Endometrial carcinoma after endometrial ablation: High-risk factors predicting its occurrence☆,☆☆,★
Section snippets
Selection and preparation of patients for endometrial ablation
The genuine indication for endometrial ablation is dysfunctional uterine bleeding unresponsive to medical treatment. Therefore anatomic conditions causing the abnormal bleeding should be identified. The endometrium should be sampled to rule out malignant or premalignant conditions. Absence of symptoms suggestive of adnexal pathologic conditions, urinary incontinence, and pelvic floor defects will limit the wrong operation from being performed. Uterine enlargement and associated cyclic pain
Endometrial ablation methods
Essentially two clinically tested modalities are used for endometrial ablation: (1) fiberoptic lasers, particularly the neodymium-YAG laser, and (2) electrosurgery. Each modality has several variations. Laser endometrial ablation may be performed with a contact or dragging technique, by making furrows in the endometrium until the entire endometrial lining is destroyed. Alternately, the laser may be fired 1 or 2 mm away from the surface, blanching the tissue and destroying the endometrium
Patients diagnosed with endometrial carcinoma after endometrial ablation
Of the 8 patients reviewed who underwent endometrial ablation and were found to have carcinoma of the endometrium later on, one was diagnosed during endometrial resection and another at biopsy during endometrial ablation. Most patients had several high-risk factors for endometrial neoplasia. Several were not good candidates for endometrial ablation.
The lifetime risk of endometrial carcinoma in the general population is considered to be 2% to 3%, and the prevalence 1 in 1000.13 However, about
Reviewed patients and their involved risk factors
The 8 patients with carcinoma of the endometrium after endometrial ablation showed the following high-risk factors for endometrial neoplasia (Table I): (1) diabetes mellitus and obesity (n = 6), (2). hypertension (n = 3), (3) postmenopausal bleeding unresponsive to hormonal treatment (n = 6), (4) associated factors such as carcinoma of the colon and polycystic ovarian disease, (5) endometrial complex hyperplasia (n = 5), (6) failure of progestin treatment (n = 8), and (7) persistent hyperplasia
Suggested recommendations for patients at high risk for endometrial carcinoma
In this high-risk group of patients, hysterectomy (rather than endometrial ablation) would be the better treatment if the patient could tolerate the surgery.15
Endometrial hyperplasia may be diagnosed on biopsy; however, the difficulty in sampling the entire endometrium with the current available techniques may contribute to missing focal atypia or carcinoma. Therefore if endometrial ablation is chosen as a method of treatment, the endometrium should be histologically normal (absence of
Comment
Because all methods of endometrial resection and ablation may not remove the entire endometrium, patients at high risk for endometrial carcinoma should be counseled about hysterectomy rather than endometrial ablation.16 Only under circumstances when the risk of hysterectomy far outweighs treatment by endometrial ablation should endometrial ablation be recommended.15
Endometrial hyperplasia is not necessarily destined to become carcinoma. For example, simple and complex hyperplasia (without
Acknowledgements
We thank Dr John R. Lurain, Professor of Obstetrics and Gynecology and Chief of the Division of Gynecologic Oncology at Northwestern University Medical School, in Chicago, Illinois, and Dr Robert J. Kurman, Professor and Director of Gynecologic Pathology at the Johns Hopkins University School of Medicine, Baltimore, Maryland, for their thoughtful review of our manuscript and their valuable suggestions.
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Cited by (0)
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From the Department of Obstetrics and Gynecology, Northwestern University Medical School,a and the Department of Obstetrics and Gynecology, Good Samaritan Medical Center.b
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Reprint requests: Rafael F. Valle, MD, Prentice Women’s Hospital and Maternity Center, 333 E Superior St, Suite 1552, Chicago, IL 60611.
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