Occult endometrial cancer in women undergoing hysterectomy for benign indications: a retrospective cohort study in a tertiary hospital in China

Occult endometrial cancer in women undergoing hysterectomy for benign indications: a retrospective cohort study in a tertiary hospital in China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Occult endometrial cancer in women undergoing hysterectomy for benign indications: a retrospective cohort study in a tertiary hospital in China Yang Cao, Honghui shi, Xiuping Zhuo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3746326/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 May, 2024 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted 5 You are reading this latest preprint version Abstract Purpose To evaluate the feasibility of further reducing the incidence of occult endometrial cancer in women undergoing hysterectomy for benign gynecological indications. Methods Patients who underwent hysterectomies for presumed benign gynecologic conditions at Peking Union Medical College Hospital were retrospectively identified. Patients with occult endometrial cancer, which was defined as endometrial cancer diagnosed on postoperative histopathology with no preoperative confirmed malignancy, were selected. Results 24/7558 (0.32%; 95% CI 0.20–0.47%) patients undergoing hysterectomy for benign indications had occult endometrial cancer. Asymptomatic patients with normal endometrial imaging all tended to have favorable pathology. Heavy menstrual bleeding was the most overlooked AUB pattern in the premenopausal group. In the postmenopausal group, all the patients with serous adenocarcinoma or G3 endometrioid adenocarcinoma histology/stage T1b disease/ LVSI space invasion had a history of persistent or recurrent PMB ≥ 6 months and/or an intracavitary lesion > 20 mm in diameter. 3/4 of the samples of the postmenopausal patients did not have adequate endometrium for evaluation. Conclusion To further reduce the incidence of occult endometrial cancer, physicians should focus on the patient's bleeding pattern and actively implement endometrial sampling whenever indicated. Transvaginal ultrasonography is a valuable preoperative evaluation. Hysteroscopy with directed biopsy is the preferred procedure in postmenopausal patients. postmenopausal bleeding abnormal uterine bleeding transvaginal ultrasonography hysteroscopy Figures Figure 1 Figure 2 What does this study adds to the clinical work The incidence of occult endometrial cancer after hysterectomy for benign gynecological indications was 0.32%. To further reduce the risk of occult endometrial cancer, physicians should focus on the bleeding symptoms of the patients and use transvaginal ultrasound as a valuable non-invasive preoperative evaluation for both symptomatic and asymptomatic patients. Introduction Hysterectomy is a therapeutic procedure commonly performed in women with benign gynecological conditions, such as symptomatic leiomyomas, adenomyosis, and pelvic organ prolapse. Routine workup before hysterectomy includes obtaining a relevant medical history (including risk factors for endometrial cancer), physical examination, cervical cytology, and transvaginal ultrasonography to rule out potential uterine malignancy. Endometrial sampling is indicated for the diagnostic evaluation of women in whom endometrial hyperplasia or carcinoma is a possibility. Endometrial cancer typically presents with postmenopausal or abnormal uterine bleeding (AUB), which is present in 75–90% of cases[ 1 – 3 ]. Most patients are diagnosed while the disease is still confined to the uterus, resulting in a five-year survival rate of over 90%. Despite all preoperative evaluations and the symptomatic nature of endometrial cancer, some patients continue to have occult endometrial cancer, presenting profound challenges to clinical care providers, including the potential spread of malignant tissue in the case of uterine fragmentation at hysterectomy. Furthermore, incomplete surgical staging entails postoperative imaging, restaging, removal of additional anatomy (adnexa, lymph nodes, and omentum), or adjuvant radiotherapy. The aim of our study was to evaluate the feasibility of further reducing the incidence of occult endometrial cancer in women undergoing hysterectomy for benign gynecological indications. Methods All cases of hysterectomies performed for benign gynecologic indications at Peking Union Medical College Hospital between January 2012 and September 2018 were identified. Patients with occult endometrial cancer, defined as endometrial cancer diagnosed on postoperative histopathology with no preoperative confirmed malignancy, were selected from the chart review for this retrospective cohort study. Patients with the diagnosis of endometrial hyperplasia with atypia in endometrial sampling before hysterectomy were excluded. Data on patient demographics, endometrial cancer risk factors, chief complaint, preoperative evaluation, surgical approach, pathology, postoperative treatment, and follow-up were extracted from the medical records of the identified cases of occult malignancy. The study was approved by the institutional review board of Peking Union Medical College Hospital. Informed consent was not required as this was a retrospective study of patient data without specific human subject identifiers. Binomial 95% confidence intervals (CIs) were calculated using the Clopper-Pearson Interval (SAS 9.4, SAS Institute, Cary, NC). Results A total of 7558 hysterectomies were performed for benign gynecologic indications during this period. Among these, 24/7558 (0.32%; 95% CI 0.20–0.47%) patients were found to have occult endometrial cancer. The patients were divided into postmenopausal and premenopausal groups with 12 patients in each group. The characteristics of the 24 patients were listed in Table 1 . Table 1 Characteristics of the patients Postmenopausal, n (%) 12 (50%) Premenopausal, n (%) 12 (50%) Age, n (%) Age, n (%) Mean ± SD, yrs 64.1 ± 9.1 Mean ± SD, yrs 49.1 ± 4.3 < 55 yrs 1 (8.3%) < 45 yrs 1 (8.3%) 55–60 yrs 2 (16.7%) 45–50 yrs 6 (50%) ≥ 60 yrs 9 (75%) ≥ 50 yrs 5 (41.7%) Parity, n (%) Parity, n (%) Nulliparous 1 (8.3%) Nulliparous 2 (16.7%) Parous 11 (91.7%) Parous 10 (83.3%) BMI, n (%) BMI, n (%) <25 kg/m 2 7 (58.3%) < 25 kg/m 2 5 (41.7%) 25–30 kg/m 2 4 (33.3%) 25–30 kg/m 2 5 (41.7%) ≥30 kg/m 2 1 (8.3%) ≥ 30 kg/m 2 2 (16.7%) Other risk factors Other risk factors Tamoxifen therapy 1 (8.3%) HTN 2 (16.7%) HTN 2 (16.7%) HTN + DM 2 (16.7%) Family history of endometrial, breast, or colon cancer 4 (33.3%) Chief complaint, n (%) PMB No PMB Intracavitary lesion Pelvic mass + intracavitary lesion Pelvic mass POP 7 (58.3%) 5 (41.7%) 1 (8.3%) 1 (8.3%) 2 (16.7%) 1 (8.3%) Chief complaint, n (%) Irregular bleeding with 3 (25%) precedent heavy menstrual bleeding 2 (16.7%) precedent infrequent uterine bleeding 1 (8.3%) Frequent uterine bleeding 1 (8.3%) Prolonged + heavy menstrual bleeding 1 (8.3%) Heavy menstrual bleeding with 5 (41.7%) infrequent uterine bleeding 1 (8.3%) leiomyoma 2 (16.7%) adenomyosis 1 (8.3%) pelvic mass 1 (8.3%) POP 2 (16.7%) Endometrial imaging, n (%) Endometrial imaging, n (%) Intracavitary lesion 6 (50%) Intracavitary lesion 5 (41.7%) Mean ± SD, mm 29 ± 12 Mean ± SD, mm 30 ± 14 Thickened endometrium (6 mm) 1 (8.3%) Heterogeneous endometrium 4 (33.3%) Normal 3 (25%) Mean ± SD, mm 25 ± 5.4 Non-measurable 1 (8.3%) Normal 3 (25%) Not addressed 1 (8.3%) Mean ± SD, mm 7.7 ± 3.8 Preoperative endometrial sampling, n (%) Preoperative endometrial sampling, n (%) N/A 8 (66.7%) N/A 10 (83.3%) Comorbidity 2 (16.7%) Comorbidity 1 (8.3%) Advanced age 1 (8.3%) Not indicated 1 (8.3%) Not indicated 3 (25%) No identified reason 8 (66.7%) No identified reason 2 (16.7%) Complex hyperplasia without atypia 2 (16.7%) Scant or no endometrium for evaluation 3 (25%) Complex hyperplasia without atypia 1 (8.3%) Surgery, n (%) Surgery, n (%) TAH + BSO 4 (33.3%) TAH + BSO 4 (33.3%) TLH + BSO 7 (58.3%) TAH + BS 2 (16.7%) TVH + Prolift™ mesh repair 1 (8.3%) TLH + BSO 1 (8.3%) TLH + BS 3 (25%) TLH + BSO + Sacrocolpopexy 1 (8.3%) TLH + BS + Sacrocolpopexy 1 (8.3%) Histology, n (%) Histology, n (%) Endometrioid 10 (83.3%) Endometrioid 12 (100%) Non-endometrioid 2 (16.7%) Non-endometrioid 0 Stage a , n (%) Stage a , n (%) T1aNxMx 7 (58.4%) T1aNxMx 9 (75%) Intramucosal 2 (16.7%) Intramucosal 4 (33.3%) < 50% myometrial invasion 5 (41.7%) < 50% myometrial invasion b 5 (41.7%) T1aN0M0 (< 50% myometrial invasion) 1 (8.3%) T1aN0M0 2 (16.7%) T1bNxMx 4 (33.3%) Intramucosal 1 (8.3%) < 50% myometrial invasion 1 (8.3%) T2NxMx 1 (8.3%) FIGO Grade, n (%) FIGO Grade, n (%) Grade 1 8 (66.7%) Grade 1 11 (91.7%) Grade 2 1 (8.3%) Grade 2 1 (8.3%) Grade 3 1 (8.3%) LVSI, n (%) LVSI, n (%) Positive 2 (16.7%) Positive 0 Negative 10 (83.3%) Negative 12 (100%) Treatment, n (%) Treatment, n (%) EX-LAP PPALND/Omentectomy 1 (8.3%) EX-LAP PPALND/Omentectomy/Appendectomy 1 (8.3%) Laparoscopic BSO 1 (8.3%) Laparoscopic BSO/Pelvic lymph node biopsy 1 (8.3%) Brachytherapy 2 (16.7%) Laparoscopic bilateral oophorectomy 2 (16.7%) Progestational agents 1 (8.3%) Brachytherapy 2 (16.7%) Surveillance 7 (58.3%) EBRT 1 (8.3%) Surveillance 5 (41.7%) Follow-up, n (%) Follow-up, n (%) Mean ± SD, mos 51.5 ± 26.3 Mean ± SD, mos 67.8 ± 24.9 Relapse of disease 2 (16.7%) Relapse of disease 1 (8.3%) BMI, body mass index; HTN, hypertension; DM, diabetes mellitus; PMB, postmenopausal bleeding; POP, pelvic organ prolapse; TAH, total abdominal hysterectomy; BSO, bilateral salpingo-oophorectomy; TLH, total laparoscopic hysterectomy; TVH, total vaginal hysterectomy; BS, bilateral salpingectomy; LVSI, lymphovascular space invasion; EX-LAP, exploratory laparotomy; PPALND, pelvic and para-aortic lymph node dissection; EBRT, external beam radiation therapy. a Union for International Cancer Control (UICC) TNM staging system b One with concurrent Stage Ia, G1 endometrioid ovarian cancer Preoperative imaging was performed on every patient found to have occult endometrial cancer. Eighteen patients underwent transvaginal ultrasonography (TVUS), one patient underwent computed tomography (CT), one patient underwent magnetic resonance imaging (MRI), three patients underwent both TVUS and CT, and one patient underwent both TVUS and MRI. TVUS provided useful information regarding the structural causes of AUB and could suggest that an endometrial polyp may be present as well as identify a heterogeneous endometrium suggesting the presence of hyperplasia or cancer. Endometrial thickness > 4 mm was considered abnormal for patients with PMB. The endometrial stripe was unable to be evaluated or not addressed through imaging in two patients. Dilation & curettage (D&C) is the standard method for endometrial sampling in our institution. In the postmenopausal group, all symptomatic patients had endometrial imaging abnormalities. Four patients underwent preoperative endometrial sampling, three of whom were found to have scant or no endometrium for evaluation. Endometrial sampling was electively omitted in two patients for cardiac disease and one patient for advanced age. Retrospective analysis revealed no evidence in support of the omission of endometrial sampling in two patients (one with PMB and an endometrial thickness of 6 mm; one with PMB, pelvic mass and endometrial thickness not addressed in ultrasonography) (Fig. 1 ). In the premenopausal group, with the exception of one patient treated with levonorgestrel intrauterine system (LNG-IUS, Mirena®, Bayer HealthCare Pharmaceuticals Inc., Whippany, NJ 07981, USA) for adenomyosis, all symptomatic patients had endometrial imaging abnormalities, yet only 2 patients underwent preoperative endometrial sampling (Fig. 2 ). Heavy menstrual bleeding is the most overlooked symptom in premenopausal women. No patient underwent manual or power morcellation during surgery in our study. In the postmenopausal group, all the patients with serous adenocarcinoma or G3 endometrioid adenocarcinoma histology/stage T1b disease/LSVI had a history of persistent or recurrent PMB ≥ 6 months and/or an intracavitary lesion > 20 mm in diameter. In the premenopausal group, endometrial imaging was not as indicative. Neither the thickness of the endometrium nor the diameter of the intracavitary lesion reflected the severity of endometrial disease very well. However, persistent, increased uterine bleeding (whether irregular, frequent, prolonged, or heavy) appeared to be associated with advanced endometrial disease. Asymptomatic patients with normal endometrial imaging in both groups tended to have favorable pathology (G1, intramucosal disease in 2 premenopausal patients; G1, T1a disease with superficial myometrial invasion in 3 postmenopausal patients). One patient with G1, stage T1a disease was lost to follow-up after her first postoperative visit one month after surgery. All other patients were followed for 15–118 months. Relapses were recorded in three patients. A postmenopausal patient with G1, T1b disease received postoperative vaginal brachytherapy. She relapsed 15 months after surgery and was lost to follow-up shortly after relapse. Another postmenopausal patient had G3, T1b disease with LVS infiltration. Medroxyprogesterone acetate was administered for 10 months, and recurrence was documented 12 months postoperatively. Her last visit was 26 months after surgery with markedly elevated serum CA 125 and a large pelvic tumor. The 47-year-old premenopausal patient had ovary preservation during surgery and G1 endometrioid adenocarcinoma, mostly confined to the endometrium with focal, superficial myometrial invasion. Active surveillance was the treatment of choice; however, MRI revealed a mass arising from the vaginal cuff and pelvic lymph node metastases 10 months after surgery. She received vaginal brachytherapy, EBRT, and 4 cycles of paclitaxel/carboplatin. She was alive with no clinically significant disease. Discussion Postmenopausal bleeding and abnormal uterine bleeding are the key points prompting an endometrium evaluation. Transvaginal ultrasonography is the preferred noninvasive preoperative evaluation performed in both symptomatic and asymptomatic women before proceeding to hysterectomy, as it costs much less than any postoperative imaging or adjuvant therapy in our hospital. Asymptomatic patients with normal endometrial imaging tended to have favorable pathology. For premenopausal patients, the retrospective analysis revealed no evidence in support of the omission of endometrial sampling in 8/12 (66.7%) of the cases in our study. Several reports and guidelines have used some combination of age, personal and genetic risk factors, and TVUS screening for endometrial echo-complex thickness