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Hysteroscopic Assessment of Menopausal Breast-Cancer Patients Taking Tamoxifen; There is a Bias from the Mode of Endometrial Sampling in Estimating Endometrial Morbidity?

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Abstract

The aim of this study is to evaluate the accuracy of hysteroscopy in detecting tamoxifen-associated endometrial morbidity. Ninety-eight menopausal breast cancer patients taking tamoxifen underwent hysteroscopy because of an endometrial thickness above 4 mm measured by Transvaginal Ultrasonography. Thirty-one women recorded uterine bleeding while 67 were asymptomatic. Hysteroscopies with operative facilities were performed, mainly in out-patient setting. Hysteroscopic findings were matched with histopathology derived from various modalities of tissue collection as suction-curettage, oriented-streak curettage, hysteroscopically-targeted biopsies or polypectomies and hysterectomies. Accuracy of hysteroscopy to estimate a normal or abnormal endometrium was calculated. Abnormal endometrium was detected in 35 patients (64.5% in symptomatic and 22.3% in asymptomatic women, P < 0.001). We found six carcinomas, 18 polyps and 11 hyperplasias. Hysteroscopy showed sensitivity and specificity of 89.2 and 98.4%, respectively. By blind sampling, tissue collection was too scant to give a diagnosis in 29.1% of patients and in 80.5% of patients in whom hysteroscopy showed cystic atrophy the pathologist failed to confirm this condition. Moreover, eight endometrial polyps (36.3%) detected by hysteroscopy were missed. Conversely, by tissue sampling under vision no inadequate specimen was sent to the pathologist and all hysteroscopies showing cystic atrophy and polyps were pathologically confirmed. From literature data, the detection-rate of endometrial pathology in tamoxifen users varies from the lowest to the highest prevalences whether blind or hysteroscopically-targeted modalities of tissue sampling were used, respectively. Hysteroscopy with targeted sampling appears to be the most effective method to assess the endometrial lining. In our experience it is safe, well tolerated and it should be considered the reference test to assess a thickened endometrium in women under tamoxifen.

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References

  1. Early Breast Cancer Trialists' Group: Tamoxifen for early breast cancer: an overview of the randomised trials. The Lancet 351: 1451–1467, 1998

    Google Scholar 

  2. Patterson JS: Clinical aspects and development of antioestrogen therapy: a review of the endocrine effects of tamoxifen in animals and men. J Endocrinol 89 (S): 67–75, 1981

    Google Scholar 

  3. Fisher B, Costantino JP, Wickerham DL: Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst 90: 1371–1388, 1998

    Article  CAS  PubMed  Google Scholar 

  4. Howell A, De Friend D: Hormonal therapy for advanced breast cancer. In: Tobias JS, Houghton J, Henderson IC (eds). Breast Cancer, New Horizons in Research and Treatment. Oxford University Press, New York, 2001, pp 237–256

    Google Scholar 

  5. Fornander T, Rutqvist LE, Cederniar KB, Glas U, Mattsson A, Silfverswand C, Lambert S, Somell A, Theve T, Wilhing N, Askergen J, Ajalmar ML: Adjuvant tamoxifen in early breast cancer: occurrence of new primary cancers. The Lancet 1: 117–120, 1989

    CAS  Google Scholar 

  6. Fisher B, Costantino JP, Redmond CK, Fisher ER, Wickerham DL, Cronin VM: Endometrial cancer in tamoxifen-treated breast cancer patients: findings from the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-14. J Natl Cancer Inst 86: 527–537, 1994

    CAS  PubMed  Google Scholar 

  7. Love CD, Muir BB, Scrimgeaur JB, Leonard RC, Dillon P, Dixon JM: Investigation of endometrial abnormalities in asymptomatic women treated with tamoxifen and an evaluation of the role of endometrial screening. J Clin Oncol 17: 2050, 1999

    CAS  PubMed  Google Scholar 

  8. Neven P, Vernaeve H: Guidelines for monitoring patients taking tamoxifen treatment. Drug Saf 22: 1–11, 2000

    Article  CAS  PubMed  Google Scholar 

  9. Gerber B, Krause A, Muller H, Reimer T, Kulz T, Makavitzky J, Kundt G, Friese K: Effects of adjuvant tamoxifen on the endometrium in postmenopausal women with breast cancer: a prospective long-term study using transvaginal ultrasound. J Clin Oncol 18: 3464–3470, 2000

    CAS  PubMed  Google Scholar 

  10. Goldstein SR: Unusual ultrasonographic appearance of the uterus in patients receiving tamoxifen. Am J Obstet Gynecol 170: 447–451, 1994

