Analysis of unexpected malignancy rates in patients undergoing hysterectomy for benign causes

Background

/aim: Hysterectomy is the most common operation performed for gynecologic reasons. In this study, we aimed to investigate unexpected malignancies in patients who underwent hysterectomy for benign reasons. Materials and methods: In this retrospective study, pathology results of hysterectomy cases performed in our clinic between 2013 and 2023 were analyzed and unexpected malignancy results were reported. Results: A total of 1954 patients underwent hysterectomy between 2013 and 2013. The mean age of the patients was 50.31 years and the most common indications for hysterectomy were myoma uteri (48.41%) and abnormal uterine bleeding (38.41%). Patients with no suspicion of malignancy in preoperative imaging and endometrial sampling results were operated and 21 patients with malignant final pathology results were identified.

The mean age of these patients was 55.47 years and 13 of them had endometium cancer and 7 of them had ovarian malignancy. Conclusion: In the literature, the rate of unexpected malignancies in hysterectomy cases was 0.73%, of which approximately half (58.3%) were uterine and the other half ovarian. In our study, the rate of endometrial malignancies was 0.66% and ovarian malignancies were 0.30%. Although malignancies can be excluded by preoperative imaging methods and endometrial sampling, tumors are rarely encountered. Keywords : Hysterectomy, malignancy, pathology.

Introduction

Hysterectomy is the most common operation performed in gynecology. The most common indication for hysterectomy, which is usually performed for benign causes, is myoma uterus ^[1]. Uterine prolapse, abnormal uterine bleeding, adenomyosis, pelvic inflammatory diseases and chronic pelvic pain are also benign causes of hysterectomy ^[2-3]. Abdominal, laparoscopic, vaginal and robotic surgery can be used for hysterectomy. Although the indication for hysterectomy plays an important role in the choice of one of the open, closed or vaginal routes, the most common abdominal (open) surgeries have been replaced by minimally invasive methods thanks to the developing technology ^[4]. Before the hysterectomy decision is made, a detailed physical examination and imaging methods are used to clarify the correctness of the indication.

Endometrial sampling is also performed preoperatively, especially in patients with vaginal bleeding, to rule out suspicion of malignancy. Although recent studies do not necessarily recommend it, there is a consensus that it should be performed especially in patients with vaginal bleeding ^[5]. Rarely, it has been reported that endometrial sampling may be confused with malignancy in patients with no complaints ^[6-7]. While some malignancies can be partially excluded by imaging methods, unexpected gynecologic malignancies are also reported despite endometrial sampling. The surgical method to be used in case of malignancy and the extent of the operationary. In our study, we aimed to investigate the incidence of unexpected malignancy in patients undergoing hysterectomy for benign reasons.

We evaluated the concordance and unexpected results by comparing the preoperative endometrial sampling with the final pathology results. MATERIAL METHOD This study was conducted with the approval of Erzincan Binali Yıldırım University Clinical Research Ethics Committee numbered 2023-20/23. In this retrospective study, the data of patients who underwent hysterectomy for benign reasons between 2013 and 2023 were accessed from the hospital automation system and evaluated. Patients with malignancy, suspected malignancy and those who underwent hysterectomy for obstetric reasons were excluded from the study, and the data of patients who had preoperative preparations and were operated in a planned manner were included in the study. Age, indication, preoperative smear, endometrial sampling, type of surgery and final pathology results were recorded.

For statistical analysis and ratios, descriptive statistical analysis was performed using SPSS 22.0 program, and mean, standard deviation, percentage and frequency values were analyzed. Manuscripts must be double-spaced with 3-cm margins on all sides of the page, in Times New Roman font size 12. Every page of the manuscript, including the title page, references, tables, etc., should be numbered. The manuscript must also have line numbers starting with 1 on each consecutive page. RESULT A total of 2425 patients underwent hysterectomy between 2013 and 2013. When patients who underwent hysterectomy for malignancy, obstetric reasons and patients who were sent frozen during the operation were excluded from the study, it was seen that there were 1950 patients who met the study criteria.

