Aspiration Biopsy Versus Dilatation and Curettage for Endometrial Hyperplasia Prior to Hysterectomy

Aspiration Biopsy Versus Dilatation and Curettage for Endometrial Hyperplasia Prior to Hysterectomy | 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 Aspiration Biopsy Versus Dilatation and Curettage for Endometrial Hyperplasia Prior to Hysterectomy Woo Yeon Hwang, Dong Hoon Suh, Kidong Kim, Jae Hong No, Yong Beom Kim This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-115013/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Jan, 2021 Read the published version in Diagnostic Pathology → Version 1 posted 8 You are reading this latest preprint version Abstract Background: To compare the diagnostic accuracy of aspiration biopsy and dilatation and curettage (D&C) in patients diagnosed with endometrial hyperplasia prior to hysterectomy. Methods: We retrospectively reviewed medical records of 250 patients diagnosed with endometrial hyperplasia by endometrial sampling between July 2003 and March 2020. Endometrial sampling was performed by aspiration biopsy (n=150) or D&C (n=100), followed by hysterectomy within 6 months. Pathological findings of hysterectomy specimens of the two groups were compared to preoperative findings. Results: The overall diagnostic concordance between endometrial sampling specimen including D&C and aspiration biopsy, and hysterectomy specimen was 51.0% (51/100) and 41.3% (62/150), respectively. Patients whose preoperative specimen was obtained by D&C were upgraded less significantly than those who underwent aspiration biopsy (27.6% vs 72.4%; P = 0.008). In particular, significantly fewer patients were upgraded after D&C than after aspiration biopsy in hyperplasia without atypia (28.0% vs 72.0%; P = 0.028) and complex hyperplasia cases (27.9% vs 72.1%; P = 0.049). In addition, when the final pathological upgrade rate to endometrial carcinoma was evaluated between the two methods of endometrial sampling, significantly fewer cases were noted after D&C than after aspiration biopsy (26.8% vs 73.2%; P =0.022). Conclusions: In our study, D&C more accurately reflected the final diagnosis in patients with endometrial hyperplasia than aspiration biopsy based on the histological examination of hysterectomy specimens. When considering the management strategy for women with an endometrial hyperplasia diagnosis obtained by aspiration biopsy, physicians should consider the significant rate of upgraded diseases with this method of endometrial sampling. Pathology Endometrial Hyperplasia Dilatation and Curettage Hysterectomy Biopsy Introduction Endometrial hyperplasia is a pathological condition characterized by abnormal proliferation of endometrial glands and stroma [ 1 ]. Endometrial hyperplasia, atypical endometrial hyperplasia in particular, is of clinical significance as it is considered to be a precursor lesion of endometrial cancer [ 2 – 4 ]. The accurate diagnosis of premalignant lesions and the exclusion of coexisting endometrial carcinomas are important aspects of the proper management of endometrial hyperplasia. The World Health Organization (WHO) 94 classifies endometrial hyperplasia into four groups based on glandular complexity and cytological nuclear atypia: simple hyperplasia without atypia, complex hyperplasia without atypia, simple atypical hyperplasia, and complex atypical hyperplasia [ 4 ]. There are several endometrial sampling methods used in practice to diagnose endometrial lesions, including endometrial hyperplasia. Among these, dilatation and curettage (D&C) has been one of the most widely used. However, it has become less favorable due to the added risk of anesthesia and complications. Endometrial aspiration biopsy has widely replaced D&C as it is easy to perform, safe, and convenient compared to D&C [ 5 , 6 ]. However, there are no reliable data regarding the best method to diagnose endometrial hyperplasia. Numerous studies comparing the diagnostic accuracy of D&C and aspiration biopsy have concluded that aspiration biopsy is as accurate as D&C in the diagnosis of endometrial pathologies [ 5 – 8 ]. However, all these studies have included patients with various pathological findings such as proliferative endometrium, secretory endometrium, endometrial hyperplasia, atrophic endometrium, and endometrial carcinoma. In addition, they were limited by their small sample size, especially for evaluating endometrial hyperplasia. They included only a small number of patients with endometrial hyperplasia and fewer than 10 patients with atypical endometrial hyperplasia. Therefore, in this study, we aimed to compare the diagnostic accuracy of aspiration biopsy and D&C in patients who were diagnosed with endometrial hyperplasia by one of these methods prior to hysterectomy. Methods This study was approved by the Institutional Review Board of the Seoul National University Bundang Hospital (No. B-2007/627 − 101) and performed in accordance with the principles of the Declaration of Helsinki. The requirement for informed consent was waived. This study was retrospectively performed between July 2003 and May 2020 at Seoul National University Bundang Hospital, a tertiary hospital in Korea. We reviewed the medical records of 250 patients who had been diagnosed with endometrial hyperplasia either by aspiration biopsy or D&C and had subsequently undergone hysterectomy. The aspiration biopsy was performed without anesthesia using the Pipelle device. D&C was performed under sedation with fentanyl and midazolam or under monitored anesthesia care using a curette. Eligible patients included those diagnosed with hyperplasia without atypia (simple and complex) and atypical hyperplasia (simple and complex). The diagnoses of the endometrial sampling specimens were independently reviewed pathologically in our institution. The maximum time interval between endometrial sampling confirming endometrial hyperplasia and hysterectomy was 6 months. We excluded the patients who had a diagnosis of “endometrial hyperplasia, cannot rule out malignancy” and those with “insufficient tissue for pathological evaluation.” Additionally, those who underwent non-surgical management such as hormone therapy after the diagnosis of endometrial hyperplasia and prior to hysterectomy were excluded. The pathological results of the preoperative endometrial sampling specimens were compared to those of the hysterectomy specimens. We evaluated the consistency of the pathological results between samples obtained by aspiration biopsy and by D&C. Results of “no residual disease,” “secretory endometrium,” and “proliferative endometrium” in postoperative specimen were considered normal. The Student’s t -test and Mann-Whitney U test were performed to compare continuous variables. Pearson’s chi-squared test or Fisher’s exact test was performed to compare categorical variables. Kappa statistics were used to assess the agreement of the two endometrial sampling methods. κ values < 0 indicated no agreement, 0 to 0.20 slight, 0.21 to 0.40 fair, 0.41 to 0.60 moderate, 0.61 to 0.80 substantial, and 0.81 to 1 almost perfect agreement. All analyses were performed using SPSS software for Windows (version 25.0; SPSS Inc., Chicago, IL, USA). A P < 0.05 indicated statistical significance. Results In this study, 250 patients were included. The overall patient characteristics are shown in Table 1 . Of the 250 patients who had been diagnosed with endometrial hyperplasia, 100 were diagnosed by D&C and 150 by aspiration biopsy. There were 40 (16.0%) postmenopausal patients. In total, 154 (61.6%) patients underwent endometrial sampling due to abnormal uterine bleeding. The mean time between endometrial sampling and hysterectomy was 1.6 ± 1.0 months (mean ± SD). The histologic results by endometrial sampling showed 76 (30.4%) patients with simple hyperplasia without atypia, 42 (16.8%) with complex hyperplasia without atypia, 4 (1.6%) with simple atypical hyperplasia, and 128 (51.2%) with complex atypical hyperplasia. Final pathological results from hysterectomy confirmed 35 (14.0%) patients with normal endometrium, 68 (27.2%) with simple hyperplasia without atypia, 24 (9.6%) with complex hyperplasia without atypia, 3 (1.2%) with simple atypical hyperplasia, 64 (25.6%) with complex atypical hyperplasia, and 56 (22.4%) with carcinoma. Table 1 Characteristics of the overall study population Characteristics n (%) Age, years 49.0 ± 6.5 BMI a , kg/m 2 24.8 ± 4.6 Parity 1.8 ± 0.7 Menopause 40 (16.0) Diabetes 9 (3.6) Hypertension 35 (14.0) Tamoxifen 21 (8.4) Abnormal uterine bleeding 154 (61.6) EM sampling method D&C 100 (40.0) Aspiration biopsy 150 (60.0) Time interval between EM sampling & hysterectomy, months 1.6 ± 1.0 EM sampling pathology SH 76 (30.4) CH 42 (16.8) SAH 4 (1.6) CAH 128 (51.2) Hysterectomy pathology Normal 35 (14.0) SH 68 (27.2) CH 24 (9.6) SAH 3 (1.2) CAH 64 (25.6) Carcinoma 56 (22.4) Data are mean ± SD or n (%) unless otherwise specified a BMI data are missing for two patients BMI, body mass index; EM, endometrial; D&C, dilatation and curettage; SH, simple hyperplasia without atypia; CH, complex hyperplasia without atypia; SAH, simple atypical hyperplasia; CAH, complex atypical hyperplasia When the diagnostic concordance between D&C and hysterectomy was assessed, in a total of 100 patients, 51 (51.0%) had diagnostic concordance: 23 (23.0%) with simple hyperplasia without atypia, 9 (9.0%) with complex hyperplasia without atypia, and 19 (19.0%) with complex atypical hyperplasia (Table 2 ). In addition, when the diagnostic concordance between aspiration biopsy and hysterectomy was assessed, in a total of 150 patients, 62 (41.3%) had diagnostic concordance: 24 (16.0%) with simple hyperplasia without atypia, 6 (4.0%) with complex hyperplasia without atypia, 1 (0.7%) with simple atypical hyperplasia, and 31 (20.6%) with complex atypical hyperplasia (Table 3 ). Table 2 Comparison of pathological results of D&C and hysterectomy D&C n (%) Hysterectomy Concordance to hysterectomy n (%) Normal SH CH SAH CAH Carcinoma SH 36 (36.0) 9 23 1 0 2 1 23 (63.9) CH 20 (20.0) 4 4 9 0 3 0 9 (45.0) SAH 0 (0.0) 0 0 0 0 0 0 0 (0.0) CAH 44 (44.0) 6 3 2 0 19 14 19 (31.8) Total 100 (100.0) 0 23 9 0 19 0 51 (51.0) a Data are mean ± SD or n (%) unless otherwise specified a Kappa value, 0.357 (Fair); diagnostic concordance 51.0% (51 out of 100 pairs); P < 0.001 D&C, dilatation and curettage; SH, simple hyperplasia without atypia; CH, complex hyperplasia without atypia; SAH, simple atypical hyperplasia; CAH, complex atypical hyperplasia Table 3 Comparison of pathological results of aspiration biopsy and hysterectomy Aspiration biopsy n (%) Hysterectomy Concordance to hysterectomy n (%) Normal SH CH SAH CAH Carcinoma SH 40 (26.7) 6 24 3 2 5 0 24 (60.0) CH 22 (14.7) 2 6 6 0 4 4 6 (27.3) SAH 4 (2.7) 1 1 0 1 0 1 1 (25.0) CAH 84 (56.0) 7 7 3 0 31 36 31 (36.9) Total 150 (100) 0 24 6 1 31 0 62 (41.3) a Data are mean ± standard deviation or n (%) unless otherwise specified a Kappa value, 0.239 (Fair); diagnostic concordance 41.3% (62 out of 150 pairs); P < 0.001 SH, simple hyperplasia without atypia; CH, complex hyperplasia without atypia; SAH, simple atypical hyperplasia; CAH, complex atypical hyperplasia We identified the upgrade rate of the final pathology based on the method of endometrial sampling. The final pathology was upgraded in significantly fewer cases after D&C than after aspiration biopsy (27.6% vs 72.4%; P = 0.008) (Table 4 ). Particularly, in patients with hyperplasia without atypia and complex hyperplasia, upgrading was found in significantly fewer cases after D&C than after aspiration biopsy (hyperplasia without atypia, 28.0% vs 72.0%; P = 0.028, complex hyperplasia, 27.9% vs 72.1%; P = 0.049). However, no significant difference in upgrading was observed between D&C and aspiration biopsy for atypical hyperplasia and simple hyperplasia (atypical hyperplasia, 27.5% vs 72.5%; P = 0.255, simple hyperplasia, 26.7% vs 73.3%; P = 0.113). Table 4 Comparison of postoperative pathological upgrade risks based on endometrial sampling methods Endometrial sampling pathology Upgrade on final pathology Endometrial sampling method P D&C (n = 100) Aspiration biopsy (n = 150) Hyperplasia without atypia No 49 (52.7) 44 (47.3) 0.028 Yes 7 (28.0) 18 (72.0) Atypical hyperplasia No 30 (37.0) 51 (63.0) 0.255 Yes 14 (27.5) 37 (72.5) Simple hyperplasia No 32 (49.2) 33 (50.8) 0.113 Yes 4 (26.7) 11 (73.3) Complex hyperplasia No 47 (43.1) 62 (56.9) 0.049 Yes 17 (27.9) 44 (72.1) Total No 79 (45.4) 95 (54.6) 0.008 Yes 21 (27.6) 55 (72.4) Data are n (%) unless otherwise specified D&C, dilatation and curettage We also assessed the final pathological upgrade rate to endometrial carcinoma based on the method of endometrial sampling. Carcinoma was found in 56 (22.4%) of the hysterectomy specimens. The final pathology was upgraded to endometrial carcinoma in significantly fewer cases after D&C than after aspiration biopsy (26.8% vs 73.2%; P = 0.022) (Table 5 ). In patients diagnosed with complex hyperplasia by D&C, 25.9% were upgraded to endometrial carcinoma after hysterectomy, whereas in those diagnosed with complex hyperplasia by aspiration biopsy, 74.1% were upgraded to endometrial carcinoma ( P = 0.031). No significant difference in the upgrade rate was observed between the two endometrial sampling methods for hyperplasia without atypia, atypical hyperplasia, and simple hyperplasia (hyperplasia without atypia, 20.0% vs 80.0%; P = 0.368, atypical hyperplasia, 27.5% vs 72.5%; P = 0.255, simple hyperplasia, 50.0% vs 50.0%; P > 0.999). Table 5 Comparison of final pathological carcinoma risks based on endometrial sampling methods Endometrial sampling pathology Carcinoma on final pathology Endometrial sampling method P D&C (n = 100) Aspiration biopsy (n = 150) Hyperplasia without atypia No 55 (48.7) 58 (51.3) 0.368* Yes 1 (20.0) 4 (80.0) Atypical hyperplasia No 30 (37.0) 51 (63.0) 0.255 Yes 14 (27.5) 37 (72.5) Simple hyperplasia No 35 (44.9) 43 (55.1) > 0.999* Yes 1 (50.0) 1 (50.0) Complex hyperplasia No 50 (43.1) 66 (56.9) 0.031 Yes 14 (25.9) 40 (74.1) Total No 85 (43.8) 109 (56.2) 0.022 Yes 15 (26.8) 41 (73.2) Data are n (%) unless otherwise specified * Fisher’s exact test for hyperplasia without atypia and complex hyperplasia D&C, dilatation and curettage Discussion Our comparison of the accuracy of aspiration biopsy and D&C in patients diagnosed with preoperative endometrial hyperplasia suggests that D&C is a more accurate endometrial sampling method, particularly for patients with complex hyperplasia, than aspiration biopsy. In patients diagnosed with endometrial hyperplasia, there are risks of hidden malignancy and the possibility of progression to endometrial carcinoma. The risk of progression is < 5% in women with endometrial hyperplasia without atypia but increases up to 30% in women with atypical endometrial hyperplasia [ 9 ]. Therefore, hysterectomy is recommended, particularly in patients with atypical endometrial hyperplasia [ 2 ]. However, in those who desire the preservation of their fertility or are unable to tolerate surgery due to coexisting medical conditions, conservative management is inevitable. In these patients, accurate diagnostic evaluation is particularly vital, as their final pathologic results might not be verified. In our study, 210 (84%) of the patients were premenopausal patients for whom special attention is required to exclude coexisting malignancy. Various methods of endometrial sampling are used in either inpatient or outpatient settings as a basis to diagnose endometrial lesions. Past studies regarding the accuracy of D&C compared to that of endometrial biopsy in diagnosing endometrial hyperplasia show conflicting results. One prospective study investigated the comparable diagnostic value of D&C and biopsy [ 10 ]. Of the 70 patients, 55% and 45% of cases were diagnosed with complex atypical hyperplasia using endometrial biopsy and D&C, respectively. No difference in the incidence of coexisting cancer at hysterectomy was observed between the two methods (41% vs 45%; P > 0.05), but this study conclusion was limited by the small sample size. Another study evaluated whether preoperative D&C lowers the risk of unexpected cancer at hysterectomy compared to biopsy alone and reported that D&C lowered the risk of unexpected carcinoma compared to endometrial biopsy in patients with complex atypical hyperplasia (30% vs 45%; P < 0.001) [ 11 ]. Dijkhuizen et al. performed a meta-analysis to assess the accuracy of endometrial sampling devices for detecting endometrial carcinoma and endometrial hyperplasia [ 12 ]. They concluded that aspiration biopsy with Pipelle is superior to other endometrial instruments with sensitivities of 99.6% and 91% for endometrial carcinoma and endometrial hyperplasia, respectively, and more than 98% specificity. However, this