    CAS  PubMed  Google Scholar 

  11. McElrath T, Anderson P, Fields A, Somma L, Gross S, Runowicz C: Saline infusion sonography: a diagnostic and therapeutic intervention for patients on tamoxifen. Obstet Gynecol 95(S): 53–54, 2000

    Google Scholar 

  12. Tapper R, Beyth Y, Altaras MM, Zalel Y, Shapira J, Cordoba M, Cohen I: Value of sonohysterography in asymptomatic postmenopausal tamoxifen treated patients. Gynecol Oncol 64: 386–391, 1997

    Google Scholar 

  13. Karlsson B, Granberg S, Wikland M: Transvaginal ultrasonography of the endometrium in women with post-menopausal bleeding. A nordic multicenter study. Am J Obstet Gynecol 172: 1488–1494, 1995

    Article  CAS  PubMed  Google Scholar 

  14. Gimpelson RJ, Rappold HO: A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases. Am J Obstet Gynecol 152: 489–492, 1988

    Google Scholar 

  15. Nagele F, O'Connor H, Davies A, Badaway A, Mohamed H, Magos A: A 2500 out-patients diagnostic hysteroscopies. Obstet Gynecol 1: 87–92, 1996

    Google Scholar 

  16. Cecchini S, Ciatto S, Bonardi R, Mazzotta A, Grazzini G, Pacini P, Muraca MG: Screening by ultrasonography for endometrial carcinoma in postmenopausal breast cancer patients under adjuvant tamoxifen. Gynecol Oncol 60: 409–411, 1996

    Article  CAS  PubMed  Google Scholar 

  17. Bertelli G, Venturini M, Del Mastro L, Garrone O, Cosso M, Gustavino C, Cusimano E, Guido T, Nicolò G, Dosso R: Tamoxifen and the endometrium: finding of pelvic ultrasound examination and endometrial biopsy in asymptomatic breast cancer patients. Breast Cancer Res Treat 47: 41–46, 1998

    Article  CAS  PubMed  Google Scholar 

  18. Ceci O, Bettocchi S, Marello F, DiVenere R, Pellegrino AR, Laricchia L, Vimercati A: Hysteroscopic evaluation of the endometrium in postmenopausal women taking tamoxifen. J Am Assoc Gynecol Laparosc 7: 185–189, 2000

    CAS  PubMed  Google Scholar 

  19. Neven P. Endometrial changes in patients on tamoxifen. The Lancet 346: 1292, 1995

    Article  CAS  Google Scholar 

  20. Neis KJ, Brandner P, Hepp H: Hysteroscopic differential diagnosis of the endometrium. In 'Hysteroscopy, Textbook and Atlas'. Thieme Medical Publishers, New York, 1994, pp 53–64

    Google Scholar 

  21. Bukley CH, Fox H: Biopsy Pathology of the Endometrium. Biopsy Pathology Series 14. Chapman and Hall Medical, London, 1989

    Google Scholar 

  22. Van Leeuwen FE, Benraadt J, Coebergh JWW, Kiemeney LAML, Gimbrere CHF, Otter R, Schouten LJ, Damhuis RAM, Bontembal M, Diepenhorst FW, Van der Belt Dusebout AW, Van Tintenteren H: Risk of endometrial cancer after tamoxifen treatment of breast cancer. The Lancet 343: 448–452, 1994

    CAS  Google Scholar 

  23. Mignotte H, Lasset C, Bonadona V, Lesur A, Luporsi E, Rodier JF, Cutuli B, Lasry S, Mauriac L, Granon C, Kerr C, Giard S, Hill C, DeLafontan B, DeGislain C, D'Anjou J, Fondrinier E, Lefeuvre C, Parache RM, Chauvin F: Iatrogenic risk of endometrial carcinoma after treatment for breast cancer in a large french case-control study. Int J Cancer 76: 325–330, 1998

    Article  CAS  PubMed  Google Scholar 

  24. McGonigle KF, Show SL, Vasilev SA, Odon-Maryon T, Roy S, Simpson JF: Abnormalities detected on transvaginal ultrasonography in tamoxifen treated postmenopausal breast cancer patients may represent endometrial cystic atrophy. Am J Obstet Gynecol 178: 1145–1150, 1998

    Article  CAS  PubMed  Google Scholar 

  25. Ozsener S, Ozaran A, Itil I, Dikmen Y: Endometrial pathology of 104 postmenopausal breast cancer patients treated with tamoxifen. Eur J Gynecol Oncol 19: 580–583, 1998

