{"paper_id":"cae78497-e2a9-475e-ab58-994cef8bfb9d","body_text":"Vol.:(0123456789)\nInternational Urogynecology Journal (2025) 36:2297–2304 \nhttps://doi.org/10.1007/s00192-025-06380-y\nORIGINAL ARTICLE\nIncidence and Outcomes of Occult Uterine Cancer in Uteri Removed \nfor Prolapse\nMorgan Gruner1 · Surabhi Tewari2 · Meng Yao M.3 · Katie Propst4 · Mariam AlHilli5\nReceived: 7 July 2025 / Accepted: 17 September 2025 / Published online: 14 October 2025 \n© The Author(s) 2025\nAbstract\nIntroduction and Hypothesis To identify the incidence of occult endometrial cancer diagnosed following hysterectomy for \nthe repair of pelvic organ prolapse, and compare patient outcomes to a control cohort of preoperatively diagnosed endome-\ntrial cancer patients.\nMethods A retrospective cohort study of patients ≥50 years with endometrial cancer between 2010 and 2020 was performed. \nDemographic, clinical, surgical, and oncologic variables were compared between occult endometrial cancer and preopera-\ntively diagnosed endometrial cancer cohorts.\nResults One thousand seventy-two patients were included, of which 30 (2.8%) had occult endometrial cancer diagnosed \nafter prolapse surgery and 1042 (97.2%) were in the preoperatively diagnosed historic cohort. The incidence of occult \nendometrial cancer was 0.56% for all hysterectomies performed for pelvic organ prolapse. Patients in the occult endometrial \ncancer cohort were more likely to have grade I disease (85.2% vs. 52.1%, p  < 0.001), less likely to have lymphovascular \nspace invasion (10.7% vs. 31.8%) or >50% myometrial invasion (11.1% vs. 24.0%, p  = 0.004) compared to the preopera-\ntively diagnosed patients. Ten occult endometrial cancer patients (33.3%) underwent a second staging procedure; 83.3% \n(n = 25) of patients received care in compliance with comprehensive national cancer guidelines. Five-year recurrence free \nsurvival was 95.0% (95% CI 85.4–100%) and 66.8% (95% CI 59.3–74.4%) for preoperatively diagnosed cohort and occult \nendometrial cancer cohort, respectively, while 5-year overall survival was 90.9% (95% CI 78.9–100%) and 83.0% (95% CI \n75.5–90.5%), respectively.\nConclusions The rate of incidental endometrial cancer after hysterectomy for pelvic organ prolapse was 0.56% in our cohort. \nMost occult diagnosed patients are diagnosed with early-stage and low-grade disease. The majority received care concurrent \nwith National Comprehensive Cancer Network recommendations.\nKeywords Hysterectomy · Occult endometrial carcinoma · Pelvic organ prolapse · Uterine cancer\nAbbreviations\nEC  Endometrial cancer\nPOP  Pelvic organ prolapse\nCPT  Current Procedural Terminology\nNCCN  National Comprehensive Cancer Network\nLVSI  Lymphovascular space invasion\nHandling Editor: Catherine Matthews\nEditor in Chief: Maria A. Bortolini\n * Mariam AlHilli \n alhillm@ccf.org\n1 Obstetrics, Gynecology, Women’s Health Institute, \nCleveland Clinic, Desk A81, 9500 Euclid Avenue, \nCleveland, OH 44195, USA\n2 Cleveland Clinic Lerner College of Medicine of Case \nWestern Reserve University School of Medicine, Cleveland, \nOH 44195, USA\n3 Department of Qualitative Health Sciences, Cleveland Clinic, \nCleveland, OH 44195, USA\n4 Division of Urogynecology, Department of Subspeciality \nCare for Women’s Health, Obstetrics and Gynecology \nInstitute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, \nCleveland, OH 44195, USA\n5 Division of Gynecologic Oncology, Department \nof Subspeciality Care for Women’s Health, Obstetrics \nand Gynecology Institute, Cleveland Clinic, 9500 Euclid \nAve., Cleveland, Ohio 44195, USA\n\n2298 International Urogynecology Journal (2025) 36:2297–2304\nMMI  Myometrial invasion\nFIGO  International Federation of Gynecology and \nObstetrics\nIntroduction\nEndometrial cancer (EC) is the most common gynecologic \nmalignancy in women with approximately 66,200 estimated \nnew cases diagnosed in 2023 and 13,030 expected deaths in \nthe United States [1, 2]. The 5-year relative survival rate is \n81.1%, and approximately 3.1% of women will be diagnosed \nwith uterine cancer at some point during their lifetime [2 ]. \nRisk factors for EC include age, obesity, estrogen hormone \nreplacement therapy, nulliparity, and a family history of EC \n[3].