review primarily included studies that examined the final pathology using D&C. Of the 39 studies, only five included studies used hysterectomy as the reference for final pathology [ 13 – 17 ]. Compared to previous studies, our study has several strengths. First, we include a substantial number of patients diagnosed with endometrial hyperplasia, which was one of the limitations of previous studies [ 10 ]. Second, we evaluate the final pathology based on hysterectomy specimens to compare two endometrial sampling methods, which provides more accuracy than using D&C as a reference. Third, in our study, the patients with “insufficient tissue for pathological examination” were excluded to further clarify the results. One of the concerns about endometrial sampling is the sufficiency of sample specimen. In some studies, inadequate pathological specimens that may have affected the results were included or the adequacy of the specimens was not considered [ 8 ]. Lastly, we also excluded patients who received hormone therapy during the period between endometrial sampling and hysterectomy, as this treatment may significantly affect pathology. One potential limitation of the current study is that we could not apply the updated endometrial hyperplasia classification. There are two classification systems of endometrial hyperplasia: the WHO94 classification, used in this study, and the endometrial intraepithelial neoplasm (EIN) classification. The current position statement of the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology recommends using the EIN classification, which includes three categories: benign (benign endometrial hyperplasia), premalignant (EIN), and malignant (well-differentiated endometrial adenocarcinoma) [ 18 ]. The EIN classification is more likely to identify precancerous lesions than the WHO94 classification. However, as our pathology department has only recently converted to the new terminology, the old WHO94 classification was used in this study. The WHO94 classification remains the most commonly used and reported classification in existing literature [ 4 ]. Another limitation of the current study is that we did not evaluate the effect of endometrial thickness. Thickened endometrium is known to be associated with endometrial pathologies. However, this may have little impact on the result of our study. A previous study evaluating the effect of endometrial thickness between biopsy methods showed no statistically significant results [ 6 ]. The final limitation is that we did not compare various devices used for endometrial sampling. It is possible that differences in sampling devices may affect the accuracy of the results. In conclusion, as a gold standard method of endometrial sampling, higher accuracy with final pathology is expected from D&C than from aspiration biopsy. For an accurate diagnosis of endometrial hyperplasia, D&C seems superior to aspiration biopsy. When considering management strategies for women with endometrial hyperplasia obtained from aspiration biopsy, physicians should take into account the considerable rate of upgraded diseases. List Of Abbreviations D&C: Dilatation and Curettage WHO: World Health Organization EIN: Endometrial Intraepithelial Neoplasm Declarations Ethics approval and consent to participate This study was approved by the Institutional Review Board of the Seoul National University Bundang Hospital (No. B-2007/627-101) Consent for publication Not applicable. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding No funding was received to support this research. Author contributions WY Hwang: Protocol/project development, Data collection, Validation, Formal analysis and investigation, Manuscript writing – original draft DH Suh: Formal analysis and investigation, Manuscript writing – review & editing K Kim: Formal analysis and investigation, Manuscript writing – review & editing JH No: Formal analysis and investigation, Manuscript writing – review & editing YB Kim: Protocol/project development, Validation, Formal analysis and investigation, Manuscript writing – review & editing, Supervision Acknowledgements Not applicable. References Kadirogullari P, Atalay CR, Ozdemir O, Sari ME (2015) Prevalence of Co-existing Endometrial Carcinoma in Patients with Preoperative Diagnosis of Endometrial Hyperplasia. Journal of clinical and diagnostic research : JCDR 9 (10):Qc10-14. doi:10.7860/jcdr/2015/12484.6618 Chandra V, Kim JJ, Benbrook DM, Dwivedi A, Rai R (2016) Therapeutic options for management of endometrial hyperplasia. Journal of gynecologic oncology 27 (1):e8. doi:10.3802/jgo.2016.27.e8 Kim MK, Seong SJ, Park DC, Hong JH, Roh JW, Kang SB (2020) Comparison of diagnostic accuracy between endometrial curettage and aspiration biopsy in patients treated with progestin for endometrial hyperplasia: a Korean Gynecologic Oncology Group study. Journal of gynecologic oncology 31 (4):e51. doi:10.3802/jgo.2020.31.e51 Sobczuk K, Sobczuk A (2017) New classification system of endometrial hyperplasia WHO 2014 and its clinical implications. Przeglad menopauzalny = Menopause review 16 (3):107-111. doi:10.5114/pm.2017.70589 Abdelazim IA, Aboelezz A, Abdulkareem AF (2013) Pipelle endometrial sampling versus conventional dilatation & curettage in patients with abnormal uterine bleeding. Journal of the Turkish German Gynecological Association 14 (1):1-5. doi:10.5152/jtgga.2013.01 Demirkiran F, Yavuz E, Erenel H, Bese T, Arvas M, Sanioglu C (2012) Which is the best technique for endometrial sampling? Aspiration (pipelle) versus dilatation and curettage (D&C). Archives of gynecology and obstetrics 286 (5):1277-1282. doi:10.1007/s00404-012-2438-8 Sanam M, Majid MM (2015) Comparison the Diagnostic Value of Dilatation and Curettage Versus Endometrial Biopsy by Pipelle--a Clinical Trial. Asian Pacific journal of cancer prevention : APJCP 16 (12):4971-4975. doi:10.7314/apjcp.2015.16.12.4971 Nair R, Bandhe S, Ganorkar OK, Saha S, Sial S, Nair A (2019) A comparative evaluation of the three different antioxidant treatments on the bond strength of composite resin to bleached enamel: An in vitro study. Journal of conservative dentistry : JCD 22 (1):82-86. doi:10.4103/jcd.Jcd_193_18 Kim MK, Seong SJ, Lee TS, Ki K-D, Lim MC, Kim YH, Kim K, Joo WD (2015) Comparison of diagnostic accuracy between endometrial curettage and pipelle aspiration biopsy in patients treated with progestin for endometrial hyperplasia: a Korean Gynecologic Oncology Group Study (KGOG 2019). Japanese Journal of Clinical Oncology 45 (10):980-982. doi:10.1093/jjco/hyv106 %J Japanese Journal of Clinical Oncology Merisio C, Berretta R, De Ioris A, Pultrone DC, Rolla M, Giordano G, Tateo S, Melpignano M (2005) Endometrial cancer in patients with preoperative diagnosis of atypical endometrial hyperplasia. European journal of obstetrics, gynecology, and reproductive biology 122 (1):107-111. doi:10.1016/j.ejogrb.2005.01.001 Suh-Burgmann E, Hung YY, Armstrong MA (2009) Complex atypical endometrial hyperplasia: the risk of unrecognized adenocarcinoma and value of preoperative dilation and curettage. Obstetrics and gynecology 114 (3):523-529. doi:10.1097/AOG.0b013e3181b190d5 Dijkhuizen FP, Mol BW, Brölmann HA, Heintz AP (2000) The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis. Cancer 89 (8):1765-1772 Stovall TG, Photopulos GJ, Poston WM, Ling FW, Sandles LG (1991) Pipelle endometrial sampling in patients with known endometrial carcinoma. Obstetrics and gynecology 77 (6):954-956 Ferry J, Farnsworth A, Webster M, Wren B (1993) The efficacy of the pipelle endometrial biopsy in detecting endometrial carcinoma. The Australian & New Zealand journal of obstetrics & gynaecology 33 (1):76-78. doi:10.1111/j.1479-828x.1993.tb02060.x Zorlu CG, Cobanoglu O, Işik AZ, Kutluay L, Kuşçu E (1994) Accuracy of pipelle endometrial sampling in endometrial carcinoma. Gynecologic and obstetric investigation 38 (4):272-275. doi:10.1159/000292495 Guido RS, Kanbour-Shakir A, Rulin MC, Christopherson WA (1995) Pipelle endometrial sampling. Sensitivity in the detection of endometrial cancer. The Journal of reproductive medicine 40 (8):553-555 Antoni J, Folch E, Costa J, Foradada CM, Cayuela E, Combalia N, Rué M (1997) Comparison of cytospat and pipelle endometrial biopsy instruments. European journal of obstetrics, gynecology, and reproductive biology 72 (1):57-61. doi:10.1016/s0301-2115(96)02658-9 The American College of Obstetricians and Gynecologists Committee Opinion no. 631. Endometrial intraepithelial neoplasia (2015). Obstetrics and gynecology 125 (5):1272-1278. doi:10.1097/01.Aog.0000465189.50026.20 Cite Share Download PDF Status: Published Journal Publication published 14 Jan, 2021 Read the published version in Diagnostic Pathology → Version 1 posted Editorial decision: Minor Revision 17 Dec, 2020 Review # 1 received at journal 12 Dec, 2020 Reviewer # 1 agreed at journal 02 Dec, 2020 Reviewers invited by journal 29 Nov, 2020 Editor assigned by journal 24 Nov, 2020 Editor invited by journal 24 Nov, 2020 Submission checks completed at journal 24 Nov, 2020 First submitted to journal 22 Nov, 2020 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. 