Rauf MELEKOĞLU, Ercan YILMAZ

4915

Asemptomatik Postmenopozal Endometrial Kalınlık Artışında Yönetim

ÖZET:Transvajinal ultrasonografinin klinik kullanıma girmesinden sonra birçok çalışma postmenopozal hastalarda endometriyum kanserinin erken tanısı için transvajinal ultrasonografinin etkin bir tarama metodu olarak önemini değerlendirmiştir. Ancak, postmenopozal kadınlarda rastlantısal olarak tanımlanan artmış endometriyal kalınlığın yönetimi henüz standardize edilmemiştir. Klinik pratikte bu insidental bulgunun saptanması çok sayıda biyopsi yapılmasına yol açmaktadır. Postmenopozal kanaması olan hastalarda transvajinal ultrasonografinin ilk değerlendirme için uygun olduğu, endometrium kalınlığının 4mm’nin altı olduğu değerlerde endometrium kanseri için negatif prediktif değerinin %99’un üstünde olduğu bildirilmiştir. Bununla birlikte kanaması olmayan postmenopozal hastalarda transvajinal ultrasonografinin endometrium kanseri taraması için uygun bir tarama aracı olmadığı, bu hasta grubunda hasta özellikleri ve risk faktörlerine göre bireyselleştirilmiş değerlendirme yapılması gerektiği gösterilmiştir. Tamoksifen kullanan kadınların endometrium kanseri erken tanısı için rutin endometrial kalınlık ölçümü ile taranması gereksiz invaziv işlemlere ve yüksek maliyetli tanısal prosedürlere neden olabileceği için önerilmemektedir. Postmenopozal asemptomatik polip saptanan hastaların tamamında cerrahi gereklilik bulunmamakla birlikte asemptomatik polip varlığında yönetim polipin çapı, hasta yaşı ve diğer endometrium kanseri risk faktörlerinin durumuna göre belirlenmesi uygundur. Tek başına asemptomatik postmenopozal endometrial sıvı koleksiyonunun varlığı ise daha ileri tanısal inceleme gerektirmemekte bu hastaların bilinen endometrium kanseri risk faktörlerinin varlığı ile birlikte değerlendirilmesi daha uygun gözükmektedir.ABSTRACT            Since the use of transvaginal ultrasonography in clinical practice, many studies have evaluated the importance of transvaginal ultrasonography as an effective screening method for the early diagnosis of endometrium cancer in postmenopausal patients. However, the management of increased endometrial thickness, which is coincidentally defined in asymptomatic postmenopausal women, has not been standardized yet. In clinical practice, the detection of this incidental finding leads to a large number of biopsies. In patients with postmenopausal bleeding, it was reported that transvaginal ultrasonography is suitable for initial evaluation and that the endometrial thickness below 4mm has more than 99% negative predictive value for endometrium cancer. However, in postmenopausal women without vaginal bleeding, it is suggested that transvaginal ultrasonography is not a suitable screening tool for endometrial cancer screening, and that individualized evaluation should be performed according to patient characteristics and risk factors in this group of patients. Endometrial thickness measurement by transvaginal ultrasonography is not recommended for women using tamoxifen because routine screening for endometrial thickness measurement for early endometrial cancer detection may result in unnecessary invasive procedures and costly diagnostic procedures. Although postmenopausal asymptomatic polyps are not required for surgery, management of asymptomatic polyps based on polyp diameter, patient age, and other endometrium cancer risk factors is appropriate. The presence of asymptomatic postmenopausal endometrial fluid collection alone does not require further diagnostic evaluation, and it is more appropriate to evaluate these patients with the presence of known endometrial cancer risk factors. 
Anahtar Kelimeler:

endometriyum, endometrial hiperplazi, endemetriyum kanseri, hormon replasman tedavisi, tamoksifen, ultrasonografi

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  • 1. Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer statistics 2007. CA Cancer J Clin 2007;57(1):43–66.