\nA woman’s lifetime risk of undergoing a procedure \nfor urinary incontinence or pelvic organ prolapse (POP) \nby the age of 80 is estimated to be 11% [4 ]. Analysis of \nthe National Hospital Discharge Summary estimated that \nover 200,000 and 100,000 inpatient surgical procedures \nare performed in the United States annually for POP and \nfemale urinary incontinence, respectively [5 , 6]. Pro-\nlapse is the most common indication for hysterectomy in \nwomen greater than 55 years of age [7 ]. The risk of an \nincidental finding of uterine pathology in women under -\ngoing hysterectomy for prolapse is overall low, studies \nquote percentages ranging from 0.5–2.6% [8 –10]. An \nincidental diagnosis of malignancy after surgery for pro-\nlapse or other benign indication can result in deviations \nfrom standard management that may potentially alter \npatients’ outcomes.\nKnowing the incidence of uterine malignancy at the time \nof surgery for prolapse can help guide preoperative evalua-\ntions to identify patients at risk and direct preoperative coun-\nseling. Our study aim was to identify the incidence of occult \nendometrial cancer identified on pathology specimens from \nsurgeries performed for POP at our institution. In addition, \nwe sought to evaluate the oncologic outcomes of patients \nwith an occult diagnosis of EC in comparison to women with \na known preoperative diagnosis of EC.\nMethods\nStudy Design\nWe performed an institutional review board approved, ret -\nrospective cohort study of patients aged 50 years and older \nwho had an incidental diagnosis of EC during primary sur -\ngery for POP at a single, tertiary care institution between \nJanuary 1, 2010 and December 31, 2020. Patients were \nexcluded if hysterectomy of any route (vaginal, laparoscopic, \nor open) was not performed.\nPatients were identified using Current Procedural Ter -\nminology (CPT) codes for prolapse surgery. This cohort \nwas then cross-referenced with patients who had Interna-\ntional Classification of Diseases-9 or −10 codes identify -\ning endometrial malignancy. Procedures for POP repair for \nwhich CPT codes were used included colpopexy, uterosa-\ncral ligament suspension, paravaginal repair, colpocleisis, \nLe Forte colpocleisis, sacrospinous ligament suspension, \nanterior colporrhaphy, combined anterior/posterior colp-\norrhaphy, posterior colporrhaphy, colpoperineorrhaphy, \ncolpoperineorrhaphy with repair of rectocele, burch or \nMarshall–Marchetti–Krantz procedure (primary or repeat), \nlaparoscopic burch or Marshall–Marchetti–Krantz, fascia \nor synthetic sling, or laparoscopic sling. Identified patients \nwere reviewed by two independent persons to verify con-\ncordance with inclusion criteria. Most procedures were \nperformed by a urogynecologist with a few completed by \neither a general OBGYN or urologist.\nThis cohort was compared to the preoperatively diag-\nnosed group, who had a diagnosis of EC prior to hyster -\nectomy and completed definitive surgery at the Cleveland \nClinic Foundation between January 1, 2004 and August 1, \n2016 as previously described by Son et al. [11]. Patients \nundergoing fertility sparing treatment were excluded.\nData Collection\nWe queried the electronic medical record for patient, sur -\ngical, and oncologic parameters. All data was collected \nand stored in a secure REDCap database [12]. Patient char-\nacteristics, including age at primary surgery, race, body \nmass index, history of smoking, comorbidities, and parity \nwere included.\nData specific to the prolapse surgery was collected, \nincluding hysterectomy approach and additional proce-\ndures performed. Oncologic parameters specific to the \noccult cohort collected included patient presentation at our \ninstitutional tumor board, and requirement for subsequent \nsurgical staging. Time to a secondary surgical procedure \nwas defined as days elapsed between the date of primary \nprolapse surgery and staging procedure. Optimal manage-\nment of disease per the National Comprehensive Cancer \nNetwork (NCCN) guidelines for uterine cancer was noted \n[13].