الفهرس 
Endometrial carcinomaOnly 14 pages are availabe for public view
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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.