الفهرس | Only 14 pages are availabe for public view |
Abstract Endometrial carcinoma is the most common gynecological malignancy in the developed countries and the third common gynecological malignancy in Egypt after breast and ovarian cancers. Nighty percent of postmenopausal women with endometrial carcinoma present with vaginal bleeding while only 10% of postmenopausal bleeding is due to endometrial carcinoma. Many studies were conducted trying to create a risk scoring model which can predict the risk of endometrial carcinoma in postmenopausal women with vaginal bleeding in order to decrease the high rate of false positive cases (decreasing the false malignancy alarm burden ) and subsequent unnecessary further investigations, although the prediction models that have been developed for this purpose showed good performance specially those used combinations of patient characteristics and ultrasound findings, they have only reached the phase of internal validation. Future research should focus on external validation and impact analysis of these prediction models to confirm their prognostic abilities. One of these risk scoring models is RHEA (Recurrent vaginal bleeding, Hypertension, Endometrial thickness and Age) which was created by Giannella and his colleagues on Italian patients in 2014. This is a prospective cohort study aimed at external validation of this scoring model and assessment of possibility of adding other patient criteria (obesity, diabetes mellitus and family history) to the scoring model to improve its accuracy in our population. This is a prospective Cohort study performed in Early Cancer Detection Unit, outpatient clinic, inpatient wards and Ultrasound Unit in Ain Shams University Maternity Hospital, included 100 postmenopausal women presented with vaginal bleeding (out of them 89 cases completed the whole study process) with endometrial thickness more than 4 mm while the postmenopausal status is defined as absence of menstruation for at least 12 months after the age of 40 years, where any pathological conditions of amenorrhea were excluded. This study excluded patient with other causes of lower genital tract bleeding and those on hormonal replacement therapy with scheduled bleeding. All candidates were interviewed with full history taking, examined and had transvaginal ultrasound done for them for endometrial thickness, then RHEA scoring was calculated for them as following : Age above 65 years takes score 1, endometrial thickness more than 8mm takes score 1, hypertension takes score 2, and recurrent vaginal bleeding takes score 3. Cut-off score equal or more than 4 is used to predict women with high risk for endometrial cancer. All candidate underwent endometrial biopsy using Novak device, while only patients in whom ultrasound showed a definitive lesion other than thick endometrium which can be taken as excisional biopsy (endometrial polyp) or with intrauterine mass were subjected to diagnostic hysteroscopy during which the endometrial biopsy was taken (direct excisional biopsy or punch biopsy by grasper instrument). Statistically significant differences were found between women who turned out to have benign or malignant pathologies regarding age, recurrence of vaginal bleeding, incidence of hypertension, postmenopausal duration and BMI, other characteristics including parity, age at menarche, history of ovarian/breast cancer, family history of related malignancies, diabetes mellitus, anovulation or tamoxifen therapy didn‟t show any statistically significant differences between the two groups.Malignant histopathology(n=24)(27%) which is significantly higher than the international rates showed: Endometriod adenocarcinoma (n=19)(21.3%), papillary serous carcinoma (n=4)(4.5%) and undifferentiated carcinoma (n=1)(1.1%). Histological examination revealed that benign pathology (n=65) (73%) was found to be: most common cause was endometrial hyperplasia without atypia (20.3%) followed by chronic endometritis (13.5%), then endometrial polyp (11.3%), cystic atrophy of endometrium (8.9%), proliferative endometrium (8.9%), endometrial hyperplasia with atypia (6.7%) and lastly mucous polyp(3.4%). The current study showed that RHEA score performs in our study population with a comparable validity to that reported by its inventors, taking in consideration some restrictions and the statistical uncertainty pertained by the under-reported results the original study. In results of the current study it was found that the time since onset of menopause rather than age was associated with endometrial cancer, but it needs multivariate analysis on larger and more representative sample size to confirm this association. Optimum cut-off for endometrial thickness for prediction of endometrial malignancy was calculated to be 16 mm. At this cut-off, a lower sensitivity is achieved compared to the 8 mm cut-off proposed by the original study, however a much higher specificity is achieved with the 16 mm cut-off. On other hand, in the current study the optimum cut-off for post-menopausal duration was estimated to be 9 years achieving a sensitivity of 87.5% and a specificity of 60.0%. RHEA scoring model was effective in decreasing the false malignancy alarm burden (and thus the subsequent need for endometrial sampling) by about half that of the standard transvaginal ultrasonography screening. Out of all women with benign endometrial pathologies, only 15.4% were falsely classified as having probable malignancy with RHEA scoring model; compared to 33.2% using the transvaginal ultrasonography alone. However, this benefit was on the cost of missing women with endometrial cancer. Using the standard transvaginal ultrasonography screening; out of every 1000 women with negative screening result, only 4 women turned out to have endometrial cancer thereafter. Whereas using the RHEA scoring model, out of every 100 women with negative screening, 2 – 8 women turned out to have endometrial cancer. The latter numbers approximate to 5 – 20 times number of missed cases. In fact, out of every 100 women with endometrial cancer, 6 will be missed with transvaginal ultrasonography screening; whereas 12 – 21 women will be missed with RHEA scoring model. |