Comparison of dilatation & curettage and endometrial aspiration biopsy accuracy in patients treated with high-dose oral progestin plus levonorgestrel intrauterine system for early-stage endometrial cancer

Highlights

• This is the first study about comparison of D&C and endometrial aspiration biopsy accuracy in case of using LNG-IUS.

• Endometrial aspiration biopsy with LNG-IUS in place is less accurate than D&C after removal of LNG-IUS.

Abstract

Objective

To compare the diagnostic accuracy of dilatation & curettage (D&C) vs. endometrial aspiration biopsy in follow-up evaluation of patients treated with high-dose oral progestin plus levonorgestrel intrauterine system (LNG-IUS) for early-stage endometrial cancer (EC).

Method

A prospective observational study was conducted with 11 patients with FIGO grade 1 or 2, clinical stage IA endometrioid adenocarcinoma. Patients were aged up to 40 years wishing to preserve fertility treated with high-dose oral progestin plus LNG-IUS. Treatment response assessment was done at three month intervals. Endometrial tissues were obtained via endometrial aspiration biopsy with LNG-IUS in place and D&C after removal of LNG-IUS. We identified 28 cases; the histologic results were compared. Kappa statistics were used to assess the agreement of two methods.

Results

Diagnostic concordance between examinations was assessed for 9 out of 28 cases examined (32.1%). These consisted of three cases with both examination results of normal, 3 cases with endometrioid adenocarcinoma, 1 case with complex endometrial hyperplasia, 2 cases with material insufficient for diagnosis. Endometrioid adenocarcinoma on D&C was diagnosed in 9 out of 28 cases, but from endometrial aspiration biopsy, only 3 of these 9 cases were diagnosed with endometrioid adenocarcinoma, giving the diagnostic concordance at 33% (kappa value = 0.27). From endometrial aspiration biopsy, 17 out of 28 cases (60.7%) had material insufficiency for diagnosis.

Conclusion

In patients treated with high-dose oral progestin plus LNG-IUS for early-stage EC, endometrial aspiration biopsy with LNG-IUS in place may be not reliable as a follow-up evaluation method.

Introduction

Endometrial cancer (EC) is the world's second most common gynecologic malignancy and the incidence is rising steadily [1]. While a majority of cases are diagnosed in post-menopausal women, up to 14% of cases will be in pre-menopausal women, including 4% diagnosed in women younger than 40 years of age. With the recent increase in the number of young patients with EC, the fertility-sparing conservative treatment is attracting growing attention. A number of studies have reported the effectiveness of hormonal therapy using systemic progestin in women clinically diagnosed with early endometrial adenocarcinoma at stage IA, grade 1, who want to maintain reproductive potential [2], [3], [4], [5], [6], [7], [8], [9], [10]. In addition, several recent studies reported the use of a levonorgestrel intrauterine system (LNG-IUS) to reduce systemic adverse effects and increase the local effectiveness to the endometrium [11], [12], [13], [14], [15], [16], [17], [18], [19]. However, there are few reports evaluating the response of the endometrium in follow-up, especially when using LNG-IUS. According to the reported literature, in cases of conservative treatment using LNG-IUS, endometrial response was evaluated by endometrial aspiration biopsy with LNG-IUS in uterus or a dilatation & curettage (D&C) after removal of LNG-IUS [11], [12], [13], [14], [15], [16], [17], [18], [19], [20]. Nevertheless, there has been no report comparing the accuracy of these methods.

Therefore we conducted a prospective observational study to evaluate the diagnostic accuracy of endometrial aspiration biopsy with the LNG-IUS in place in the uterus compared with a D&C after removal of LNG-IUS in the evaluation of endometrial response in patients treated with high-dose oral progestin plus LNG-IUS for early endometrial adenocarcinoma at stage IA, grade 1 or 2.