\nOncologic parameters collected for both the occult \nand preoperatively diagnosed cohorts included stage and \ngrade at diagnosis, histology, lymphovascular space inva-\nsion (LVSI), tumor size, and depth of myometrial inva-\nsion (MMI). Adjuvant therapy, including chemotherapy, \n\n2299International Urogynecology Journal (2025) 36:2297–2304 \nextended beam radiation therapy, and vaginal brachyther -\napy was documented.\nStatistical Analysis\nApproximately normally distributed continuous meas-\nures were summarized using means and standard devia-\ntions and compared using two-sample t -tests. Continuous \nmeasures that demonstrated departure from normality and \nordinal measures were summarized using medians and \nquartiles or frequencies and percentages and compared \nusing Wilcoxon rank sum tests. Categorical factors were \nsummarized using frequencies and percentages and were \ncompared using Pearson’s chi-square tests or Fisher’s \nexact tests. Owing to the different follow-up durations \nbetween the two cohorts and the low event rates in the \noccult cohort, only descriptive survival analysis was \ndone. Survival starting date was set to be the surgery \ndate, and month was defined as 30 days. Data analysis \nwas performed using SAS software (version 9.4; SAS \nInstitute, Cary, NC). P  values of < 0.05 were considered \nsignificant.\nResults\nPatient Demographics\nA total of 1072 patients were included in this analysis of \nwhich 30 (2.8%) patients were in the occult cohort and 1042 \n(97.2%) were in the preoperatively diagnosed cohort. Patient \ncharacteristics comparing the two cohorts are illustrated in \nTable  1. The age at surgery was similar between the occult \nand preoperatively diagnosed cohorts (mean 67.2 years ± \nSD 9.1 vs. 63.9 years ± 9.2, p = 0.054). Patients in the \noccult cohort had a lower body mass index (kg/m2) in com-\nparison to the preoperatively diagnosed cohort (30.1 ± 6.4 \nvs. 34.7 ± 9.3, p  < 0.001) and higher rate of smoking his-\ntory (40.0% vs. 0.29%, p  <0.001). The distribution of race \ndiffered significantly between the two cohorts as the occult \ncohort had fewer African American patients (3.3% vs. 9.4%) \nand more Asian/Pacific Islander patients (6.7% vs. 1.9%) \n(p = 0.006) in comparison to the preoperatively diagnosed \ncohort. The two cohorts had similar rates of hypertension \ndiabetes mellitus pulmonary disease, cardiac disease, other \ncancers, and Lynch syndrome (Table  1).\nTable 1  Demographics \ncomparing the occult \nendometrial cancer to \npreoperative endometrial cancer \ncohorts\nStatistics presented as mean ± SD, median [P25, P75], N (column %)\np values: a1 t-test, a2 Satterthwaite t-test, b Wilcoxon Rank Sum test, c Pearson’s chi-square test, d Fisher’s \nExact test\nOccult (N = 30) Preoperative (N = 1 \n042)\nFactor Total\n(N=1,072)\nN Statistics N Statistics p value\nAge at surgery 64.0 ± 9.3 30 67.2 ± 9.1 1042 63.9 ± 9.2 0.054a1\nBody mass index (kg/m2) 34.6 ± 9.3 30 30.1 ± 6.4 1031 34.7 ± 9.3 <0.001a2\nRace 30 1024 0.006d\n     Non-Hispanic White 935 (88.7) 26 (86.7) 909 (88.8)\n     Hispanic 1 (0.09) 1 (3.3) 0 (0.00)\n     Black/African American 97 (9.2) 1 (3.3) 96 (9.4)\n     Asian/Pacific Islander 21 (2.0) 2 (6.7) 19 (1.9)\nComorbidities\n     Hypertension 628 (58.6) 30 22 (73.3) 1042 606 (58.2) 0.096c\n     Diabetes 304 (28.4) 30 6 (20.0) 1042 298 (28.6) 0.30c\n     Pulmonary disease 174 (16.2) 30 3 (10.0) 1042 171 (16.4) 0.46d\n     Cardiac disease 229 (21.4) 30 4 (13.3) 1042 225 (21.6) 0.28c\n     Other cancer history 150 (14.1) 30 3 (10.0) 1032 147 (14.2) 0.79d\nHistory of Lynch syndrome 30 1042 0.99d\n     Yes 5 (0.47) 0 (0.00) 5 (0.48)\n     No 1,061 (99.0) 30 (100.0) 1031 (98.9)\n     Unknown 6 (0.56) 0 (0.00) 6 (0.58)\nSmoking history 15 (1.4) 30 12 (40.0) 1042 3 (0.29) <0.001d\nParity 2.0 [1.00, 3.0] 29 2.0 [2.0, 3.0] 993 2.0 [1.00, 3.0] 0.091b\n\n2300 International Urogynecology Journal (2025) 36:2297–2304\nUrogynecologic Surgery Parameters\nA total of 5376 