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Sbharris[atsign]ix.netcom.com wrote:
> David Rind wrote:
> > fresh~horses@xxxxxxxxxxxxx wrote:
> > > Today I received a pathology report which both concerns and confuses
> > > me. I have come to respect each of you, and sincerely wish to know your
> > > most candid comments.
> > >
> > > When *you* see this, what are you seeing? When *you* see this, what do
> > > you advise? How is this treated where you practise? What are my
> > > options, as you see them?
> > >
> > > The gynecologist who did my diagnostic surgery is now on vacation. Her
> > > stand-in was very kind, and gave me some idea of my options. I want to
> > > hear from you. Also, I kind of blanked out here and there, and he is
> > > run off his feet. Yesterday he was a resident. Today he's flying on his
> > > own. ; )
> > >
> > > I have been told I have a pre-cancerous condition. Here is my
> > > pathology.
> > >
> > > "...three polyp like structures. The first measures 2.5 x 1 cm... The
> > > other two polyp like structures measure 1.0 x 1.9 and 1.2 x 1.2 cm
> > > (Zee: and some remarks which I assume mean location 2E and 2F)
> > >
> > > "sections show endocervix and endometrium with evidence of simple and
> > > complex hyperplasia with focal atypia. Most of the hyperplasia is seen
> > > within the polyps. Some appear to involve the underlying endometrium.
> > > ..."
> > >
> > >
> > > With thanks.
> > >
> > >
> > > Zee
> >
> > Unfortunately, I don't have much experience with pathology reports for
> > endometrial polyps. Without your comments/concerns, I would have thought
> > this was a pretty benign sounding report. With those comments, I'm
> > guessing that one option recommended was to perform a hysterectomy to
> > prevent the future development of endometrial cancer. I have no idea,
> > though, what the risk of progression is.
> >
> > --
> > David Rind
> > drind@xxxxxxxxxxxxxxxxxxxxx
>
>
>
> COMMENT:
>
> And since most of my patients are frozen and also I'm not a
> gynecologist, there's little I can add to that. Uterine cancer can be
> anywhere, and you don't always biopsy through it. So the biopsy is
> sepecific but not sensitive. If it's not in the area where you
> biopsied, it might not show.
>
> There's argument about whether or not endometrial polyps _per se_ even
> predispose to cancer-- they aren't like colon polyps. Hyperplasia is a
> risk factor for cancer, but far more important is age and endometrial
> thickness-- if it's less than 5 or 6 mm, usually you can avoid the
> reflex hysterectomy. Age (>70), diabetes and no childbearing history
> are also important risk factors for uterine cancer in post menopausal
> bleeding.
>
> Complex hyperplasia in women of childbearing years who want to preserve
> the uterus is sometimes treated with high dose progestins. This is
> often successful but not always. If it was, everybody could avoid
> hysterectomy. Since most women with complex hyperplasia and bleeding
> who are > 10 years from menopause just get the hysterectomy, there's
> not a lot of experience treating this any other way.
>
> I recommend take it out. You can't get cancer in an organ that has been
> removed. Progestins like Provera aren't completely benign, and do bad
> things to blood lipids. I would encourage natural progesterone if a
> women insisted on going that route.
>
> SBH
Update on pre-cancerous uterine polyps:
My gynecologist's suggested course is similar to Steve's: I'll be on
prometrium for six months, after which I'll have another hysteroscopy
and D&C. No talk of surgery until we see that result, but at that time
I would only ok hysterectomy, and only then if there is frank,
diagnosed cancer.
Thanks again to Drs. Harris, McCollister and Rind.
Zee
>
>
>
> 1: Acta Obstet Gynecol Scand. 1985;64(8):653-9.
>
> Endometrial polyps and hyperplasia as risk factors for endometrial
> carcinoma. A
> case-control study of curettage specimens.
>
> Pettersson B, Adami HO, Lindgren A, Hesselius I.