to determine which patients should undergo endometrial sampling[ 4 ]. Neither the thickness of the endometrium nor the diameter of the intracavitary lesion reflected the severity of endometrial disease very well in our study. However, persistent, increased uterine bleeding (whether irregular, frequent, prolonged, or heavy) appeared to be associated with advanced endometrial disease. In clinical practice, physicians tend to pay more attention to changes in menstrual regularity, frequency, and duration than to increase in volume; the latter, however, is often arbitrarily attributed to endometrial polyp, submucosal myoma, or adenomyosis. In fact, heavy menstrual bleeding was the most overlooked AUB pattern in our study. In the postmenopausal group, all the patients with serous adenocarcinoma or G3 endometrioid adenocarcinoma histology/stage T1b disease/LSVI had a history of persistent or recurrent PMB ≥ 6 months and/or an intracavitary lesion > 20 mm in diameter. It has been reported that in women with postmenopausal bleeding and not on hormonal replacement therapy, the sensitivity and specificity of TVUS for detection of endometrial cancer at a 4 mm thickness threshold were 96 and 53 percent; that cancer became increasingly frequent relative to benign disease as the endometrial thickness approached 20 mm[ 5 ]. Endometrial thickness is less predictive of endometrial neoplasia in asymptomatic women. Sensitivity is estimated to be 20 percent lower in asymptomatic compared with symptomatic women. These results are consistent with our study. In the postmenopausal group, four patients had a preoperative endometrial sampling. However, three were found to have scant or no endometrium present for evaluation, one even had a hysteroscopy and curettage. Several limitations to successful endometrial sampling have been reported including cervical stenosis and pelvic organ prolapse which hindered access to the uterine cavity as well as focal endometrial pathology (e.g., endometrial polyps and submucosal fibroids) and endometrial atrophy which reduces sample adequacy. Thus, we suggested diagnostic hysteroscopy and directed biopsy of suspicious lesions, with concurrent ultrasound surveillance in difficult cases, for postmenopausal patients. Three patients whose preoperative endometrial sampling revealed complex hyperplasia without atypia were eventually diagnosed with endometrial cancer. The postmenopausal patient had T1a disease with LVSI; the two premenopausal patients had intramucosal disease. Concurrent endometrial carcinoma rates can be as high as 18.9% in patients with endometrial biopsies diagnosed as less than atypical endometrial hyperplasia in a prospective cohort study published by Gynecologic Oncology Group (GOG)[ 6 ]. Complex hyperplasia without atypia should be managed very cautiously, including informing the patient of the possibility of more severe postoperative pathology and planning surgery accordingly. Diagnostic hysteroscopy and directed biopsy together with expert pathology are also very important to optimize patient care. Three POP patients were identified in our study, which seemed quite prominent. All three patients were asymptomatic and had normal endometrial imaging. Pathology revealed G1, intramucosal disease in two premenopausal patients, and G1, stage T1a disease with less than 50% myometrial invasion in the postmenopausal patient. Based on current literature, the prevalence of occult endometrial cancer in asymptomatic postmenopausal women undergoing hysterectomy with pelvic organ prolapse repair ranges from 0.12 to 3.17%[ 7 – 10 ]. In a study enrolled 708 women undergoing hysterectomy for pelvic organ prolapse and/or urinary incontinence, five cases of endometrial cancer (0.6%) were detected; four of these women had normal preoperative screening, including endometrial biopsy (2 cases), TVUS (1case), or both tests (1 case) [ 11 ]. Considering the low prevalence, the low efficiency of screening, and their favorable prognosis, universal screening via endometrial sampling should not be recommended in asymptomatic women planning POP surgery with normal endometrial imaging, however, simultaneous bilateral salpingo-oophorectomy does offer an advantage over a second, unplanned surgery, especially in postmenopausal patients. The strength of this study was that it proposed practical measures to further reduce the incidence of occult endometrial cancer. Bleeding patterns should be highly valued and used as the primary basis for clinical decision-making, with particular emphasis on persistent or recurrent heavy bleeding. The combination of transvaginal ultrasonography and hysteroscopy with directed biopsy may further reduce the incidence of occult endometrial cancer, especially in postmenopausal patients. The limitation of this study was that it did not propose a solution to systematically address the issue of complex hyperplasia without atypia pathology escalating to endometrial cancer after hysterectomy. Occult endometrial cancer is undesirable. Measures to further reduce the incidence of occult endometrial cancer include: (1) Physicians should focus on the patient's bleeding pattern, although sometimes concomitant genital disorders, such as pelvic mass, fibroids, or adenomyosis, can be very distracting. Persistent, increased uterine bleeding (whether irregular, frequent, prolonged, or heavy) appeared to be associated with advanced endometrial disease in the premenopausal group, while in our study heavy menstrual bleeding was the most overlooked AUB pattern; (2) transvaginal ultrasonography is a valuable noninvasive preoperative evaluation, especially in postmenopausal patients. All the symptomatic patients (17/24, 70.8%) had abnormal endometrial imaging except for one treated with LNG-IUS for adenomyosis. Asymptomatic patients with normal endometrial imaging all tended to have favorable pathology. A history of persistent or recurrent PMB ≥ 6 months and/or an intracavitary lesion > 20 mm in diameter is suggestive of advanced disease or unfavorable histologic type in postmenopausal patients; (3) active implementation of endometrial sampling when indicated; and (4) hysteroscopy with directed biopsy in postmenopausal patients. Declarations Author contribution HHS and YC contributed to the study conception and design. Material preparation, data collection and analysis were performed by YC and XPZ. The first draft of the manuscript was written by YC and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Data availability All available data is presented in this paper. Funding This work was supported by a grant from National High Level Hospital Clinical Research Funding (2022-PUMCH-C-031). Conflict of interest The authors have no relevant financial or non-financial interests to disclose. Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Peking Union Medical College Hospital (reference no: I-22PJ848). 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Smith-Bindman, R., et al., Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA, 1998. 280(17): p. 1510-7. https://doi.org/ 10.1001/jama.280.17.1510. Trimble, C.L., et al., Concurrent endometrial carcinoma in women with a biopsy diagnosis of atypical endometrial hyperplasia: a Gynecologic Oncology Group study. Cancer, 2006. 