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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-115013","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":5259543,"identity":"1262b75d-afbb-4b62-b43c-51037484fa81","order_by":0,"name":"Woo Yeon Hwang","email":"","orcid":"https://orcid.org/0000-0003-0231-8330","institution":"Seoul National University Bundang Hospital","correspondingAuthor":false,"prefix":"","firstName":"Woo","middleName":"Yeon","lastName":"Hwang","suffix":""},{"id":5259544,"identity":"b28fcab4-9a11-4ea0-a232-8c5873255b92","order_by":1,"name":"Dong Hoon Suh","email":"","orcid":"","institution":"Seoul National University Bundang Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dong","middleName":"Hoon","lastName":"Suh","suffix":""},{"id":5259545,"identity":"59b66e75-9a1b-4b26-b165-a63568390717","order_by":2,"name":"Kidong Kim","email":"","orcid":"https://orcid.org/0000-0001-9254-6024","institution":"Seoul National University Bundang Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kidong","middleName":"","lastName":"Kim","suffix":""},{"id":5259546,"identity":"096479f5-0b7c-4af3-a1a3-999dadcdc7d2","order_by":3,"name":"Jae Hong No","email":"","orcid":"","institution":"Seoul National University Bundang Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jae","middleName":"Hong","lastName":"No","suffix":""},{"id":5259547,"identity":"5a2dc121-17d6-4e1d-8471-775ac5cc5af3","order_by":4,"name":"Yong Beom Kim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYDACCTaGAwwFB+SATDZmErQYHDAmTQsDUEtiA9FaDG63JR66YXAnff7sHrPHBQw2+fIOhLTcOXbgcI7Bs9wNd86YG89gSLPceICQlhvpDUAth3M3SOSYSfMwHDYwbCBSS7r8DOK1pIEcdjiB4QZUizwBHQySd44lgLQYbriRVm7MY5BmYEBIC9/tNuPPORWH5eVnJG97zFNhYyBPyGEKB1DdCYojAlowzSRoyygYBaNgFIw4AABm+0TT4LfTBgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-1196-369X","institution":"Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea","correspondingAuthor":true,"prefix":"","firstName":"Yong","middleName":"Beom","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2020-11-24 12:17:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-115013/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-115013/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13000-020-01065-0","type":"published","date":"2021-01-14T15:01:40+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":13620986,"identity":"a0d1e5a5-a277-4134-bc57-84b81fb1274b","added_by":"auto","created_at":"2021-09-17 07:08:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":345494,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-115013/v1/9524c24e-7f3e-4d88-8f9b-adaf0579a921.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eAspiration Biopsy Versus Dilatation and Curettage for Endometrial Hyperplasia Prior to Hysterectomy\u003c/p\u003e","fulltext":[{"header":"Introduction","content":" \u003cp\u003eEndometrial hyperplasia is a pathological condition characterized by abnormal proliferation of endometrial glands and stroma [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Endometrial hyperplasia, atypical endometrial hyperplasia in particular, is of clinical significance as it is considered to be a precursor lesion of endometrial cancer [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The accurate diagnosis of premalignant lesions and the exclusion of coexisting endometrial carcinomas are important aspects of the proper management of endometrial hyperplasia. The World Health Organization (WHO) 94 classifies endometrial hyperplasia into four groups based on glandular complexity and cytological nuclear atypia: simple hyperplasia without atypia, complex hyperplasia without atypia, simple atypical hyperplasia, and complex atypical hyperplasia [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere are several endometrial sampling methods used in practice to diagnose endometrial lesions, including endometrial hyperplasia. Among these, dilatation and curettage (D\u0026amp;C) has been one of the most widely used. However, it has become less favorable due to the added risk of anesthesia and complications. Endometrial aspiration biopsy has widely replaced D\u0026amp;C as it is easy to perform, safe, and convenient compared to D\u0026amp;C [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, there are no reliable data regarding the best method to diagnose endometrial hyperplasia. Numerous studies comparing the diagnostic accuracy of D\u0026amp;C and aspiration biopsy have concluded that aspiration biopsy is as accurate as D\u0026amp;C in the diagnosis of endometrial pathologies [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, all these studies have included patients with various pathological findings such as proliferative endometrium, secretory endometrium, endometrial hyperplasia, atrophic endometrium, and endometrial carcinoma. In addition, they were limited by their small sample size, especially for evaluating endometrial hyperplasia. They included only a small number of patients with endometrial hyperplasia and fewer than 10 patients with atypical endometrial hyperplasia.\u003c/p\u003e \u003cp\u003eTherefore, in this study, we aimed to compare the diagnostic accuracy of aspiration biopsy and D\u0026amp;C in patients who were diagnosed with endometrial hyperplasia by one of these methods prior to hysterectomy.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eThis study was approved by the Institutional Review Board of the Seoul National University Bundang Hospital (No. B-2007/627\u0026thinsp;\u0026minus;\u0026thinsp;101) and performed in accordance with the principles of the Declaration of Helsinki. The requirement for informed consent was waived.\u0026nbsp;This study was retrospectively performed between July 2003 and May 2020\u0026nbsp;at Seoul National University Bundang Hospital, a tertiary hospital in Korea.\u003c/p\u003e\n\u003cp\u003eWe reviewed the medical records of 250 patients who had been diagnosed with endometrial hyperplasia either by aspiration biopsy or D\u0026amp;C and had subsequently undergone hysterectomy. The aspiration biopsy was performed without anesthesia using the Pipelle device. D\u0026amp;C was performed under sedation with fentanyl and midazolam or under monitored anesthesia care using a curette. Eligible patients included those diagnosed with hyperplasia without atypia (simple and complex) and atypical hyperplasia (simple and complex). The diagnoses of the endometrial sampling specimens were independently reviewed pathologically in our institution. The maximum time interval between endometrial sampling confirming endometrial hyperplasia and hysterectomy was 6 months. We excluded the patients who had a diagnosis of \u0026ldquo;endometrial hyperplasia, cannot rule out malignancy\u0026rdquo; and those with \u0026ldquo;insufficient tissue for pathological evaluation.\u0026rdquo; Additionally, those who underwent non-surgical management such as hormone therapy after the diagnosis of endometrial hyperplasia and prior to hysterectomy were excluded.\u003c/p\u003e\n\u003cp\u003eThe pathological results of the preoperative endometrial sampling specimens were compared to those of the hysterectomy specimens. We evaluated the consistency of the pathological results between samples obtained by aspiration biopsy and by D\u0026amp;C. Results of \u0026ldquo;no residual disease,\u0026rdquo; \u0026ldquo;secretory endometrium,\u0026rdquo; and \u0026ldquo;proliferative endometrium\u0026rdquo; in postoperative specimen were considered normal.