>
> As part of a comprehensive case-control study, the impact of previous
> endometrial pathology on the risk of developing endometrial carcinoma
> was
> investigated. The study comprised 254 consecutive women with
> histopathologically
> confirmed cancer of the uterine body in a well-defined population, and
> their
> age-matched controls. Ninety-eight (39%) of the patients and 81 (32%)
> of the
> controls had previously undergone endometrial curettage. More than one
> previous
> curettage was positively associated with endometrial carcinoma (odds
> ratio =
> 2.5; 95% CL = 1.4-4.5). Endometrial abnormalities in previous curettage
> specimens occurred significantly more often among carcinoma patients
> (57%) than
> among controls (25%) (odds ratio = 4.0; 95% CL = 2.0-8.0). Twelve
> patients, but
> no controls, had adenomatous hyperplasia and this hyperplasia antedated
> the
> cancer diagnosis by a mean of 4.6 years. Endometrial polyps were
> present
> significantly more often in patients (20%) than in controls (10%) (odds
> ratio =
> 3.4; 95% CL = 1.3-9.3). The present results suggest that both of these
> conditions are risk factors for endometrial carcinoma. Among women who
> had
> undergone endometrial curettage more than 4 years after the menopause,
> 19 out of
> 30 patients, but none out of 7 controls, showed abnormality in the
> curettage
> specimens. Postmenopausal women with endometrial abnormality should
> thus be
> regarded as being at risk of developing endometrial carcinoma.
>
> PMID: 3832756 [PubMed - indexed for MEDLINE]
>
> 2: J Clin Ultrasound. 2004 Jun;32(5):219-24.
>
> Combination of endometrial thickness and time since menopause in
> predicting
> endometrial cancer in women with postmenopausal bleeding.
>
> Bruchim I, Biron-Shental T, Altaras MM, Fishman A, Beyth Y, Tepper R,
> Aviram R.
>
> Department of Obstetrics and Gynecology, Sapir Medical Center, 59
> Tchernichovsky
> Street, Kfar Saba, 44281, Israel.
>
> PURPOSE: This study was conducted to assess the combination of
> endometrial
> thickness, as measured by transvaginal sonography, and time since
> menopause, in
> predicting the presence of endometrial cancer in women with
> postmenopausal
> bleeding. METHODS: The study group consisted of 95 women with
> postmenopausal
> bleeding who underwent sonographic measurement of endometrial thickness
> followed
> by endometrial biopsy. No patient had ever received hormone replacement
> therapy.
> RESULTS: The mean endometrial thickness was significantly lower in the
> absence
> of endometrial carcinoma (6.9 +/- 4.3 mm) than in its presence (13.5
> +/- 7.7 mm)
> (p < 0.005). The incidence of endometrial carcinoma increased with
> increases in
> endometrial thickness and the number of years since menopause. No
> patient had
> carcinoma when the endometrium was less than 5 mm thick, but 18.5% did
> when the
> thickness exceeded 9 mm. The incidence of cancer was 2.6% in women who
> had
> undergone menopause less than 5 years earlier but was 21.4% in women
> who had
> undergone menopause more than 15 years prior. Multiple logistic
> regression
> analysis showed that time since menopause and endometrial thickness
> were
> statistically significant predictors of endometrial carcinoma.
> CONCLUSIONS: Time
> since menopause and endometrial thickness together define cutoff points
> for the
> diagnostic biopsy of tissue samples for endometrial carcinoma; that is,
> within a
> particular time interval, sampling should not be performed if the
> thickness is
> below a given value. When using cutoff points of 6 mm of endometrial
> thickness
> for women experiencing menopause 5-15 years prior and 5 mm in those
> going
> through menopause 15 or more years prior, approximately 60% of invasive
> procedures may be avoided. In addition, models derived by multiple
> logistic
> regression can be used to calculate a patient's risk of cancer based on
> her age
> and endometrial thickness. Copyright 2004 Wiley Periodicals, Inc.