106(4): p. 812-9. https://doi.org/ 10.1002/cncr.21650. Theben, J.U., et al., Unexpected malignancies after laparoscopic-assisted supracervical hysterectomies (LASH): an analysis of 1,584 LASH cases. Arch Gynecol Obstet, 2013. 287(3): p. 455-62. https://doi.org/ 10.1007/s00404-012-2559-0. Mahnert, N., et al., Unexpected gynecologic malignancy diagnosed after hysterectomy performed for benign indications. Obstet Gynecol, 2015. 125(2): p. 397-405. https://doi.org/ 10.1097/AOG.0000000000000642. Takamizawa, S., et al., Risk of complications and uterine malignancies in women undergoing hysterectomy for presumed benign leiomyomas. Gynecol Obstet Invest, 1999. 48(3): p. 193-6. https://doi.org/ 10.1159/000010172. Frick, A.C., et al., Risk of unanticipated abnormal gynecologic pathology at the time of hysterectomy for uterovaginal prolapse. Am J Obstet Gynecol, 2010. 202(5): p. 507 e1-4. https://doi.org/ 10.1016/j.ajog.2010.01.077. Ramm, O., et al., Utility of preoperative endometrial assessment in asymptomatic women undergoing hysterectomy for pelvic floor dysfunction. Int Urogynecol J, 2012. 23(7): p. 913-7. https://doi.org/ 10.1007/s00192-012-1694-2. Cite Share Download PDF Status: Published Journal Publication published 10 May, 2024 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted Reviewers agreed at journal 28 Dec, 2023 Reviewers invited by journal 28 Dec, 2023 Editor invited by journal 18 Dec, 2023 Editor assigned by journal 12 Dec, 2023 First submitted to journal 11 Dec, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3746326","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":264182847,"identity":"87ea5e52-0e73-4e57-93ae-c43f58a12e43","order_by":0,"name":"Yang Cao","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Cao","suffix":""},{"id":264182848,"identity":"a25c3de6-7903-4d01-80ce-29e20d5865d1","order_by":1,"name":"Honghui shi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYBACAyBmZmCQYDBgZj7AkECiFrYEkrSAGDwGxDnMnL338OvCNgt7c3aezx8e7rBj4G/vxm+ZZc+5NOuZbRKJO5t5t0kknklmkDhzdgN+h93IMTPmbZNIMDjMu40hsY2ZwUAilzgt9gaHeR5/SGyrJ0qL8WOgFsYNh3kYJBLbDhOh5cwZM2aecxKJGw6zmQG1HOch7JfjPcafecrq7A3OH3788WdbtRx/ey9+LUDAJoHM4yGkHASYPxCjahSMglEwCkYwAABGnEOuTnJ7ZgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-3908-1322","institution":"Peking Union Medical College Hospital Department of Obstetrics and Gynecology","correspondingAuthor":true,"prefix":"","firstName":"Honghui","middleName":"","lastName":"shi","suffix":""},{"id":264182849,"identity":"e5aa3f41-46af-4e62-aa73-e0ebc84df6f1","order_by":2,"name":"Xiuping Zhuo","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Xiuping","middleName":"","lastName":"Zhuo","suffix":""}],"badges":[],"createdAt":"2023-12-13 03:25:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3746326/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3746326/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00404-024-07532-z","type":"published","date":"2024-05-10T21:17:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":49134002,"identity":"1a67c797-1ff8-4a02-98f2-69472b16de15","added_by":"auto","created_at":"2024-01-03 16:49:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":38048,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative evaluation of the postmenopausal patients\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3746326/v1/75db13e2e77923a658903e57.png"},{"id":49134001,"identity":"f52ddc98-4062-4f2d-9ba1-4337a2c9b0f4","added_by":"auto","created_at":"2024-01-03 16:49:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":33489,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative evaluation of the premenopausal patients\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3746326/v1/4158d8eadd38762a5045afa5.png"},{"id":56488069,"identity":"cfcfc288-ae52-4d54-848e-29c3a048d0b3","added_by":"auto","created_at":"2024-05-14 21:28:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":702475,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3746326/v1/fef346e9-5151-4819-b8d6-9d2175bb08e5.pdf"}],"financialInterests":"","formattedTitle":"Occult endometrial cancer in women undergoing hysterectomy for benign indications: a retrospective cohort study in a tertiary hospital in China","fulltext":[{"header":"What does this study adds to the clinical work ","content":"\u003cp\u003eThe incidence of occult endometrial cancer after hysterectomy for benign gynecological indications was 0.32%. To further reduce the risk of occult endometrial cancer, physicians should focus on the bleeding symptoms of the patients and use transvaginal ultrasound as a valuable non-invasive preoperative evaluation for both symptomatic and asymptomatic patients.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eHysterectomy is a therapeutic procedure commonly performed in women with benign gynecological conditions, such as symptomatic leiomyomas, adenomyosis, and pelvic organ prolapse. Routine workup before hysterectomy includes obtaining a relevant medical history (including risk factors for endometrial cancer), physical examination, cervical cytology, and transvaginal ultrasonography to rule out potential uterine malignancy. Endometrial sampling is indicated for the diagnostic evaluation of women in whom endometrial hyperplasia or carcinoma is a possibility. Endometrial cancer typically presents with postmenopausal or abnormal uterine bleeding (AUB), which is present in 75\u0026ndash;90% of cases[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Most patients are diagnosed while the disease is still confined to the uterus, resulting in a five-year survival rate of over 90%. Despite all preoperative evaluations and the symptomatic nature of endometrial cancer, some patients continue to have occult endometrial cancer, presenting profound challenges to clinical care providers, including the potential spread of malignant tissue in the case of uterine fragmentation at hysterectomy. Furthermore, incomplete surgical staging entails postoperative imaging, restaging, removal of additional anatomy (adnexa, lymph nodes, and omentum), or adjuvant radiotherapy. The aim of our study was to evaluate the feasibility of further reducing the incidence of occult endometrial cancer in women undergoing hysterectomy for benign gynecological indications.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eAll cases of hysterectomies performed for benign gynecologic indications at Peking Union Medical College Hospital between January 2012 and September 2018 were identified. Patients with occult endometrial cancer, defined as endometrial cancer diagnosed on postoperative histopathology with no preoperative confirmed malignancy, were selected from the chart review for this retrospective cohort study. Patients with the diagnosis of endometrial hyperplasia with atypia in endometrial sampling before hysterectomy were excluded. Data on patient demographics, endometrial cancer risk factors, chief complaint, preoperative evaluation, surgical approach, pathology, postoperative treatment, and follow-up were extracted from the medical records of the identified cases of occult malignancy. The study was approved by the institutional review board of Peking Union Medical College Hospital. Informed consent was not required as this was a retrospective study of patient data without specific human subject identifiers. Binomial 95% confidence intervals (CIs) were calculated using the Clopper-Pearson Interval (SAS 9.4, SAS Institute, Cary, NC).