PPV, NPV and accuracy (95 % CI) of 85 %, 89 %, 85 %, 88 % and 87 % respectively. Comparing HEB + MRI to HEB alone, no statistical differences were noted in all fields. Considering parametrial invasion, MRI had better sensitivity but there were no statistical differences to HEB in other fields, showing both a worthy NPV.

Conclusion: HEB was accurate in all fields for cervical stroma assessment and had a fine NPV to exclude massive cervical involvement up to parametrial. Considering the new FIGO staging a preoperative molecular and histological evaluation of the cervical stroma may be useful. Operative hysteroscopy seems to be a feasible and accurate method for this purpose.

Keywords: Cervical involvement; Hysteroscopic excisional biopsy; Magnetic resonance imaging; Stage II endometrial cancer.