\u003c/p\u003e\n\u003cp\u003eThe Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-test and Mann-Whitney \u003cem\u003eU\u003c/em\u003e test were performed to compare continuous variables. Pearson\u0026rsquo;s chi-squared test or Fisher\u0026rsquo;s exact test was performed to compare categorical variables. Kappa statistics were used to assess the agreement of the two endometrial sampling methods. \u0026kappa; values\u0026thinsp;\u0026lt;\u0026thinsp;0 indicated no agreement, 0 to 0.20 slight, 0.21 to 0.40 fair, 0.41 to 0.60 moderate, 0.61 to 0.80 substantial, and 0.81 to 1 almost perfect agreement. All analyses were performed using SPSS software for Windows (version 25.0; SPSS Inc., Chicago, IL, USA). A \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicated statistical significance.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn this study, 250 patients were included. The overall patient characteristics are shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Of the 250 patients who had been diagnosed with endometrial hyperplasia, 100 were diagnosed by D\u0026amp;C and 150 by aspiration biopsy. There were 40 (16.0%) postmenopausal patients. In total, 154 (61.6%) patients underwent endometrial sampling due to abnormal uterine bleeding. The mean time between endometrial sampling and hysterectomy was 1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 months (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD). The histologic results by endometrial sampling showed 76 (30.4%) patients with simple hyperplasia without atypia, 42 (16.8%) with complex hyperplasia without atypia, 4 (1.6%) with simple atypical hyperplasia, and 128 (51.2%) with complex atypical hyperplasia. Final pathological results from hysterectomy confirmed 35 (14.0%) patients with normal endometrium, 68 (27.2%) with simple hyperplasia without atypia, 24 (9.6%) with complex hyperplasia without atypia, 3 (1.2%) with simple atypical hyperplasia, 64 (25.6%) with complex atypical hyperplasia, and 56 (22.4%) with carcinoma.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eCharacteristics of the overall study population\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCharacteristics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003en (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge, years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBMI\u003csup\u003ea\u003c/sup\u003e, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eParity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMenopause\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(16.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(3.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHypertension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(14.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTamoxifen\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(8.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAbnormal uterine bleeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e154\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(61.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEM sampling method\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eD\u0026amp;C\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(40.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAspiration biopsy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e150\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(60.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTime interval between EM sampling \u0026amp; hysterectomy, months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEM sampling pathology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(30.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(16.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSAH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(1.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCAH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e128\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(51.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHysterectomy pathology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNormal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(14.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e68\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(27.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(9.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSAH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCAH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(25.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(22.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\"\u003eData are mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or n (%) unless otherwise specified\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\"\u003e\u003csup\u003ea\u003c/sup\u003eBMI data are missing for two patients\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\"\u003eBMI, body mass index; EM, endometrial; D\u0026amp;C, dilatation and curettage; SH, simple hyperplasia without atypia; CH, complex hyperplasia without atypia; SAH, simple atypical hyperplasia; CAH, complex atypical hyperplasia\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen the diagnostic concordance between D\u0026amp;C and hysterectomy was assessed, in a total of 100 patients, 51 (51.0%) had diagnostic concordance: 23 (23.0%) with simple hyperplasia without atypia, 9 (9.0%) with complex hyperplasia without atypia, and 19 (19.0%) with complex atypical hyperplasia (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). In addition, when the diagnostic concordance between aspiration biopsy and hysterectomy was assessed, in a total of 150 patients, 62 (41.3%) had diagnostic concordance: 24 (16.0%) with simple hyperplasia without atypia, 6 (4.0%) with complex hyperplasia without atypia, 1 (0.7%) with simple atypical hyperplasia, and 31 (20.6%) with complex atypical hyperplasia (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eComparison of pathological results of D\u0026amp;C and hysterectomy\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eD\u0026amp;C\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003en (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"6\" align=\"left\"\u003e\n\u003cp\u003eHysterectomy\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eConcordance to hysterectomy\u003c/p\u003e\n\u003cp\u003en (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNormal\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSH\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCH\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSAH\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCAH\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCarcinoma\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(36.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(63.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(20.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(45.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSAH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCAH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(44.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(31.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e(100.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e51\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(51.0) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"11\"\u003eData are mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or n (%) unless otherwise specified\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"11\"\u003e\u003csup\u003ea\u003c/sup\u003eKappa value, 0.357 (Fair); diagnostic concordance 51.0% (51 out of 100 pairs); \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"11\"\u003eD\u0026amp;C, dilatation and curettage; SH, simple hyperplasia without atypia; CH, complex hyperplasia without atypia; SAH, simple atypical hyperplasia; CAH, complex atypical hyperplasia\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eComparison of pathological results of aspiration biopsy and hysterectomy\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAspiration biopsy\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003en (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"6\" align=\"left\"\u003e\n\u003cp\u003eHysterectomy\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eConcordance to hysterectomy\u003c/p\u003e\n\u003cp\u003en (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNormal\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSH\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCH\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSAH\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCAH\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCarcinoma\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(26.