unique POP surgeries occurred between \nJanuary 1, 2010 and December 30, 2020 at our institution. \nA total of 30 patients had an incidental diagnosis of EC \nconfirmed postoperatively after prolapse surgery for an \noverall incidence of EC of 0.56%. No patients diagnosed \nwith EC demonstrated signs or symptoms of EC preopera-\ntively, particularly postmenopausal bleeding. The surgical \nparameters for the occult cohort are described in Table  2. \nMost patients had a vaginal hysterectomy ( n = 22, 75.9%). \nTen percent (n = 3) had a unilateral salpingectomy, 40.0% \n(n = 12) had a bilateral salpingectomy, 6.7% (n  = 2) had \na unilateral oophorectomy, 33.3% (n  = 10) had a bilateral \noophorectomy, and 3.3% (n  = 1) had a colpocleisis. The \nmedian uterine weight for all hysterectomies performed \nin the occult cohort was 59.3 grams [Interquartile range \n(IQR) 42.5–99.0].\nOf the 30 patients diagnosed with occult EC, no patients \nunderwent lymph node assessment during prolapse surgery, \n13.3% ( n = 4) of patients were presented at a multidisci -\nplinary tumor board, and 33.3% (n  = 10) underwent a sec-\nond staging procedure. The median time to second staging \nprocedure was 52.0 days [IQR 28.0–64.0]. In 26.7% (n  = \n8) patients, a second staging procedure was documented as \ndiscussed with the patient in the medical record but was \ndeferred due to either patient preference or low risk status. \nFor 40.0% (n = 12) of patients, a second staging procedure \nwas not recommended. Adnexal involvement was present in \n15.8% (n = 3) of patients who had an oophorectomy either \nat initial surgery or at secondary staging. Overall, 83.3% (nn \n= 25) of patients received care in compliance with NCCN \nguidelines for uterine cancer.\nOncologic Parameters for Occult Endometrial Cancer \nVersus Preoperative Diagnosed Cohorts\nThere was no difference in stage or histology at diagnosis \nwith the majority of patients presenting with stage I or II \n(87.5% vs. 83.7%, p  = 0.78) and endometrioid histology \n(90.0% vs. 80.1%, p = 0.44) in the occult and preoperatively \ndiagnosed cohorts, respectively (Table  3). Patients in the \noccult cohort were more likely to present with International \nFederation of Gynecology and Obstetrics (FIGO) grade 1 \ndisease (85.2% vs. 52.1%, p  < 0.001) when compared to \nthe preoperatively diagnosed cohort and were less likely \nto have LVSI (10.7% vs. 31.8%, p  = 0.017) or MMI of > \n50% (11.1% vs. 24.0%, p  = 0.004). Patients in the occult \ncohort had smaller median tumor sizes on pathology (2.0 \ncm IQR [0.60–2.7] vs. median 3.0 cm IQR [1.1–4.5], p  = \n0.005) in comparison to the control cohort and were less \nlikely to receive any form of adjuvant therapy (24.1% vs \n48.9%, p = 0.008), including chemotherapy (13.3% vs. \n30.7%, p = 0.041) and vaginal brachytherapy (10.0% vs. \n32.9%, p = 0.008). However, no differences in likelihood \nof receiving external beam radiotherapy between cohorts \nwas noted ( p = 0.11). With a median follow-up duration \nof 72.0 months [IQR 32.3–94.5], two recurrences (6.7%) \nand 5 deaths (16.7%) were observed in the occult cohort. \nAs is seen in Fig.  1A/B, the 5-year recurrence free survival \nwas 95.0% (95% CI 85.4% −100%) and 5-year overall sur -\nvival was 90.9% (95% CI 78.9%–100%). The preoperatively \ndiagnosed cohort had a median follow-up duration of 18.0 \nmonths [IQR 8.9–26.4] with 5-year recurrence-free survival \nof 66.8% (95% CI 59.3–74.4%), and 5-year overall survival \nof 83.0% (95% CI 75.5–90.5%).\nTable 2  Characteristics of surgical variables for occult endometrial \ncancer cohort\nNCCN National Comprehensive Cancer Network\nStatistics presented as Median [P25, P75], N (column %).