The ages of the patients included in the study ranged from 33 to 83 years with a mean age of 50.31 years. In terms of hysterectomy methods, 192 (9.8%) patients underwent vaginal hysterectomy, 289 (14.8%) underwent laparoscopic hysterectomy and 1469 (75.3%) underwent total abdominal hysterectomy. In terms of indications, 749 patients underwent hysterectomy for abnormal uterine bleeding, 944 for myoma uteri, 54 for ovarian causes and 203 for uterine prolapse. The most common indications for hysterectomy were myoma uteri (48.41%) and abnormal uterine bleeding (38.41%). 1118 of 1950 patients underwent endometrial sampling in the preoperative period and 462 (41.3%) of them had endometrial polyps, 21% had superficial endometrial glands (n=235), 11% (n=124) had secretory endometrium, 8.4% (n=94) had proliferative endometrium, 16.2% (n=182) had endometritis findings and 21 patients were reported as simple endometrial hyperplasia.(Table 1) Patients with no suspicion of malignancy in preoperative imaging and endometrial sampling results were operated and a total of 21 patients with malignant final pathology results were identified.

The ages of the patients with malignancy ranged between 40 and 74 years with a mean age of 55.47 years. Laparoscopic hysterectomy was performed in 4, vaginal hysterectomy in 1 and total abdominal hysterectomy in 16 patients. Smear results were obtained in 17 of the cases in which malignancy was detected and the results were found to be normal, while endometrial sampling was performed in the preoperative period in 19 cases and no finding in favor of malignancy was detected. Endometrial adenocarcinoma was found in 11 cases, endometrial carcinosarcoma in 2 cases, ovarian serous papillary tumor in 4 cases, endometrioid ovarian carcinoma in 1 case, granulosa cell tumor in 2 cases and endometrial intraepithelial neoplasia in 1 case.

In 5 patients with ovarian cancer, sonography revealed ovarian masses between 5 and 11 cm and all of them had normal Ca-125 values (Table 2). Table 1. Indications for hysterectomy Indication N % Myoma uteri 944 48.41 Abnormal uterine bleeding / treatment-resistant menometrorrhagia 749 38.41 Adnexial mass 54 2.76 Prolapse uteri 203 10.41 Research Article Tablo 2. characteristics of patients whose final histopathological results were reported as malignant Indication for hysterectomy age Endometrial sampling Operation Final pathology result 1. Case involved during colon operation 71 None TAH+BSO Endometrial adenocarcinoma 2. Adnexial mass 56 Superficial endometrial glands TAH+BSO Serous papillary tumor 3. Abnormal uterine bleeding 45 Endometrial polyp TAH+BSO Endometrioid adenocarcinoma on polyp background 4.Postmenopausal bleeding 74 Endometrial polyp TAH+BSO adenocarcinoma on polyp background 5.

Adnexial mass 51 Superficial endometrial glands TLH+BSO Granulosa cell tumor 6. Abnormal uterine bleeding 46 Simple endometrial hyperplasia TLH Endometrial adenocarcinoma 7. Myoma uteri 49 Superficial endometrial glands TAH+BSO Uterine sarcoma 8.Postmenopausal bleeding 67 Superficial endometrial glands TLH+BSO Endometrioid adenocarcinoma 9. Desensus uteri 62 Superficial endometrial glands VAH Endometrioid adenocarcinoma 10. Adnexial mass 46 Simple endometrial hyperplasia TAH+BSO Endometrioid ovarian ca 11. Adnexial mass 56 Superficial endometrial glands TAH+BSO High grade serous carcinoma 12. Myoma uteri 65 Endometrial polyp TAH+BSO Endometrial carcinosarcoma 13.Postmenopausal bleeding 60 Superficial endometrial glands TAH+BSO Endometrioid adenocarcinoma 14.Postmenopausal bleeding 64 Superficial endometrial glands TAH+BSO Endometrioid adenocarcinoma 15. Abnormal uterine bleeding 40 None TAH+BSO Endometrial adenocarcinoma 16.

Adnexial mass 58 Atrophic endometrium TAH+BSO High grade serous carcinoma 17. Abnormal uterine bleeding 48 Superficial endometrial glands TAH+BSO Endometrial intraepithelial neoplasia 18. Abnormal uterine bleeding 57 Simple endometrial hyperplasia TLH+BSO Endometrioid adenocarcinoma 19. Postmenopausal bleeding 62 Simple endometrial hyperplasia TAH+BSO Endometrioid adenocarcinoma 20. Adnexial mass 42 Secretory endometrium TAH+BSO Granulosa cell tumor 21. Abnormal uterine bleeding 46 Endometrial polyp TAH+BSO Endometrial stromal sarcoma Research Article