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(60.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(14.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(27.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSAH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(2.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(25.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCAH\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e84\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(56.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(36.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e150\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(100)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(41.3) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"11\"\u003eData are mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or n (%) unless otherwise specified\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"11\"\u003e\u003csup\u003ea\u003c/sup\u003eKappa value, 0.239 (Fair); diagnostic concordance 41.3% (62 out of 150 pairs); \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"11\"\u003eSH, simple hyperplasia without atypia; CH, complex hyperplasia without atypia; SAH, simple atypical hyperplasia; CAH, complex atypical hyperplasia\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe identified the upgrade rate of the final pathology based on the method of endometrial sampling. The final pathology was upgraded in significantly fewer cases after D\u0026amp;C than after aspiration biopsy (27.6% vs 72.4%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). Particularly, in patients with hyperplasia without atypia and complex hyperplasia, upgrading was found in significantly fewer cases after D\u0026amp;C than after aspiration biopsy (hyperplasia without atypia, 28.0% vs 72.0%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.028, complex hyperplasia, 27.9% vs 72.1%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.049). However, no significant difference in upgrading was observed between D\u0026amp;C and aspiration biopsy for atypical hyperplasia and simple hyperplasia (atypical hyperplasia, 27.5% vs 72.5%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.255, simple hyperplasia, 26.7% vs 73.3%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.113).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eComparison of postoperative pathological upgrade risks based on endometrial sampling methods\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eEndometrial sampling pathology\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eUpgrade on final pathology\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eEndometrial sampling method\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eD\u0026amp;C\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAspiration biopsy (n\u0026thinsp;=\u0026thinsp;150)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHyperplasia without atypia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(52.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(47.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.028\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(28.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(72.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAtypical hyperplasia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(37.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e51\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(63.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.255\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(27.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(72.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSimple hyperplasia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(49.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(50.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.113\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(26.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(73.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eComplex hyperplasia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e47\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(43.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(56.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.049\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(27.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(72.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e79\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(45.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e95\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(54.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.008\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(27.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(72.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003eData are n (%) unless otherwise specified\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003eD\u0026amp;C, dilatation and curettage\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe also assessed the final pathological upgrade rate to endometrial carcinoma based on the method of endometrial sampling. Carcinoma was found in 56 (22.4%) of the hysterectomy specimens. The final pathology was upgraded to endometrial carcinoma in significantly fewer cases after D\u0026amp;C than after aspiration biopsy (26.8% vs 73.2%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.022) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). In patients diagnosed with complex hyperplasia by D\u0026amp;C, 25.9% were upgraded to endometrial carcinoma after hysterectomy, whereas in those diagnosed with complex hyperplasia by aspiration biopsy, 74.1% were upgraded to endometrial carcinoma (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031). No significant difference in the upgrade rate was observed between the two endometrial sampling methods for hyperplasia without atypia, atypical hyperplasia, and simple hyperplasia (hyperplasia without atypia, 20.0% vs 80.0%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.368, atypical hyperplasia, 27.5% vs 72.5%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.255, simple hyperplasia, 50.0% vs 50.0%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.999).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eComparison of final pathological carcinoma risks based on endometrial sampling methods\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eEndometrial sampling pathology\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCarcinoma on final pathology\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eEndometrial sampling method\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eD\u0026amp;C\u003c/p\u003e\n\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAspiration biopsy (n\u0026thinsp;=\u0026thinsp;150)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHyperplasia without atypia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(48.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(51.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.368*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(20.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(80.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAtypical hyperplasia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(37.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e51\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(63.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.255\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(27.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(72.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSimple hyperplasia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(44.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(55.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;0.999*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eComplex hyperplasia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(43.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(56.