\nTotal\n(N = 30)\nFactor N Statistics\nHysterectomy approach 29\n     Abdominal 2 (6.9)\n     Laparoscopic 5 (17.2)\n     Vaginal 22 (75.9)\nType of urogynecology surgery\n     Tension free vaginal tape sling 30 5 (16.7)\n     Transobturator tape sling 30 7 (23.3)\n     Anterior colporrhaphy 30 21 (70.0)\n     Posterior colporrhaphy 30 18 (60.0)\n     Sacrocolpopexy 30 5 (16.7)\n     Uterosacral ligament suspension 30 16 (53.3)\n     Perineorrhaphy 30 5 (16.7)\n     Sacrospinous ligament suspension 30 2 (6.7)\n     Unilateral salpingectomy 30 3 (10.0)\n     Bilateral salpingectomy 30 12 (40.0)\n     Unilateral oophorectomy 30 2 (6.7)\n     Bilateral oophorectomy 30 10 (33.3)\n     Colpocleisis 30 1 (3.3)\nUterus weight (g) 28 59.3 [42.5, 99.0]\nStaging at urogynecology surgery 30 0 (0)\nAdnexal involvement 19 3 (15.8)\nCervical involvement 27 0 (0)\nPatient presented at tumor board 30 4 (13.3)\nSecond staging procedure required 30\n     Yes 10 (33.3)\n     No 12 (40.0)\n     Yes but not performed 8 (26.7)\nTime to second staging procedure (days) 10 52.0 [28.0, 64.0]\nCompliance with NCCN guidelines 30 25 (83.3)\n\n2301International Urogynecology Journal (2025) 36:2297–2304 \nDiscussion\nMortality rates for EC have increased by 1.8% overall and \n2.7% for non-endometrioid subtypes in recent years [14]. \nWith hysterectomy being one of the most common gyneco-\nlogic procedures performed, the importance of preoperative \nevaluation for malignancy is of utmost importance. The Fed-\neral Drug Administration warning against the use of power \nmorcellation due to possible dissemination of occult malig-\nnancy has made for more robust preoperative cancer screen-\ning practices in patients with large uteri or abnormal uterine \nbleeding [15, 16]. Despite increased screening efforts, occult \nuterine malignancy is still identified in patients undergo-\ning benign surgery. The incidence of occult EC was 0.56% \nin our study, which is consistent with previously reported \ndata. In our study, patients with occult EC were more likely \nto have FIGO grade 1 disease, and less likely to have LVSI, \nlarger tumor size, and deep MMI than the preoperatively \ndiagnosed cohort. Furthermore, occult patients had a sig-\nnificantly lower body mass index and were less likely to be \nof African American race than the preoperatively diagnosed \ncohort. Overall, 83.3% (n  = 25) patients received care in \ncompliance with NCCN guidelines for uterine cancer.\nGiven recent increases in rates of hysteropexy [17], \nawareness of risk factors for occult endometrial pathology is \nimportant. While the literature does not consistently deline-\nate risk factors, as outlined above, there are established con-\ntraindications to uterine preservation. Patients with genetic \npredisposition for malignancy and those with a personal his-\ntory of an estrogen receptor positive breast cancer, especially \nif on tamoxifen, should not be offered uterine preserving \nprolapse repair. Other contraindications include endome-\ntrial hyperplasia and post-menopausal bleeding, even if the \nendometrial biopsy is negative. Obesity is cited as a relative \ncontraindication to uterine preservation, given that this is a \nrisk factor for development of endometrial cancer [18].\nIdentifying and understanding risk factors for inciden-\ntal uterine pathology at time of hysterectomy is essential \nfor optimizing preoperative screening and patient coun-\nseling in women undergoing hysterectomy for benign \nindications. Several studies have reviewed this topic. \nReported rates of incidental EC or hyperplasia range from \nTable 3  Oncologic variables \ncomparing occult endometrial \ncancer to preoperative \nendometrial cancer cohorts\nStatistics presented as median [P25, P75], N (column %)\np values: b Wilcoxon rank sum test, c Pearson’s chi-square test, d Fisher’s exact test\nOccult\n(N=30)\nPreoperative\n(N = 1042)\nFactor Total\n(N=1,072)\nN Statistics N Statistics p value\nStage at diagnosis 24 1014 0.78d\n     I/II 870 (83.8) 21 (87.5) 849 (83.7)\n     III/IV 168 (16.2) 3 (12.5) 165 (16.3)\nGrade 27 936 <0.001b\n     FIGO 1 511 (53.1) 23 (85.2) 488 (52.1)\n     FIGO 2 272 (28.2) 4 (14.8) 268 (28.6)\n     FIGO 3 180 (18.7) 0 (0.00) 180 (19.2)\nHistology 30 1,037 0.44d\n     Endometrioid 858 (80.4) 27 (90.0) 831 (80.1)\n     Serous 77 (7.2) 1 (3.3) 76 (7.3)\n     Clear cell 17 (1.6) 0 (0.00) 17 (1.6)\n     Mixed 71 (6.7) 0 (0.00) 71 (6.8)\n     Other 44 (4.1) 2 (6.7) 42 (4.1)\nLVSI 331 (31.3) 28 3 (10.7) 1030 328 (31.8) 