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 7558 hysterectomies were performed for benign gynecologic indications during this period. Among these, 24/7558 (0.32%; 95% CI 0.20\u0026ndash;0.47%) patients were found to have occult endometrial cancer. The patients were divided into postmenopausal and premenopausal groups with 12 patients in each group. The characteristics of the 24 patients were listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostmenopausal, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (50%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePremenopausal, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (50%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;55 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;45 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e55\u0026ndash;60 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u0026ndash;50 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;60 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;50 yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eParity, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNulliparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNulliparous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (91.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParous\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eBMI, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;25 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (58.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;25 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;30 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u0026ndash;30 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;30 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;30 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOther risk factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eOther risk factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTamoxifen therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHTN\u0026thinsp;+\u0026thinsp;DM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily history of endometrial, breast, or\u003c/p\u003e \u003cp\u003ecolon cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003e\u003cb\u003eChief complaint, n (%)\u003c/b\u003e\u003c/p\u003e \u003cp\u003ePMB\u003c/p\u003e \u003cp\u003eNo PMB\u003c/p\u003e \u003cp\u003eIntracavitary lesion\u003c/p\u003e \u003cp\u003ePelvic mass\u0026thinsp;+\u0026thinsp;intracavitary lesion\u003c/p\u003e \u003cp\u003ePelvic mass\u003c/p\u003e \u003cp\u003ePOP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"11\" rowspan=\"12\"\u003e \u003cp\u003e7 (58.3%)\u003c/p\u003e \u003cp\u003e5 (41.7%)\u003c/p\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eChief complaint, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIrregular bleeding with\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eprecedent heavy menstrual bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eprecedent infrequent uterine bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequent uterine bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProlonged\u0026thinsp;+\u0026thinsp;heavy menstrual bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeavy menstrual bleeding with\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003einfrequent uterine bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eleiomyoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eadenomyosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003epelvic mass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePOP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEndometrial imaging, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eEndometrial imaging, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracavitary lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntracavitary lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u0026thinsp;\u0026plusmn;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u0026thinsp;\u0026plusmn;\u0026thinsp;14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThickened endometrium (6 mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeterogeneous endometrium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-measurable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot addressed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, mm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative endometrial sampling, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003ePreoperative endometrial sampling, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdvanced age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot indicated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot indicated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo identified reason\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo identified reason\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComplex hyperplasia without atypia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScant or no endometrium for evaluation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplex hyperplasia without atypia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgery, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eSurgery, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTAH\u0026thinsp;+\u0026thinsp;BSO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTAH\u0026thinsp;+\u0026thinsp;BSO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTLH\u0026thinsp;+\u0026thinsp;BSO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (58.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTAH\u0026thinsp;+\u0026thinsp;BS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTVH\u0026thinsp;+\u0026thinsp;Prolift\u0026trade; mesh repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTLH\u0026thinsp;+\u0026thinsp;BSO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTLH\u0026thinsp;+\u0026thinsp;BS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTLH\u0026thinsp;+\u0026thinsp;BSO\u0026thinsp;+\u0026thinsp;Sacrocolpopexy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTLH\u0026thinsp;+\u0026thinsp;BS\u0026thinsp;+\u0026thinsp;Sacrocolpopexy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistology, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eHistology, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometrioid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEndometrioid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-endometrioid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-endometrioid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStage\u003c/b\u003e\u003csup\u003ea\u003c/sup\u003e, \u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eStage\u003c/b\u003e\u003csup\u003ea\u003c/sup\u003e, \u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1aNxMx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (58.