>
> Publication Types:
> Clinical Trial
> Controlled Clinical Trial
>
> PMID: 15124187 [PubMed - indexed for MEDLINE]
>
> 3: Ann Chir Gynaecol. 1983;72(5):274-7.
>
> Endometrial findings following curettage in 2018 women according to age
> and
> indications.
>
> Holst J, Koskela O, von Schoultz B.
>
> A retrospective study on 2018 Scandinavian women undergoing
> conventional and
> aspiration curettage was performed. The outcome in terms of endometrial
> pathology was analyzed against age and indications. A large number of
> operations
> (38.2%) were performed on young women before the age of 45 years. 98%
> of
> endometrial samples were normal from 430 younger than 40 years. Better
> selection
> of cases might help to reduce the number of operations. In women of
> reproductive
> age the relation between normal and pathological findings was the same
> for both
> methods with the exception that conventional curettage seemed to detect
> more
> polyps. The frequency of insufficient samples after aspiration
> curettage
> increased markedly with age. Postmenopausal bleeding remains a strong
> indication
> for conventional curettage.
>
> PMID: 6660829 [PubMed - indexed for MEDLINE]
>
> 4: Am J Obstet Gynecol. 2003 Feb;188(2):401-8.
>
> Comment in:
> Am J Obstet Gynecol. 2004 Aug;191(2):677; author reply 678.
>
> Can ultrasound replace dilation and curettage? A longitudinal
> evaluation of
> postmenopausal bleeding and transvaginal sonographic measurement of the
> endometrium as predictors of endometrial cancer.
>
> Gull B, Karlsson B, Milsom I, Granberg S.
>
> Department of Obstetrics and Gynecology, University of Goteborg,
> Sahlgrenska
> University Hospital, Sweden. berit.gull@xxxxxxxxxxx
>
> OBJECTIVE: The purpose of this study was to evaluate postmenopausal
> bleeding and
> transvaginal sonographic measurement of endometrial thickness as
> predictors of
> endometrial cancer and atypical hyperplasia in women whose cases were
> followed
> for > or =10 years after referral for postmenopausal bleeding. STUDY
> DESIGN:
> Women (n = 394) who had postmenopausal bleeding from November 1987 to
> October
> 1990 underwent transvaginal sonographic measurement of endometrial
> thickness and
> curettage. It was possible to assess the medical records (regarding
> recurrence
> of a postmenopausal bleeding, development of endometrial cancer, and
> death) in
> 339 of the 394 women (86%) > or =10 years after referral for
> postmenopausal
> bleeding. RESULTS: Thirty-nine of the 339 women (11.5%) had endometrial
> cancer,
> and 5 women (1.5%) had atypical hyperplasia. The relative risk of
> endometrial
> cancer in women who were referred for postmenopausal bleeding was 63.9
> (95% CI,
> 46.0-88.8); the corresponding relative risk for endometrial cancer and
> atypical
> hyperplasia together was 72.1 (95% CI, 52.8-98.5) compared with women
> of the
> same age from the general population of the same region of Sweden. No
> woman with
> an endometrial thickness of < or =4 mm was diagnosed as having
> endometrial
> cancer. The relative risk of the development of endometrial cancer in
> women with
> an endometrial thickness of >4 mm was 44.5 (95% CI, 6.5-320.1) compared
> with
> women with an endometrial thickness of < or =4 mm. The reliability of
> endometrial thickness (cutoff value, < or =4 mm) as a diagnostic test
> for
> endometrial cancer was assessed: Sensitivity, 100%; specificity, 60%;
> positive
> predictive value, 25%; and negative predictive value, 100%. The
> incidence of
> endometrial cancer or atypical hyperplasia in women with an intact
> uterus whose
> cases had been followed for > or =10 years was 5.8% (15/257 women)
> compared with
> 22.7% (15/66 women) in women who had < or =1 episode of recurrent
> bleeding. No
> endometrial cancer was diagnosed in women with a recurrent
> postmenopausal
> bleeding who had an endometrial thickness of < or =4 mm at the initial
> scan.