0.017c\nTumor size (cm) 3.0 [1.1, 4.5] 19 2.0 [0.60, 2.7] 1034 3.0 [1.1, 4.5] 0.005b\nDepth of myometrial invasion 27 964 0.004c\n     0% 272 (27.4) 15 (55.6) 257 (26.7)\n     < or = 50% 485 (48.9) 9 (33.3) 476 (49.4)\n     >50% 234 (23.6) 3 (11.1) 231 (24.0)\nAdjuvant therapy 517 (48.3) 29 7 (24.1) 1042 510 (48.9) 0.008c\n     Chemotherapy 324 (30.2) 30 4 (13.3) 1042 320 (30.7) 0.041c\n     External beam 189 (17.6) 30 2 (6.7) 1042 187 (17.9) 0.11c\n     Vaginal brachytherapy 346 (32.3) 30 3 (10.0) 1042 343 (32.9) 0.008c\n\n2302 International Urogynecology Journal (2025) 36:2297–2304\n0.3 to 2.6% [8 , 9, 19]. Some notable risk factors in these \nstudies include age >60 years, a concomitant diagnosis of \nhypertension or diabetes, and uterine weight > 250 grams. \nHowever, these factors were not found to be predictive \nof occult EC in our cohort [ 19]. In our study, the occult \ncohort had significantly different body mass index, race, \nand smoking history compared to the preoperatively diag-\nnosed cohort. Previously published occult EC rates after \nsurgery for varying benign indications were consistent \nwith our findings.\nFig. 1  A/B: Oncologic out-\ncomes in occult endometrial \ncancer versus preoperatively \ndiagnosed endometrial cancer \ncohorts\n\n\n2303International Urogynecology Journal (2025) 36:2297–2304 \nOur study is also one of the few to report and compare \noncologic descriptors and treatment outcomes after an occult \nEC diagnosis, and compare these women to a similar cohort \nof patients with preoperatively diagnosed EC. The inciden-\ntal diagnosis of EC after surgery creates a dilemma in the \nabsence of prognostic information that lymph node status \nprovides [13]. In our study, ten patients (33.3%) underwent \na second staging procedure and in eight (26.7%) patients, a \nsecond staging procedure was documented as discussed with \nthe provider in the medical record, but was deferred due to \npatient preference or low risk status. Ambiguity regarding \nadjuvant care in situations when EC is identified on pathol-\nogy specimens can be mitigated by the use of clinical criteria \nto estimate risk of recurrence and lymph node metastasis \nor use of a risk scoring system that has been described pre-\nviously [20]. These tools can allow patients to receive the \nmost appropriate surgery or adjuvant therapy for their can-\ncer, and optimize oncologic outcomes even when cancer is \nincidentally diagnosed. Additionally, NCCN provides guide-\nlines for patients with incidentally diagnosed EC who are \nincompletely staged which may include observation, vaginal \nbrachytherapy, surgical restaging, or further imaging with \ntreatment decisions altered on the basis of positive or suspi-\ncious imaging results [13].\nLess than 25% of women in our study required adju-\nvant therapy. The majority of our patients had early-stage \nand low-grade disease and thus were able to be safely and \nappropriately observed. Emerging data regarding molecu-\nlar classification of EC and its prognostic role may further \nsimplify risk stratification and support evidence-based treat-\nment decisions according to molecular subtypes [21]. These \ncriteria are anticipated to enhance oncologic care, and allow \nwomen to avoid undertreatment or overtreatment of their \ndisease.\nThe incidental diagnosis of EC is very low in patients \nundergoing hysterectomy for benign indications, with \nvarying estimates ranging from 0.5–2.6% [8 –10]. The \nincidental finding of uterine malignancy at time of hys-\nterectomy for prolapse repair highlights continued diffi-\nculty with preoperative screening and diagnosis of EC, as \nmost patients in this population were asymptomatic and \nhad no identifiable risk factors. Despite the excellent out-\ncomes and diagnosis of early-stage low-grade disease, an \nincidental diagnosis of EC is alarming to patients. The \nlifetime risk of an American woman developing EC is \napproximately 2.8%, and rising in recent years as previ-\nously described [22]. Our study contributes to the pub-\nlished literature, in providing support that the incidence \nof incidentally diagnosed EC at the time of hysterectomy \nfor POP is lower than a woman’s lifetime risk of devel-\noping the disease. Future research is needed, especially \nin regard to cost effectiveness of preoperative screening \nwith transvaginal ultrasound or endometrial biopsy in the \nsetting of low risk patients and a rare primary outcome of \nincidentally diagnosed EC at time of surgery for benign \nindications.