Does Hysteroscopy Facilitate Tumor Cell Dissemination?

abstract & commentary

Synopsis: Dissemination of endometrial carcinoma cells occurs after fluid hysteroscopy. Determining whether positive peritoneal cytology affects prognosis of patients without further evidence of extrauterine disease will require further study.

Source: Obermair A, et al. Cancer 2000;88:139-143.

Obermair and colleagues conducted a multicenter, retrospective cohort analysis in which 113 consecutive patients with endometrial cancer treated between 1996 and 1997 were included. Endometrial cancer had to be limited to the inner half or less than the inner half of the myometrium. Positive peritoneal cytology was obtained during staging laparotomy. Patients underwent dialation and curettage (D & C) either with or without diagnostic fluid hysteroscopy. Positive peritoneal cytology, defined as malignant or suspicious, was considered the primary statistical endpoint. The purpose of the study was to compare the incidence of positive peritoneal cytology in patients who underwent D & C with or without previous hysteroscopy. Peritoneal cytology was suspicious or positive in 10 of 113 patients (9%). The presence of suspicious or positive peritoneal cytology was associated with a history of hysteroscopy but not with myometrial invasion, histologic subtype, histologic grade, or the time between D & C and staging laparotomy. Based on the limited extent of endometrial cancer in the current analysis, Obermair et al conclude that their data strongly suggest dissemination of endometrial cancer cells after fluid hysteroscopy. They further conclude that determining whether a positive peritoneal cytology affects the prognoses of patients without further evidence of extrauterine disease will require longer follow-up.

Comment by David M. Gershenson, MD

The implications of positive peritoneal cytology in patients with endometrial cancer have undergone a major transition during the past decade or so. Prior to that time, positive peritoneal cytology in endometrial cancer patients was believed to be uniformly associated with an unfavorable prognosis. More recent studies have suggested that positive peritoneal cytology is usually only meaningful if accompanied by unfavorable prognostic factors, including deep myometrial invasion, high grade, poor prognosis histologic subtype, or evidence of extrauterine disease. According to the International Federation of Gynecology and Obstetrics staging classification, patients with tumors otherwise confined to the endometrial cavity but with malignant cells in the peritoneal washing are classified as having stage IIIA. Prior to this study, several case reports documented positive peritoneal cytology in patients who underwent hysterectomy following hysteroscopy. This retrospective review also raises concern about the possibility of dissemination of tumor cells into the peritoneal cavity by saline irrigation of the endometrial cavity during hysteroscopy. However, several unanswered questions remain. The most important of these: Are these cells in the peritoneal washings truly viable and capable of metastasizing to other sites, thereby leading to an increased risk of recurrence? No one knows the answer to this important question. Clearly, prospective studies of peritoneal cytology after hysteroscopy are needed to confirm the retrospective findings.

Patients who have endometrial cancer with tumor otherwise confined to the uterine cavity but with malignant cells in the peritoneal washing are classified by the International Federation of Gynecology and Obstetrics as having:

a. stage IC.

b. stage IIC.

c. stage IIIA.

d. stage IIIC.

e. stage IV.