Discussion

The aim of this study was to investigate the incidence of unexpected gynecologic malignancy in patients undergoing hysterectomy for benign reasons. The data of 1950 patients who met the inclusion and exclusion criteria in our center were accessed. Endometrial sampling was performed in 1118 (57.3%) of these cases, and the incidence of unanticipated gynecologic cancers was 1.07%, of which 61.9% were uterine malignancies and 33.3% were ovarian malignancies. Hysterectomy is the most common operation performed in gynecology. Hysterectomy is performed for many benign indications such as abnormal uterine bleeding, myoma uteri, prolapse and adenomosis ^[7-8]. In our study, 48.41% of all hysterectomies were performed for myoma uteri and 38.41% for abnormal uterine bleeding.

The results of this study support that the most common reasons for hysterectomy are myoma uteri and abnormal uterine bleeding in accordance with the literature. All studies in the current literature recommend preopretive endometrial sampling in all symptomatic women with abnormal uterine bleeding ^[5]. In the study by Pessoa et al., it was argued that the diagnostic value of endometrial sampling was higher in women over 50 years of age and therefore endometrial sampling should be performed in women over 50 years of age ^[9]. There are also studies suggesting that endometrial sampling in patients with abnormal uterine bleeding has a negative prediction of 91% ^[10]. In our study, it was observed that endometrial sampling was not performed in only 1 of the patients whose final pathology result showed endometrial malignancy because the patient refused, and the pathology results of all patients who underwent endometrial sampling were reported as benign.

In a study by Yuk et al. including 12850 patients, the rate of unexpected endometrial malignancy was reported as 0.19% ^[11]. In a study conducted by Kadıoğlu et al. and similar in size to our study, the rate of unexpected endometrial malignancy was reported to be 0.73% ^[12]. In a study by Ouldamer et al. in which unexpected endometrial malignancies were examined, it was found that the malignancy rate was 0.4% after accurate and reliable endometrial sampling ^[13]. In our study, this rate was found to be 0.66% and is similar to the studies mentioned. Again, in terms of unexpected ovarian malignancies, Desai et al. found an unexpected malignancy rate of 0.19% ^[14], which is similar to the rate of 0.3% in our study.

Sarcoma rate was 0.15% in the study by Desai et al. ^[14], 0.13% in the study by Multinu et al. and 0.9% in the study by Elliot et al. ^[15-16]. In our study, sarcoma was detected in only 1 patient and the rate was 0.05%. In a similar study by Parsons et al. involving 6981 patients, the rate of unexpected endometrial cancer was reported as 0.19% ^[17]. In our study, this rate was 0.66%, which is similar to this study. Chao et al. 2019, which examined patients who underwent reoperation for pelvic mass following hysterectomy for benign reasons, it was found that 34.01% were diagnosed with malignant tumors, which emphasizes the importance of postoperative follow-up and follow-up for patients undergoing hysterectomy for benign indications ^[18].

Conclusion

In the literature, the rate of unexpected malignancy in hysterectomy cases is 0.73%, of which approximately half (58.3%) are uterine and the rest ovarian. In our study, the rate of endometrial malignancies was 0.66% and ovarian malignancies were 0.30%. Although malignancies can be excluded by preoperative imaging methods and endometrial sampling, it is possible to encounter tumors rarely. Acknowledgment and/or disclaimers None.