    CAS  Google Scholar 

  26. Tesoro MR, Borgida AF, MacLaurin NA, Asuncion CM: Transvaginal endometrial sonography in postmenopausal women taking tamoxifen. Obstet Gynecol 93: 363–366, 1999

    Article  CAS  PubMed  Google Scholar 

  27. Cohen I, Altaras MM, Shapira J, Tepper R, Cordoba M, Figer A, Zalel Y, Oror Y, Beyth Y: Different coexisting endometrial histological features in asymptomatic postmenopausal breast cancer patients treated with tamoxifen. Gynecol Obstet Invest 43: 60–63, 1997

    CAS  PubMed  Google Scholar 

  28. Franchi M, Ghezzi F, Donadello N, Zanaboni N, Beretta P, Bolis P: Endometrial thickness in tamoxifen-treated patients: an independent predictor of endometrial disease. Obstet Gynecol 93: 1004–1008, 1999

    Article  CAS  PubMed  Google Scholar 

  29. Giorda G, Scarabelli C, Franceschi S, Campagnutta E: Feasibility and pain control in out patient hysteroscopy in postmenopausal women: a randomized trial. Acta Obstet Gynecol Scand 79: 593–597, 2000

    Article  CAS  PubMed  Google Scholar 

  30. Jansen FW, Vredevoogd CB, Van Ulzen K, Hermans J, Trimbos JB, Trimbos-Kemper TC: Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol 96: 266–270, 2000

    Article  CAS  PubMed  Google Scholar 

  31. Mourits MJ, Van der Zee AG, Willemse DH, TenHoor KA, Hollema H, DeVries EG: Discrepancy between ultrasonography and hysteroscopy and histology of endometrium in postmenopausal breast cancer patients using tamoxifen. Gynecol Oncol 73: 21–26, 1999

    Article  CAS  PubMed  Google Scholar 

  32. Loffer FD: Hysteroscopy with selective endometrial sampling compared with dilatation and curettage for abnormal uterine bleeding: the value of a negative hysteroscopic view. Obstet Gynecol 73: 16–20, 1989

    CAS  PubMed  Google Scholar 

  33. Garuti G, Sambruni I, Cellani F, Garzia D, Alleva P, Luerti M: Hysteroscopy and transvaginal ultrasonography in postmenopausal women with uterine bleeding. Int J Gynecol Obstet 65: 25–33, 1999

    Article  CAS  Google Scholar 

  34. Neven P, De Muylder X, VanBelle Y, VanHooff I, Vanderick G: Longitudinal hysteroscopic follow-up during tamoxifen treatment. The Lancet 351: 36, 1998

    CAS  Google Scholar 

  35. Elhelw B, Ghorab MNM, Farrag SH: Saline sonohysterography for monitoring asymptomatic postmenopausal breast cancer patients taking tamoxifen. Int J Gynecol Obstet 67: 81–86, 1999

    Article  CAS  Google Scholar 

  36. Remondette LM, Sherwood JB, Dunton CJ, Palazzo JP: Endometrial cancer in polyps associated with tamoxifen use. Am J Obstet Gynecol 180: 340–341, 1999

    Google Scholar 

  37. Cohen I, Azaria R, Fishman A, Tepper R, Shapira J, Beyth Y: Endometrial cancers in postmenopausal breast cancer patients with tamoxifen treatment. Int J Gynecol Pathol 18: 304–309, 1999

    CAS  PubMed  Google Scholar 

  38. Timmerman D, Deprest J, Bourne T, Van der Berghe I, Collins WP, Vergote I: A randomized trial on the use of ultrasonography or office hysteroscopy for endometrial assessment in postmenopausal patients with breast cancer who were treated with tamoxifen. Am J Obstet Gynecol 179: 62–70, 1998

    CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Gynecology and Obstetrics, Lodi Hospital, Lodi, Italy

    Giancarlo Garuti, Francesco Grossi, Fulvia Cellani, Giovanna Centinaio, Monica Colonnelli & Massimo Luerti

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  1. Giancarlo Garuti
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  2. Francesco Grossi
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  3. Fulvia Cellani
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  4. Giovanna Centinaio
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  5. Monica Colonnelli
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  6. Massimo Luerti
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Garuti, G., Grossi, F., Cellani, F. et al. Hysteroscopic Assessment of Menopausal Breast-Cancer Patients Taking Tamoxifen; There is a Bias from the Mode of Endometrial Sampling in Estimating Endometrial Morbidity?. Breast Cancer Res Treat 72, 245–253 (2002). https://doi.org/10.1023/A:1014957524845

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