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT1aNxMx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (75%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntramucosal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntramucosal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;50% myometrial invasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;50% myometrial invasion\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1aN0M0 (\u0026lt;\u0026thinsp;50% myometrial invasion)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT1aN0M0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1bNxMx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntramucosal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;50% myometrial invasion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eT2NxMx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFIGO Grade, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eFIGO Grade, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGrade 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (91.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGrade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLVSI, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eLVSI, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTreatment, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTreatment, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEX-LAP PPALND/Omentectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEX-LAP\u003c/p\u003e \u003cp\u003ePPALND/Omentectomy/Appendectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopic BSO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLaparoscopic BSO/Pelvic lymph node biopsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrachytherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLaparoscopic bilateral oophorectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgestational agents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBrachytherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurveillance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (58.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEBRT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurveillance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (41.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFollow-up, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eFollow-up, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, mos\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.5\u0026thinsp;\u0026plusmn;\u0026thinsp;26.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, mos\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.8\u0026thinsp;\u0026plusmn;\u0026thinsp;24.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelapse of disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRelapse of disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eBMI, body mass index; HTN, hypertension; DM, diabetes mellitus; PMB, postmenopausal bleeding; POP, pelvic organ prolapse; TAH, total abdominal hysterectomy; BSO, bilateral salpingo-oophorectomy; TLH, total laparoscopic hysterectomy; TVH, total vaginal hysterectomy; BS, bilateral salpingectomy; LVSI, lymphovascular space invasion; EX-LAP, exploratory laparotomy; PPALND, pelvic and para-aortic lymph node dissection; EBRT, external beam radiation therapy.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003e Union for International Cancer Control (UICC) TNM staging system\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003eb\u003c/sup\u003e One with concurrent Stage Ia, G1 endometrioid ovarian cancer\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePreoperative imaging was performed on every patient found to have occult endometrial cancer. Eighteen patients underwent transvaginal ultrasonography (TVUS), one patient underwent computed tomography (CT), one patient underwent magnetic resonance imaging (MRI), three patients underwent both TVUS and CT, and one patient underwent both TVUS and MRI. TVUS provided useful information regarding the structural causes of AUB and could suggest that an endometrial polyp may be present as well as identify a heterogeneous endometrium suggesting the presence of hyperplasia or cancer. Endometrial thickness\u0026thinsp;\u0026gt;\u0026thinsp;4 mm was considered abnormal for patients with PMB. The endometrial stripe was unable to be evaluated or not addressed through imaging in two patients.\u003c/p\u003e \u003cp\u003eDilation \u0026amp; curettage (D\u0026amp;C) is the standard method for endometrial sampling in our institution. In the postmenopausal group, all symptomatic patients had endometrial imaging abnormalities. Four patients underwent preoperative endometrial sampling, three of whom were found to have scant or no endometrium for evaluation. Endometrial sampling was electively omitted in two patients for cardiac disease and one patient for advanced age. Retrospective analysis revealed no evidence in support of the omission of endometrial sampling in two patients (one with PMB and an endometrial thickness of 6 mm; one with PMB, pelvic mass and endometrial thickness not addressed in ultrasonography) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In the premenopausal group, with the exception of one patient treated with levonorgestrel intrauterine system (LNG-IUS, Mirena\u0026reg;, Bayer HealthCare Pharmaceuticals Inc., Whippany, NJ 07981, USA) for adenomyosis, all symptomatic patients had endometrial imaging abnormalities, yet only 2 patients underwent preoperative endometrial sampling (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Heavy menstrual bleeding is the most overlooked symptom in premenopausal women.\u003c/p\u003e \u003cp\u003eNo patient underwent manual or power morcellation during surgery in our study. In the postmenopausal group, all the patients with serous adenocarcinoma or G3 endometrioid adenocarcinoma histology/stage T1b disease/LSVI had a history of persistent or recurrent PMB\u0026thinsp;\u0026ge;\u0026thinsp;6 months and/or an intracavitary lesion\u0026thinsp;\u0026gt;\u0026thinsp;20 mm in diameter. In the premenopausal group, endometrial imaging was not as indicative. Neither the thickness of the endometrium nor the diameter of the intracavitary lesion reflected the severity of endometrial disease very well. However, persistent, increased uterine bleeding (whether irregular, frequent, prolonged, or heavy) appeared to be associated with advanced endometrial disease. Asymptomatic patients with normal endometrial imaging in both groups tended to have favorable pathology (G1, intramucosal disease in 2 premenopausal patients; G1, T1a disease with superficial myometrial invasion in 3 postmenopausal patients).\u003c/p\u003e \u003cp\u003eOne patient with G1, stage T1a disease was lost to follow-up after her first postoperative visit one month after surgery. All other patients were followed for 15\u0026ndash;118 months. Relapses were recorded in three patients. A postmenopausal patient with G1, T1b disease received postoperative vaginal brachytherapy. She relapsed 15 months after surgery and was lost to follow-up shortly after relapse. Another postmenopausal patient had G3, T1b disease with LVS infiltration. Medroxyprogesterone acetate was administered for 10 months, and recurrence was documented 12 months postoperatively. Her last visit was 26 months after surgery with markedly elevated serum CA\u003csub\u003e125\u003c/sub\u003e and a large pelvic tumor. The 47-year-old premenopausal patient had ovary preservation during surgery and G1 endometrioid adenocarcinoma, mostly confined to the endometrium with focal, superficial myometrial invasion. Active surveillance was the treatment of choice; however, MRI revealed a mass arising from the vaginal cuff and pelvic lymph node metastases 10 months after surgery. She received vaginal brachytherapy, EBRT, and 4 cycles of paclitaxel/carboplatin. She was alive with no clinically significant disease.