  • 2 .Munstedt K, Grant P, Woenckhaus J, Roth G, Tinneberg HR. Cancer of the endometrium: current aspects of diagnostics and treatment. World J Surg Oncol 2004;2:24.
  • 3. Bray F, Loos AH, Oostindier M, Weiderpass E (2005) Geographic and temporal variations in cancer of the corpus uteri: incidence and mortality in pre- and postmenopausal women in Europe. Int J Cancer 117:123–131.
  • 4. Malkasian Jr GD, Annegers JF, Fountain KS. Carcinoma of the endometrium: Stage I. Am J Obstet Gynecol 1980;136(7):872–88.
  • 5. Gull B, Karlsson B, Milsom I, Granberg S. Can ultrasound replace dilation and curettage? A longitudinal evaluation of postmenopausal bleeding and transvaginal sonographic measurement of the endometrium as predictors of endometrial cancer. Am J Obstet Gynecol 2003;188(2):401–8.
  • 6. Epstein E, Valentin L. Rebleeding and endometrial growth in women with postmenopausal bleeding and endometrial thickness < 5 mm managed by dilatation and curettage or ultrasound follow-up: a randomized controlled study. Ultrasound Obstet Gynecol 2001;18(5):499–504.
  • 7. Lynch HT, Lynch JF. Lynch syndrome: history and current status. Dis Markers 2004; 20: 181–198.
  • 8. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelines for the early detection of cancer. 2006. CA Cancer J Clin 2006; 56: 11–25.
  • 9. Kondo E, Tabata T, Koduka Y, et al. What is the best method of detecting endometrial cancer in outpatients? Endometrial sampling, suction curettage, endometrial cytology. Cytopathology 2008;19(1):28–33.
  • 10. Kanat-Pektas M, Gungor T, Mollamahmutoglu L. The evaluation of endometrial tumors by transvaginal and Doppler ultrasonography. Arch Gynecol Obstet 2008;277(6):495–9.
  • 11. Smith-Bindman R, Weiss E, Feldstein V. How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol. 2004;24(5):558-65.
  • 12. Menzies R, Wallace S, Ennis M, et al. Significance of abnormal sonographic findings in postmenopausal women with and without bleeding. J Obstet Gynaecol Can 2011;33(9):944–51.
  • 13. Osmers R, Vӧlksen M, Schauer A. Vaginosonography for early detection of endometrial carcinoma. Lancet 1990;335(8705):1569–71.
  • 14. Schmidt T, Breidenbach M, Nawroth F, et al. Hysteroscopy for asymptomatic postmenopausal women with sonographically thickened endometrium. Maturitas 2009;62(2):176–8.
  • 15. Yasa C, Dural O, Bastu E, Ugurlucan FG, Nehir A, İyibozkurt AC. Evaluation of the diagnostic role of transvaginal ultrasound measurements of endometrial thickness to detect endometrial malignancy in asymptomatic postmenopausal women. Arch Gynecol Obstet. 2016;294(2):311-6.
  • 16. Saatli B, Yildirim N, Olgan S, Koyuncuoglu M, Emekci O, Saygılı U. The role of endometrial thickness for detecting endometrial pathologies in asymptomatic postmenopausal women. Aust N Z J Obstet Gynaecol. 2014;54(1):36-40.
  • 17. Seckin B, Cicek MN, Dikmen AU, Bostancı EI, Muftuoglu KH. Diagnostic value of sonography for detecting endometrial pathologies in postmenopausal women with and without bleeding. J Clin Ultrasound. 2016 Jul 8;44(6):339-46.
  • 18. Fleischer AC, Wheeler JE, Lindsay I, et al. An assessment of the value of ultrasonographic screening for endometrial disease in postmenopausal women without symptoms. Am J Obstet Gynecol. 2001;184(2):70-5.
