Endometrial carcinoma after endometrial ablation: High-risk factors predicting its occurrence☆,☆☆,★

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Abstract

Our purpose was to review reported cases of endometrial carcinoma after endometrial ablation and to evaluate high-risk factors predicting its occurrence. We present guidelines for the treatment of abnormal uterine bleeding unresponsive to medical therapy in this high-risk group of patients. Eight detailed reports on endometrial carcinoma after endometrial ablation were reviewed. The indications, methods of treatment, follow-up, and associated high-risk factors for endometrial carcinoma were analyzed. A focused list of high-risk factors for endometrial carcinoma was developed on the basis of the data collected. Guidelines were established to enable surgeons to minimize the risks of subsequent uterine cancer in women with abnormal uterine bleeding that is unresponsive to medical therapy (ie, candidates for ablation). Women who had endometrial carcinoma develop after ablation had predictive high-risk factors for subsequent neoplasia, and all eventually underwent a hysterectomy. Women with abnormal uterine bleeding and high-risk factors for endometrial carcinoma who did not respond to medical treatment may safely undergo endometrial ablation but must have a preablation biopsy indicating normal endometrium. Persistent hyperplasia unresponsive to hormonal therapy should influence the selection of a hysterectomy. Careful screening of patients before undergoing endometrial destructive procedures is prescient because minimally invasive, nonhysteroscopic ablative techniques are now emerging. (Am J Obstet Gynecol 1998;179:569-72.)

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)

    ☆

    From the Department of Obstetrics and Gynecology, Northwestern University Medical School,a and the Department of Obstetrics and Gynecology, Good Samaritan Medical Center.b

    ☆☆

    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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