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePostmenopausal bleeding and abnormal uterine bleeding are the key points prompting an endometrium evaluation. Transvaginal ultrasonography is the preferred noninvasive preoperative evaluation performed in both symptomatic and asymptomatic women before proceeding to hysterectomy, as it costs much less than any postoperative imaging or adjuvant therapy in our hospital. Asymptomatic patients with normal endometrial imaging tended to have favorable pathology.\u003c/p\u003e \u003cp\u003eFor premenopausal patients, the retrospective analysis revealed no evidence in support of the omission of endometrial sampling in 8/12 (66.7%) of the cases in our study. Several reports and guidelines have used some combination of age, personal and genetic risk factors, and TVUS screening for endometrial echo-complex thickness to determine which patients should undergo endometrial sampling[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Neither the thickness of the endometrium nor the diameter of the intracavitary lesion reflected the severity of endometrial disease very well in our study. However, persistent, increased uterine bleeding (whether irregular, frequent, prolonged, or heavy) appeared to be associated with advanced endometrial disease. In clinical practice, physicians tend to pay more attention to changes in menstrual regularity, frequency, and duration than to increase in volume; the latter, however, is often arbitrarily attributed to endometrial polyp, submucosal myoma, or adenomyosis. In fact, heavy menstrual bleeding was the most overlooked AUB pattern in our study.\u003c/p\u003e \u003cp\u003eIn the postmenopausal group, all the patients with serous adenocarcinoma or G3 endometrioid adenocarcinoma histology/stage T1b disease/LSVI had a history of persistent or recurrent PMB\u0026thinsp;\u0026ge;\u0026thinsp;6 months and/or an intracavitary lesion\u0026thinsp;\u0026gt;\u0026thinsp;20 mm in diameter. It has been reported that in women with postmenopausal bleeding and not on hormonal replacement therapy, the sensitivity and specificity of TVUS for detection of endometrial cancer at a 4 mm thickness threshold were 96 and 53 percent; that cancer became increasingly frequent relative to benign disease as the endometrial thickness approached 20 mm[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Endometrial thickness is less predictive of endometrial neoplasia in asymptomatic women. Sensitivity is estimated to be 20 percent lower in asymptomatic compared with symptomatic women. These results are consistent with our study.\u003c/p\u003e \u003cp\u003eIn the postmenopausal group, four patients had a preoperative endometrial sampling. However, three were found to have scant or no endometrium present for evaluation, one even had a hysteroscopy and curettage. Several limitations to successful endometrial sampling have been reported including cervical stenosis and pelvic organ prolapse which hindered access to the uterine cavity as well as focal endometrial pathology (e.g., endometrial polyps and submucosal fibroids) and endometrial atrophy which reduces sample adequacy. Thus, we suggested diagnostic hysteroscopy and directed biopsy of suspicious lesions, with concurrent ultrasound surveillance in difficult cases, for postmenopausal patients.\u003c/p\u003e \u003cp\u003eThree patients whose preoperative endometrial sampling revealed complex hyperplasia without atypia were eventually diagnosed with endometrial cancer. The postmenopausal patient had T1a disease with LVSI; the two premenopausal patients had intramucosal disease. Concurrent endometrial carcinoma rates can be as high as 18.9% in patients with endometrial biopsies diagnosed as less than atypical endometrial hyperplasia in a prospective cohort study published by Gynecologic Oncology Group (GOG)[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Complex hyperplasia without atypia should be managed very cautiously, including informing the patient of the possibility of more severe postoperative pathology and planning surgery accordingly. Diagnostic hysteroscopy and directed biopsy together with expert pathology are also very important to optimize patient care.\u003c/p\u003e \u003cp\u003eThree POP patients were identified in our study, which seemed quite prominent. All three patients were asymptomatic and had normal endometrial imaging. Pathology revealed G1, intramucosal disease in two premenopausal patients, and G1, stage T1a disease with less than 50% myometrial invasion in the postmenopausal patient. Based on current literature, the prevalence of occult endometrial cancer in asymptomatic postmenopausal women undergoing hysterectomy with pelvic organ prolapse repair ranges from 0.12 to 3.17%[\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In a study enrolled 708 women undergoing hysterectomy for pelvic organ prolapse and/or urinary incontinence, five cases of endometrial cancer (0.6%) were detected; four of these women had normal preoperative screening, including endometrial biopsy (2 cases), TVUS (1case), or both tests (1 case) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Considering the low prevalence, the low efficiency of screening, and their favorable prognosis, universal screening via endometrial sampling should not be recommended in asymptomatic women planning POP surgery with normal endometrial imaging, however, simultaneous bilateral salpingo-oophorectomy does offer an advantage over a second, unplanned surgery, especially in postmenopausal patients.\u003c/p\u003e \u003cp\u003eThe strength of this study was that it proposed practical measures to further reduce the incidence of occult endometrial cancer. Bleeding patterns should be highly valued and used as the primary basis for clinical decision-making, with particular emphasis on persistent or recurrent heavy bleeding. The combination of transvaginal ultrasonography and hysteroscopy with directed biopsy may further reduce the incidence of occult endometrial cancer, especially in postmenopausal patients. The limitation of this study was that it did not propose a solution to systematically address the issue of complex hyperplasia without atypia pathology escalating to endometrial cancer after hysterectomy.