Hysteroscopy-view with targeted biopsy in the assessment of endometrial carcinoma. What’s the rate of underestimated diagnosis of atypical hyperplasia? The results of a multicenter Italian trial

Objective: In the last two decades many reports demonstrated the unreliability of endometrial biopsy pathology showing an AH (Atypical Hyperplasia) to exclude a synchronous EEC (Endometrioid Endometrial Carcinoma), with an underestimation of EEC in up to 50% of women. Hysteroscopy is now considered the standard diagnostic tool for endometrial pathology. However, a recent meta-analysis showed that hysteroscopically-guided biopsy provides a high rate of failure with respect to dilatation and curettage (D&C) and endometrial resection, in underestimating AH instead of concurrent EC. The aim of this study was to assess the sensitivity of hysteroscopy-view and hysteroscopic sampling in diagnosing EEC. Materials and Methods: A multicenter, retrospective, observational trial was conducted between January 2012 and December 2018 in 14 Italian Gynecological Units (University-affiliated or Public Hospitals). Eligible patients were identified as those women in whom either a pathologic report of EEC was found on hysterectomy specimen and a preoperative hysteroscopy assessment with endometrial biopsy targeted under vision had been performed. As primary outcome we calculated the sensitivity of hysteroscopy-view and biopsy pathology on hysteroscopically-driven sampling in the diagnostic work-up of EC. Results: 948 patients (age 65,83±10,43) resulted eligible for analysis. Hysteroscopy-view showed a sensitivity of 54.2%, specificity 47,2% and accuracy 54% in the diagnosis of EC. Moreover, hysteroscopic view was significantly able to distinguish carcinoma from hyperplasia (p<0.001). We evidenced an important difference of the results comparing the centers involved. Hysteroscopy-driven biopsy presented a sensitivity of 76,2%, a specificity of 52,8% and an accuracy of 75,3%. AH pathology was reported in 19% of the cases. Conclusion: Our study showed that EEC diagnosis via hysteroscopy diagnosis could be improved through the implementation of operator training. Hysteroscopy-driven biopsies have excellent sensitivity and accuracy in the diagnosis of EEC, and the advantages of using hysteroscopy for making a diagnosis can improve the management of the patients with EEC. While it seems reasonable that hysteroscopy is the preferred technique for diagnosing and treating a benign pathology of the uterus, it could play a major role even in the diagnosis of a malignancy.