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.031\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(25.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(74.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(43.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e109\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(56.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.022\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(26.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e(73.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003eData are n (%) unless otherwise specified\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003e* Fisher\u0026rsquo;s exact test for hyperplasia without atypia and complex hyperplasia\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003eD\u0026amp;C, dilatation and curettage\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur comparison of the accuracy of aspiration biopsy and D\u0026amp;C in patients diagnosed with preoperative endometrial hyperplasia suggests that D\u0026amp;C is a more accurate endometrial sampling method, particularly for patients with complex hyperplasia, than aspiration biopsy.\u003c/p\u003e\n\u003cp\u003eIn patients diagnosed with endometrial hyperplasia, there are risks of hidden malignancy and the possibility of progression to endometrial carcinoma. The risk of progression is \u0026lt;\u0026thinsp;5% in women with endometrial hyperplasia without atypia but increases up to 30% in women with atypical endometrial hyperplasia [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e]. Therefore, hysterectomy is recommended, particularly in patients with atypical endometrial hyperplasia [\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, in those who desire the preservation of their fertility or are unable to tolerate surgery due to coexisting medical conditions, conservative management is inevitable. In these patients, accurate diagnostic evaluation is particularly vital, as their final pathologic results might not be verified. In our study, 210 (84%) of the patients were premenopausal patients for whom special attention is required to exclude coexisting malignancy.\u003c/p\u003e\n\u003cp\u003eVarious methods of endometrial sampling are used in either inpatient or outpatient settings as a basis to diagnose endometrial lesions. Past studies regarding the accuracy of D\u0026amp;C compared to that of endometrial biopsy in diagnosing endometrial hyperplasia show conflicting results. One prospective study investigated the comparable diagnostic value of D\u0026amp;C and biopsy [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. Of the 70 patients, 55% and 45% of cases were diagnosed with complex atypical hyperplasia using endometrial biopsy and D\u0026amp;C, respectively. No difference in the incidence of coexisting cancer at hysterectomy was observed between the two methods (41% vs 45%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), but this study conclusion was limited by the small sample size. Another study evaluated whether preoperative D\u0026amp;C lowers the risk of unexpected cancer at hysterectomy compared to biopsy alone and reported that D\u0026amp;C lowered the risk of unexpected carcinoma compared to endometrial biopsy in patients with complex atypical hyperplasia (30% vs 45%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e]. Dijkhuizen et al. performed a meta-analysis to assess the accuracy of endometrial sampling devices for detecting endometrial carcinoma and endometrial hyperplasia [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]. They concluded that aspiration biopsy with Pipelle is superior to other endometrial instruments with sensitivities of 99.6% and 91% for endometrial carcinoma and endometrial hyperplasia, respectively, and more than 98% specificity. However, this review primarily included studies that examined the final pathology using D\u0026amp;C. Of the 39 studies, only five included studies used hysterectomy as the reference for final pathology [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eCompared to previous studies, our study has several strengths. First, we include a substantial number of patients diagnosed with endometrial hyperplasia, which was one of the limitations of previous studies [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e]. Second, we evaluate the final pathology based on hysterectomy specimens to compare two endometrial sampling methods, which provides more accuracy than using D\u0026amp;C as a reference. Third, in our study, the patients with \u0026ldquo;insufficient tissue for pathological examination\u0026rdquo; were excluded to further clarify the results. One of the concerns about endometrial sampling is the sufficiency of sample specimen. In some studies, inadequate pathological specimens that may have affected the results were included or the adequacy of the specimens was not considered [\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]. Lastly, we also excluded patients who received hormone therapy during the period between endometrial sampling and hysterectomy, as this treatment may significantly affect pathology.\u003c/p\u003e\n\u003cp\u003eOne potential limitation of the current study is that we could not apply the updated endometrial hyperplasia classification. There are two classification systems of endometrial hyperplasia: the WHO94 classification, used in this study, and the endometrial intraepithelial neoplasm (EIN) classification. The current position statement of the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology recommends using the EIN classification, which includes three categories: benign (benign endometrial hyperplasia), premalignant (EIN), and malignant (well-differentiated endometrial adenocarcinoma) [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. The EIN classification is more likely to identify precancerous lesions than the WHO94 classification. However, as our pathology department has only recently converted to the new terminology, the old WHO94 classification was used in this study. The WHO94 classification remains the most commonly used and reported classification in existing literature [\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e]. Another limitation of the current study is that we did not evaluate the effect of endometrial thickness. Thickened endometrium is known to be associated with endometrial pathologies. However, this may have little impact on the result of our study. A previous study evaluating the effect of endometrial thickness between biopsy methods showed no statistically significant results [\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]. The final limitation is that we did not compare various devices used for endometrial sampling. It is possible that differences in sampling devices may affect the accuracy of the results.\u003c/p\u003e\n\u003cp\u003eIn conclusion, as a gold standard method of endometrial sampling, higher accuracy with final pathology is expected from D\u0026amp;C than from aspiration biopsy. For an accurate diagnosis of endometrial hyperplasia, D\u0026amp;C seems superior to aspiration biopsy. When considering management strategies for women with endometrial hyperplasia obtained from aspiration biopsy, physicians should take into account the considerable rate of upgraded diseases.