> CONCLUSION: Postmenopausal bleeding incurs a 64-fold increase risk for
> endometrial cancer. There was no increased risk of endometrial cancer
> or atypia
> in women who did not have recurrent bleeding, whereas women with
> recurrent
> bleeding were a high-risk group. No endometrial cancer was missed when
> endometrial thickness measurement (cutoff value, < or =4 mm) was used,
> even if
> the women were followed up for < or =10 years. We conclude that
> transvaginal
> sonographic scanning is an excellent tool for the determination of
> whether
> further investigation with curettage or some form of endometrial biopsy
> is
> necessary
>
> PMID: 12592247 [PubMed - indexed for MEDLINE]
>
> 5: Gynecol Oncol. 1995 Mar;56(3):376-81.
>
> Predicting endometrial cancer among older women who present with
> abnormal
> vaginal bleeding.
>
> Feldman S, Cook EF, Harlow BL, Berkowitz RS.
>
> Department of Obstetrics, Gynecology, Brigham and Women's Hospital,
> Boston,
> Massachusetts, USA.
>
> We studied 203 women ages 49 or over who presented with abnormal
> vaginal
> bleeding and who underwent either endometrial biopsy or dilation and
> curettage
> at the Brigham and Women's Hospital. Using information from the
> clinical
> history, we predicted their risk for endometrial cancer (36 patients)
> or complex
> endometrial hyperplasia (16 patients). Factors independently associated
> with
> endometrial cancer/complex hyperplasia included age 70 or older (OR =
> 9.1, P =
> 0.0001), diabetes (OR = 3.7, P = 0.02), and nulliparity (OR = 2.7, P =
> 0.02).
> After adjusting for age, menopause was borderline significant (OR =
> 2.6, P =
> 0.07). Our data estimated a risk of endometrial cancer/complex
> hyperplasia of
> 87% for a woman possessing all of these factors, and a risk of less
> than 3% if
> she had none of them. Our model provides an inexpensive, simple means
> for
> assessing the risk of endometrial cancer and complex hyperplasia in the
> post- or
> perimenopausal woman with abnormal bleeding.
>
> PMID: 7705671 [PubMed - indexed for MEDLINE]
>
> 6: Acta Obstet Gynecol Scand. 2000 Apr;79(4):317-20.
>
> The risk of premalignant and malignant pathology in endometrial polyps.
>
> Bakour SH, Khan KS, Gupta JK.
>
> Birmingham Minimal Access Surgical Training Centre, Academic Department
> of
> Obstetrics and Gynaecology, University of Birmingham, UK.
>
> OBJECTIVE: To evaluate the risk of premalignant and malignant pathology
> among
> endometrial polyps. DESIGN: Prospective cohort study. SETTING: Minimal
> Access
> Surgical Training (MAST) center in a large teaching hospital. METHODS:
> Among 248
> patients seen in outpatient hysteroscopy clinic (1996-97), 62 had
> endometrial
> polyps. All patients had endometrial sampling for histological
> assessment. To
> determine the magnitude of malignant potential among polyps, we
> compared the
> pathological findings in polyps (cases) with non-polypoidal specimens
> (controls). RESULTS: Out of 62 polyps, histologically 53 (85.5%) were
> benign,
> seven (11.3%) had hyperplasia, and two (3.2%) were associated with
> malignancy.
> Hyperplasia was more frequent in endometrial specimens with polyps than
> in those
> without (11.3% vs 4.3%, p=0.04), but the incidence of carcinoma in the
> two
> groups was the same (3.2% vs 3.2%, p= 1.0). CONCLUSION: In abnormal
> uterine
> bleeding, hyperplasia was, but cancer was not, more common in women
> with
> endometrial polyps compared to those without polyps.
>
> PMID: 10746849 [PubMed - indexed for MEDLINE]
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