Clinical aspects of hysteroscopic diagnosis of atypical endometrial hyperplasia

We read with interest the article by Mittal et al [1], “Diagnostic criteria for distinguishing endometrial adenocarcinoma from endometrial complex atypical hyperplasia”. The article is noteworthy not only for diagnostic aspects but also for clinical repercussions. We report our clinical experience on the diagnostic accuracy of hysteroscopy with regard to atypical endometrial hyperplasia. All hysteroscopies were performed using a continuous-flow office hysteroscope with a 5F working channel. The biopsy forceps has a diameter of 5F and jaws of 5 mm in length. The forceps features small teeth on both sides of the jaws to retain the obtained tissue. With the combination of this kind of forceps and adequate technique, a very large amount of biopsied endometrial tissue (mean, 5.7 mm2 measured in 2 dimensions on histologic section) was sampled [2]. We compared the hysteroscopic findings (including targeted biopsies) with the histologic findings obtained after hysterectomy. On the basis of histologic examination of endometrial biopsy during a period of 10 years, we had 29 cases of atypical endometrial hyperplasia. Of these, 14 cases (48.3%) were found to be endometrial carcinoma with atypical endometrial hyperplasia at the hysterectomy. All carcinomas were endometrioid carcinomas, except for 1 case of adenosquamous carcinoma. Endometrioid carcinomas were well differentiated except for 2 cases, which were poorly differentiated. The myometrial invasion was present in the inner third of the uterus in 2 cases of endometrioid carcinoma. In the 14 cases of endometrial carcinoma diagnosed by hysterectomy, the image-based diagnosis by hysteroscopy led to a suspicion of endometrial carcinoma. The biopsies did not confirm the suspicion but revealed an atypical endometrial hyperplasia. The problem may be due to the amount of the biopsy, even when properly executed, because it was performed in a targeted manner. In our clinical perspective, we appreciate all effort to establish morphological criteria in biopsies to distinguish endometrial adenocarcinoma from atypical endometrial hyperplasia. If there is any doubt and the operator has a suspicion of endometrial cancer, then we will definitely suggest the repetition of the biopsy: this is the peculiarity of hysteroscopy [3]. Other “blind” techniques of endometrial biopsy (dilatation and curettage, Novak, Vabra, Pipelle) cannot suggest any suspicion and, thereupon, cannot suggest any repetition of the biopsy.