References

1. SpilsburyK,SemmensJB,HammondI, BolckA.Persistent high rates of hysterectomy in Western Australia: a population-based study of 83 000 procedures over 23 years. BJOG 2006: An International Journal of Obstetrics & Gynaecology, 113(7), 804-809 https://doi.org/10.1111/ j.1471-0528.2006.00962.x
2. American College of Obstetricians and Gynecologists. (2009). ACOG Committee Opinion No. 444: choosing the route of hysterectomy for benign disease. Obstet Gynecol, 114(5), 1156-1158. https://doi.org/10.1097/ AOG.0b013e3181c33c72
3. Wright JD, Herzog TJ, Tsui J, Ananth CV, Lewin SN. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstetrics and gynecology 2013, 122(2 0 1), 233. https://doi org/10.1097/AOG.0b013e318299a6cf
4. Madhvani K, Curnow T, Carpenter T. Route of hysterectomy: a retrospective, cohort study in English NHS Hospitals from 2011 to 2017. BJOG: An International Journal of Obstetrics & Gynaecology 2019, 126(6), 795- 802. https://doi.org/10.1111/1471-0528.15539
5. Hanlıgil E, Ekici MA. Is it necessary to perform an endometrial sampling prior to hysterectomies for benign conditions?. Experimental Biomedical Research 2019, 76-84 https://doi.org/10.30714/j-ebr.2019250353 Research Article
6. Mahnert N, Morgan D, Campbell D, Johnston C, As- Sanie S. Unexpected gynecologic malignancy diagnosed after hysterectomy performed for benign indications. Obstetrics & Gynecology 2015, 125(2), 397-405. https:// doi.org/10.1097/AOG.0000000000000642
7. Yilmaz EPT, Senocak GNC, Topdagi YE, Yildiz GA, Kumtepe Y. Incidence of occult malignancies identified during hysterectomies performed for benign indications. Journal of Gynecology Obstetrics and Human Reproduction 2020, 49(3), 101620 https://doi org/10.1016/j.jogoh.2019.08.003
8. Parsons LHP, Pedersen R, Richardson DL, Kho KA . The prevalence of occult endometrial cancer in women undergoing hysterectomy for benign indications. European Journal of Obstetrics & Gynecology and Reproductive Biology 2018, 223, 108-112. https://doi org/10.1016/j.ejogrb.2018.02.017
9. Pessoa JN, Freitas ACL, Guimaraes RA, Lima J, Dos Reis HLB. Endometrial assessment: when is it necessary?. Journal of clinical medicine research 2014 , 6(1), 21.
10. Getpook C, Wattanakumtornkul S. Endometrial thickness screening in premenopausal women with abnormal uterine bleeding. Journal of Obstetrics and Gynaecology Research 2006, 32(6), 588-592 https://doi org/10.1111/j.1447-0756.2006.00455.x
11. Yuk J S, Shin JY, Moon HS, Lee JH. The incidence of unexpected uterine malignancy in women undergoing hysteroscopic myomectomy or polypectomy: A national population-based study. European Journal of Obstetrics & Gynecology and Reproductive Biology 2018, 224, 12- 16 https://doi.org/10.1016/j.ejogrb.2018.03.003
12. Kadioğlu BG, Aksoy AN, Özmen SA, Uluğ P, Aydin Ö. Unexpected Malignancy Rate of 1630 Hysterectomies Performed for Benign Indications: A 10-year Retrospective Analysis. Turkish Journal of Oncology 2021, 36(2). https://doi.org/10.5505/tjo.2020.2561
13. Ouldamer L, Rossard L, Arbion F, Marret H, Body G. Risk of incidental finding of endometrial cancer at the time of hysterectomy for benign condition. Journal of Minimally Invasive Gynecology 2014, 21(1), 131-135. https://doi org/10.1016/j.jmig.2013.08.002
14. Desai VB, Wright JD, Gross CP, Lin H, Boscoe F P. Prevalence, characteristics, and risk factors of occult uterine cancer in presumed benign hysterectomy. American journal of obstetrics and gynecology 2019, 221(1), 39-e1. https://doi.org/10.1016/j ajog.2019.02.051
15. Multinu F, Casarin J, Tortorella L, Huang Y, Weaver A. Incidence of sarcoma in patients undergoing hysterectomyforbenignindications:apopulation-based study. American journal of obstetrics and gynecology 2019, 220(2), 179-e1. https://doi.org/10.1016/j ajog.2018.11.1086
16. Elliott CG, Murji A, Matelski J, Adekola AB, Chrzanowski J. Unexpected malignancy at the time of hysterectomy performed for a benign indication: A retrospective review. Plos one 2022, 17(4), e0266338. https://doi org/10.1371/journal.pone.0266338
17. Parsons LHP, PedersenR, Richardson DL, Kho KA. The prevalence of occult endometrial cancer in women undergoing hysterectomy for benign indications. European Journal of Obstetrics & Gynecology and Reproductive Biology 2018, 223, 108-112. https://doi org/10.1016/j.ejogrb.2018.02.017
18. Chao X, Wang X, Xiao Y, Ji M, Wang S. Effects of hysterectomywithsimultaneousbilateralsalpingectomy on the subsequent pelvic mass. Journal of Ovarian Research 2019, 12(1), 1-8. https://doi.org/10.1186/ s13048-019-0504-6 Research Article

This is a text version generated from the article. For the formatted version of record (with original tables & figures), download the PDF →