\u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cp\u003eD\u0026amp;C: Dilatation and Curettage\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u003c/p\u003e\n\u003cp\u003eEIN: Endometrial Intraepithelial Neoplasm\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of the Seoul National University Bundang Hospital (No. B-2007/627-101)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received to support this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWY Hwang: Protocol/project development, Data collection, Validation, Formal analysis and investigation, Manuscript writing \u0026ndash; original draft\u003c/p\u003e\n\u003cp\u003eDH Suh: Formal analysis and investigation, Manuscript writing \u0026ndash; review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eK Kim: Formal analysis and investigation, Manuscript writing \u0026ndash; review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eJH No: Formal analysis and investigation, Manuscript writing \u0026ndash; review \u0026amp; editing\u003c/p\u003e\n\u003cp\u003eYB Kim: Protocol/project development, Validation, Formal analysis and investigation, Manuscript writing \u0026ndash; review \u0026amp; editing, Supervision\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKadirogullari P, Atalay CR, Ozdemir O, Sari ME (2015) Prevalence of Co-existing Endometrial Carcinoma in Patients with Preoperative Diagnosis of Endometrial Hyperplasia. Journal of clinical and diagnostic research : JCDR 9 (10):Qc10-14. doi:10.7860/jcdr/2015/12484.6618\u003c/li\u003e\n\u003cli\u003eChandra V, Kim JJ, Benbrook DM, Dwivedi A, Rai R (2016) Therapeutic options for management of endometrial hyperplasia. Journal of gynecologic oncology 27 (1):e8. doi:10.3802/jgo.2016.27.e8\u003c/li\u003e\n\u003cli\u003eKim MK, Seong SJ, Park DC, Hong JH, Roh JW, Kang SB (2020) Comparison of diagnostic accuracy between endometrial curettage and aspiration biopsy in patients treated with progestin for endometrial hyperplasia: a Korean Gynecologic Oncology Group study. Journal of gynecologic oncology 31 (4):e51. doi:10.3802/jgo.2020.31.e51\u003c/li\u003e\n\u003cli\u003eSobczuk K, Sobczuk A (2017) New classification system of endometrial hyperplasia WHO 2014 and its clinical implications. 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Asian Pacific journal of cancer prevention : APJCP 16 (12):4971-4975. doi:10.7314/apjcp.2015.16.12.4971\u003c/li\u003e\n\u003cli\u003eNair R, Bandhe S, Ganorkar OK, Saha S, Sial S, Nair A (2019) A comparative evaluation of the three different antioxidant treatments on the bond strength of composite resin to bleached enamel: An in vitro study. Journal of conservative dentistry : JCD 22 (1):82-86. doi:10.4103/jcd.Jcd_193_18\u003c/li\u003e\n\u003cli\u003eKim MK, Seong SJ, Lee TS, Ki K-D, Lim MC, Kim YH, Kim K, Joo WD (2015) Comparison of diagnostic accuracy between endometrial curettage and pipelle aspiration biopsy in patients treated with progestin for endometrial hyperplasia: a Korean Gynecologic Oncology Group Study (KGOG 2019). 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Cancer 89 (8):1765-1772\u003c/li\u003e\n\u003cli\u003eStovall TG, Photopulos GJ, Poston WM, Ling FW, Sandles LG (1991) Pipelle endometrial sampling in patients with known endometrial carcinoma. Obstetrics and gynecology 77 (6):954-956\u003c/li\u003e\n\u003cli\u003eFerry J, Farnsworth A, Webster M, Wren B (1993) The efficacy of the pipelle endometrial biopsy in detecting endometrial carcinoma. The Australian \u0026amp; New Zealand journal of obstetrics \u0026amp; gynaecology 33 (1):76-78. doi:10.1111/j.1479-828x.1993.tb02060.x\u003c/li\u003e\n\u003cli\u003eZorlu CG, Cobanoglu O, Işik AZ, Kutluay L, Kuş\u0026ccedil;u E (1994) Accuracy of pipelle endometrial sampling in endometrial carcinoma. Gynecologic and obstetric investigation 38 (4):272-275. doi:10.1159/000292495\u003c/li\u003e\n\u003cli\u003eGuido RS, Kanbour-Shakir A, Rulin MC, Christopherson WA (1995) Pipelle endometrial sampling. Sensitivity in the detection of endometrial cancer. The Journal of reproductive medicine 40 (8):553-555\u003c/li\u003e\n\u003cli\u003eAntoni J, Folch E, Costa J, Foradada CM, Cayuela E, Combalia N, Ru\u0026eacute; M (1997) Comparison of cytospat and pipelle endometrial biopsy instruments. European journal of obstetrics, gynecology, and reproductive biology 72 (1):57-61. doi:10.1016/s0301-2115(96)02658-9\u003c/li\u003e\n\u003cli\u003eThe American College of Obstetricians and Gynecologists Committee Opinion no. 631. Endometrial intraepithelial neoplasia (2015). Obstetrics and gynecology 125 (5):1272-1278. doi:10.1097/01.Aog.0000465189.50026.20\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":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"diagnostic-pathology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dpat","sideBox":"Learn more about [Diagnostic Pathology](http://diagnosticpathology.biomedcentral.com)","snPcode":"13000","submissionUrl":"https://submission.nature.com/new-submission/13000/3","title":"Diagnostic Pathology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Endometrial Hyperplasia, Dilatation and Curettage, Hysterectomy, Biopsy","lastPublishedDoi":"10.21203/rs.3.rs-115013/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-115013/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eTo compare the diagnostic accuracy of aspiration biopsy and dilatation and curettage (D\u0026amp;C) in patients diagnosed with endometrial hyperplasia prior to hysterectomy. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe retrospectively reviewed medical records of 250 patients diagnosed with endometrial hyperplasia by endometrial sampling between July 2003 and March 2020. Endometrial sampling was performed by aspiration biopsy (n=150) or D\u0026amp;C (n=100), followed by hysterectomy within 6 months. Pathological findings of hysterectomy specimens of the two groups were compared to preoperative findings.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe overall diagnostic concordance between endometrial sampling specimen including D\u0026amp;C and aspiration biopsy, and hysterectomy specimen was 51.0% (51/100) and 41.3% (62/150), respectively. Patients whose preoperative specimen was obtained by D\u0026amp;C were upgraded less significantly than those who underwent aspiration biopsy (27.6% vs 72.4%; \u003cem\u003eP \u003c/em\u003e= 0.008). In particular, significantly fewer patients were upgraded after D\u0026amp;C than after aspiration biopsy in hyperplasia without atypia (28.0% vs 72.0%; \u003cem\u003eP \u003c/em\u003e= 0.028) and complex hyperplasia cases (27.9% vs 72.1%; \u003cem\u003eP \u003c/em\u003e= 0.049). In addition, when the final pathological upgrade rate to endometrial carcinoma was evaluated between the two methods of endometrial sampling, significantly fewer cases were noted after D\u0026amp;C than after aspiration biopsy (26.8% vs 73.2%; \u003cem\u003eP\u003c/em\u003e=0.022).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eIn our study, D\u0026amp;C more accurately reflected the final diagnosis in patients with endometrial hyperplasia than aspiration biopsy based on the histological examination of hysterectomy specimens. When considering the management strategy for women with an endometrial hyperplasia diagnosis obtained by aspiration biopsy, physicians should consider the significant rate of upgraded diseases with this method of endometrial sampling.\u003c/p\u003e","manuscriptTitle":"Aspiration Biopsy Versus Dilatation and Curettage for Endometrial Hyperplasia Prior to Hysterectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-12-01 18:00:28","doi":"10.21203/rs.3.rs-115013/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor Revision","date":"2020-12-18T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-12-13T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"reviewerAgreed","content":"","date":"2020-12-03T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-11-30T00:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-11-25T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-11-24T23:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-11-24T12:17:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-11-23T00:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"diagnostic-pathology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"dpat","sideBox":"Learn more about [Diagnostic Pathology](http://diagnosticpathology.biomedcentral.com)","snPcode":"13000","submissionUrl":"https://submission.nature.com/new-submission/13000/3","title":"Diagnostic Pathology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e6726927-8872-4cf1-bbfb-65bf6ffab2e2","owner":[],"postedDate":"December 1st, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":1225112,"name":"Pathology"}],"tags":[],"updatedAt":"2021-01-17T15:03:00+00:00","versionOfRecord":{"articleIdentity":"rs-115013","link":"https://doi.org/10.1186/s13000-020-01065-0","journal":{"identity":"diagnostic-pathology","isVorOnly":false,"title":"Diagnostic Pathology"},"publishedOn":"2021-01-14 15:01:40","publishedOnDateReadable":"January 14th, 2021"},"versionCreatedAt":"2020-12-01 18:00:28","video":"","vorDoi":"10.1186/s13000-020-01065-0","vorDoiUrl":"https://doi.org/10.1186/s13000-020-01065-0","workflowStages":[]},"version":"v1","identity":"rs-115013","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-115013","identity":"rs-115013","version":["v1"]},"buildId":"B-jG_2CBjPDmsCi4Wdhf-","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}