\nThe main strength of our study is that it includes data \nfrom a large volume academic institution with special -\nized gynecologic pathology review. Only two reviewers \nperformed the chart review to minimize selection bias and \nstandardize data collection. In addition, we were able to \nconduct a comparison of oncologic parameters to a similar \ncohort at the same institution with known EC at the time \nof primary surgery.\nThere are several limitations to our study that must be \nconsidered. The retrospective study design, the possibility \nof bias in patient selection by different staff surgeons, and \nthe availability of medical records data cannot be disre-\ngarded. Furthermore, with the small sample size of the \noccult EC cohort and overall low incidence of postopera-\ntive complications, it is possible that the study was not \nadequately powered to detect significance with respect \nto specific associations. The patients in this study were \ntreated at a high-volume tertiary care center and the major -\nity identified as white, which may limit generalizability. \nThe study also occurred over a 10-year study period with \ndiscrepancy in duration of study between the occult and \npreoperatively diagnosed cohort due to data availability, \nwhich may not account for practice or societal guidelines \nchanges.\nIn summary, in this single institution retrospective \ncohort study of women incidentally diagnosed with EC \nat time of POP repair, the incidence of EC was similar \nto published rates in the literature. The majority of our \npatients received care concurrent with NCCN recommen-\ndations for EC despite their incidental diagnosis.\nAuthor Contributions Morgan Gruner: Conceptualization, data cura-\ntion, writing—original draft, writing—review and editing, project \nadministration.\nSurabhi Tewari: Conceptualization, data curation, writing—original \ndraft, writing—review and editing.\nMeng Yao: Methodology, statistical analysis, data curation, writ-\ning—original draft, writing—review and editing.\nKatie Propst: Conceptualization, Data curation, writing—original \ndraft, writing—review and editing.\nMariam AlHilli: Conceptualization, methodology, investigation, \ndata curation, writing—original draft, writing—review and editing, \nproject administration, project supervision.\nFunding There has been no financial support for this work.\nDeclarations \nEthical Approval IRB Number 21-538. IRB approval obtained from \nCleveland Clinic Foundation IRB.\nConflict of Interest The authors have no known conflicts of interest.\n\n2304 International Urogynecology Journal (2025) 36:2297–2304\nOpen Access This article is licensed under a Creative Commons Attri-\nbution 4.0 International License, which permits use, sharing, adapta-\ntion, distribution and reproduction in any medium or format, as long \nas you give appropriate credit to the original author(s) and the source, \nprovide a link to the Creative Commons licence, and indicate if changes \nwere made. The images or other third party material in this article are \nincluded in the article’s Creative Commons licence, unless indicated \notherwise in a credit line to the material. If material is not included in \nthe article’s Creative Commons licence and your intended use is not \npermitted by statutory regulation or exceeds the permitted use, you will \nneed to obtain permission directly from the copyright holder. 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Treasure Island: StatPearls; 2023.\nPublisher’s Note Springer Nature remains neutral with regard to \njurisdictional claims in published maps and institutional affiliations.","source_license":"CC0","license_restricted":false}