  • 19. Breijer MC, Peeters JA, Opmeer BC, et al. Capacity of endometrial thickness measurement to diagnose endometrial carcinoma in asymptomatic postmenopausal women: a systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2012;40(6):621-9.
  • 20. Louie M, Canavan TP, Mansuria S. Threshold for endometrial sampling among postmenopausal patients without vaginal bleeding. Int J Gynaecol Obstet. 2016;132(3):314-7.
  • 21. Jokubkiene L, Sladkevicius P, Valentin L. Transvaginal ultrasound examination of the endometrium in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol. 2016;48(3):390-6.
  • 22. ACOG Committee Opinion No. 734: The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding. Obstet Gynecol. 2018;131(5):e124-e129.
  • 23. Wolfman W. No. 249-Asymptomatic Endometrial Thickening. J Obstet Gynaecol Can. 2018;40(5):e367-e377.
  • 24. Grady D, Gebretsadik T, Kerlikowske K, Ernster V, Petitti D. Hormone replacement therapy and endometrial cancer risk: a meta-analysis. Obstet Gynecol. 1995;85(2):304-13.
  • 25. Weiderpass E, Adami HO, Baron JA, et al. Risk of endometrial cancer following estrogen replacement with and without progestins. J Natl Cancer Inst. 1999;91(13):1131-7.
  • 26. Kurman RJ, Kaminshi PF, Norm HJ. The behaviour of endometrial hyperplasia. A long term study of ’untreated’ hyperplasia in 170 patients. Cancer 1985;56:403–12.
  • 27. Rozenberg S, Caubel P, Lim PC. Constant estrogen, intermittent progestogen vs continuous combined hormone replacement: tolerability and effect on vasomotor symptoms. Int J Gynecol Obstet. 2001;72:235–43.
  • 28. Anderson GL, Judd HL, Kaunitz AM, et al. Effects of estrogen plus progestin on gynecologic cancers and associated diagnostic procedures: the Women’s Health Initiative randomized trial. JAMA 2003; 290 (13):1739–48.
  • 29. HickeyM, Davis SR, Sturdee DW. Treatment of menopausal symptoms: what shall we do now?. Lancet 2005;366(9483):409–21.
  • 30. Furness S, Roberts H, Marjoribanks J, Lethaby A. Hormone therapy in postmenopausal women and risk of endometrial hyperplasia. Cochrane Database Syst Rev. 2012;(8):CD000402.
  • 31. Mossa B, Imperato F, Marziani R, et al. Hormonal replacement therapy and evaluation of intrauterine pathology in postmenopausal women: a ten-year study. Eur J Gynaecol Oncol. 2003;24(6):507-12.
  • 32. Affinito P, Palomba S, Pellicano M, et al. Ultrasonographic measurement of endometrial thickness during hormonal replacement therapy in postmenopausal women. Ultrasound Obstet Gynecol. 1998;11(5):343-6.
  • 33. Sismondi P, Biglia N, Volpi E, Giai M, de Grandis T. Tamoxifen and endometrial cancer. Ann N Y Acad Sci 1994;734:310–21.
  • 34. Bissett D, Davis JA, George WD. Gynaecological monitoring during tamoxifen therapy. Lancet 1994;344:1244.
  • 35. Barakat RR, Wong G, Curtin JP, Vlamis V, Hoskins WJ. Tamoxifen use in breast cancer patients who subsequently develop corpus cancer is not associated with a higher incidence of adverse histologic features. Gynecol Oncol 1994; 55:164–8.
  • 36. Magriples U, Naftolin F, Schwartz PE, Carcangiu ML. High-grade endometrial carcinoma in tamoxifen-treated breast cancer patients. J Clin Oncol 1993;11:485–90.
  • 37. Fisher B, Costantino JP, Redmond CK, Fisher ER, Wickerham DL, Cronin WM. 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 1994;86:527–37.