\u003c/p\u003e \u003cp\u003eOccult endometrial cancer is undesirable. Measures to further reduce the incidence of occult endometrial cancer include: (1) Physicians should focus on the patient's bleeding pattern, although sometimes concomitant genital disorders, such as pelvic mass, fibroids, or adenomyosis, can be very distracting. Persistent, increased uterine bleeding (whether irregular, frequent, prolonged, or heavy) appeared to be associated with advanced endometrial disease in the premenopausal group, while in our study heavy menstrual bleeding was the most overlooked AUB pattern; (2) transvaginal ultrasonography is a valuable noninvasive preoperative evaluation, especially in postmenopausal patients. All the symptomatic patients (17/24, 70.8%) had abnormal endometrial imaging except for one treated with LNG-IUS for adenomyosis. Asymptomatic patients with normal endometrial imaging all tended to have favorable pathology. A history of persistent or recurrent PMB\u0026thinsp;\u0026ge;\u0026thinsp;6 months and/or an intracavitary lesion\u0026thinsp;\u0026gt;\u0026thinsp;20 mm in diameter is suggestive of advanced disease or unfavorable histologic type in postmenopausal patients; (3) active implementation of endometrial sampling when indicated; and (4) hysteroscopy with directed biopsy in postmenopausal patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHHS and YC contributed to the study conception and design. Material preparation, data collection and analysis were performed by YC and XPZ. The first draft of the manuscript was written by YC and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll available data is presented in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by a grant from National High Level Hospital Clinical Research Funding (2022-PUMCH-C-031).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Peking Union Medical College Hospital (reference no: I-22PJ848).\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmerican College of, O. and Gynecologists, ACOG practice bulletin, clinical management guidelines for obstetrician-gynecologists, number 65, August 2005: management of endometrial cancer. Obstet Gynecol, 2005. 106(2): p. 413-25. https://doi.org/10.1097/00006250-200508000-00050.\u003c/li\u003e\n\u003cli\u003eKimura, T., et al., Abnormal uterine bleeding and prognosis of endometrial cancer. Int J Gynaecol Obstet, 2004. 85(2): p. 145-50. https://doi.org/ 10.1016/j.ijgo.2003.12.001.\u003c/li\u003e\n\u003cli\u003eSeebacher, V., et al., The presence of postmenopausal bleeding as prognostic parameter in patients with endometrial cancer: a retrospective multi-center study. BMC Cancer, 2009. 9: p. 460. https://doi.org/ 10.1186/1471-2407-9-460.\u003c/li\u003e\n\u003cli\u003eMunro, M.G., et al., FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet, 2011. 113(1): p. 3-13. https://doi.org/ 10.1016/j.ijgo.2010.11.011.\u003c/li\u003e\n\u003cli\u003eSmith-Bindman, R., et al., Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA, 1998. 280(17): p. 1510-7. https://doi.org/ 10.1001/jama.280.17.1510.\u003c/li\u003e\n\u003cli\u003eTrimble, C.L., et al., Concurrent endometrial carcinoma in women with a biopsy diagnosis of atypical endometrial hyperplasia: a Gynecologic Oncology Group study. Cancer, 2006. 106(4): p. 812-9. https://doi.org/ 10.1002/cncr.21650.\u003c/li\u003e\n\u003cli\u003eTheben, J.U., et al., Unexpected malignancies after laparoscopic-assisted supracervical hysterectomies (LASH): an analysis of 1,584 LASH cases. Arch Gynecol Obstet, 2013. 287(3): p. 455-62. https://doi.org/ 10.1007/s00404-012-2559-0.\u003c/li\u003e\n\u003cli\u003eMahnert, N., et al., Unexpected gynecologic malignancy diagnosed after hysterectomy performed for benign indications. Obstet Gynecol, 2015. 125(2): p. 397-405. https://doi.org/ 10.1097/AOG.0000000000000642.\u003c/li\u003e\n\u003cli\u003eTakamizawa, S., et al., Risk of complications and uterine malignancies in women undergoing hysterectomy for presumed benign leiomyomas. Gynecol Obstet Invest, 1999. 48(3): p. 193-6. https://doi.org/ 10.1159/000010172.\u003c/li\u003e\n\u003cli\u003eFrick, A.C., et al., Risk of unanticipated abnormal gynecologic pathology at the time of hysterectomy for uterovaginal prolapse. Am J Obstet Gynecol, 2010. 202(5): p. 507 e1-4. https://doi.org/ 10.1016/j.ajog.2010.01.077.\u003c/li\u003e\n\u003cli\u003eRamm, O., et al., Utility of preoperative endometrial assessment in asymptomatic women undergoing hysterectomy for pelvic floor dysfunction. Int Urogynecol J, 2012. 23(7): p. 913-7. https://doi.org/ 10.1007/s00192-012-1694-2.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"postmenopausal bleeding, abnormal uterine bleeding, transvaginal ultrasonography, hysteroscopy","lastPublishedDoi":"10.21203/rs.3.rs-3746326/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3746326/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo evaluate the feasibility of further reducing the incidence of occult endometrial cancer in women undergoing hysterectomy for benign gynecological indications.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients who underwent hysterectomies for presumed benign gynecologic conditions at Peking Union Medical College Hospital were retrospectively identified. Patients with occult endometrial cancer, which was defined as endometrial cancer diagnosed on postoperative histopathology with no preoperative confirmed malignancy, were selected.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e24/7558 (0.32%; 95% CI 0.20\u0026ndash;0.47%) patients undergoing hysterectomy for benign indications had occult endometrial cancer. Asymptomatic patients with normal endometrial imaging all tended to have favorable pathology. Heavy menstrual bleeding was the most overlooked AUB pattern in the premenopausal group. In the postmenopausal group, all the patients with serous adenocarcinoma or G3 endometrioid adenocarcinoma histology/stage T1b disease/ LVSI space invasion had a history of persistent or recurrent PMB\u0026thinsp;\u0026ge;\u0026thinsp;6 months and/or an intracavitary lesion\u0026thinsp;\u0026gt;\u0026thinsp;20 mm in diameter. 3/4 of the samples of the postmenopausal patients did not have adequate endometrium for evaluation.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eTo further reduce the incidence of occult endometrial cancer, physicians should focus on the patient's bleeding pattern and actively implement endometrial sampling whenever indicated. Transvaginal ultrasonography is a valuable preoperative evaluation. Hysteroscopy with directed biopsy is the preferred procedure in postmenopausal patients.\u003c/p\u003e","manuscriptTitle":"Occult endometrial cancer in women undergoing hysterectomy for benign indications: a retrospective cohort study in a tertiary hospital in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-03 16:49:07","doi":"10.21203/rs.3.rs-3746326/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2023-12-28T20:50:54+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-12-28T20:19:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Archives of Gynecology and Obstetrics","date":"2023-12-18T13:41:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-12-12T13:45:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Gynecology and Obstetrics","date":"2023-12-11T23:09:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"5dc01a5e-6c4d-48aa-b783-209e2f94182c","owner":[],"postedDate":"January 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-05-14T21:20:08+00:00","versionOfRecord":{"articleIdentity":"rs-3746326","link":"https://doi.org/10.1007/s00404-024-07532-z","journal":{"identity":"archives-of-gynecology-and-obstetrics","isVorOnly":false,"title":"Archives of Gynecology and Obstetrics"},"publishedOn":"2024-05-10 21:17:33","publishedOnDateReadable":"May 10th, 2024"},"versionCreatedAt":"2024-01-03 16:49:07","video":"","vorDoi":"10.1007/s00404-024-07532-z","vorDoiUrl":"https://doi.org/10.1007/s00404-024-07532-z","workflowStages":[]},"version":"v1","identity":"rs-3746326","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3746326","identity":"rs-3746326","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}