  • 38. Fishman M, Boda M, Sheiner E, Rotmensch J, Abramowicz J. Changes in the sonographic appearance of the uterus after discontinuation of tamoxifen therapy. J Ultrasound Med. 2006 ;25(4):469-73.
  • 39. Kazerooni T, Ghaffarpasand F, Mosalaei A, Kazerooni Y. The value of transvaginal ultrasonography in the endometrial evaluation of breast cancer patients using tamoxifen. Med Princ Pract. 2010;19(3):222-7.
  • 40. Achiron R, Lipitz S, Sivan E, et al. Changes mimicking endometrial neoplasia in postmenopausal, tamoxifen-treated women with breast cancer: a transvaginal Doppler study. Ultrasound Obstet Gynecol 1995;6:116–20.
  • 41. Fung MF, Reid A, Faught W, et al. Prospective longitudinal study of ultrasound screening for endometrial abnormalities in women with breast cancer receiving tamoxifen. Gynecol Oncol 2003;91:154–9.
  • 42. Markovitch O, Tepper R, Aviram R, Fishman A, Shapira J, Cohen I. The value of sonohysterography in the prediction of endometrial pathologies in asymptomatic postmenopausal breast cancer tamoxifen-treated patients. Gynecol Oncol 2004;94:754–9.
  • 43. Dreisler E, Stampe Sorensen S, Ibsen PH, Lose G. Prevalence of endometrial polyps and abnormal uterine bleeding in a Danish population aged 20–74 years. Ultrasound Obstet Gynecol 2009; 33:102–8.
  • 44. Savelli L, de Iaco P, Santini D, et al. Histopathologic features and risk factors for benignity, hyperplasia, and cancer in endometrial polyps. Am J Obstet Gynecol 2003;188:927–31.
  • 45. Gebauer G, Hafner A, Siebzehnrqbl E, Lang N. Role of hysteroscopy in detection and extraction of endometrial polyps: results of a prospective study. Am J Obstet Gynecol 2001;184:59– 63.
  • 46. Schmidt T, Breidenbach M, Nawroth F, et al. Hysteroscopy for asymptomatic postmenopausal women with sonographically thickened endometrium. Maturitas. 2009;62(2):176-8.
  • 47. Gregoriou O, Konidaris S, Vrachnis N, et al. Clinical parameters linked with malignancy in endometrial polyps. Climacteric. 2009;12(5):454-8.
  • 48. Fernández-Parra J, Rodríguez Oliver A, López Criado S, Parrilla Fernández F, Montoya Ven-toso F. Hysteroscopic evaluation of endometrial polyps. Int J Gynaecol Obstet. 2006;95(2):144-8.
  • 49. Ferrazzi E, Zupi E, Leone FP, et al. How often are endometrial polyps malignant in asymptomatic postmenopausal women? A multicenter study. Am J Obstet Gynecol. 2009;200(3):235.e1-6.
  • 50. Bar-Hava I, Orvieto R, Ferber A, et al. Asymptomatic postmenopausal intrauterine fluid accumulation: characterization and significance. Climacte-ric. 1998;1(4):279-83.
  • 51. Debby A, Malinger G, Glezerman M, Golan A. Intra-uterine fluid collection in postmenopausal women with cervical stenosis. Maturitas. 2006;55(4):334-7.
  • 52. Topçu HO, Taşdemir Ü, İslimye M, Bayramoğlu H, Yılmaz N. The clinical significance of endometrial fluid collection in asymptomatic postmenopausal women. Climacteric. 2015;18(5):733-6.
  • 53. Inceboz U, Uyar Y, Baytur Y, Kandiloglu AR. Endometrial fluid in postmenopausal women. Int J Gynaecol Obstet. 2009;107(2):154-5.
Türk Jinekolojik Onkoloji Dergisi-Cover
  • ISSN: 2148-5372
  • Başlangıç: 2014
  • Yayıncı: Türk Jinekolojik Onkoloji Derneği
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