**4. Pre-operative assessment of grade and histological subtype of the disease**

## **4.1 Pathology**

In addition to a TVS, a patient with post-menopausal bleeding needs a tissue diagnosis. This can be done by pipelle biopsy (office endometrial biopsy) or dilatation and curettage (D&C). The sensitivity of pipelle biopsy in detecting endometrial cancer is 99.6%. The sensitivity of D&C is similar; it serves as the diagnostic procedure when pipelle biopsy is not feasible or is inadequate (Dijkhuizen et al., 2000). After the diagnosis of endometrial cancer is made, preoperative assessment of the aggressiveness of the disease is very important to tailor the surgery. Patients with a high-grade endometrial cancer have a 15% to 20% risk of having metastatic lymph nodes (Creasman et al., 1987). Therefore, the ability to grade the tumor accurately on the diagnostic sample, be it a pipelle biopsy or a D&C, is crucial.

A D&C reflects the final FIGO grade more accurately than a pipelle biopsy. Leitao et al., (2009) reported a higher grade at the time of hysterectomy in 8.7% of patients when the diagnosis was made with a D&C, compared to 17.4% with a pipelle biopsy. Obermaier et al. (1999) found that 20% of Grade 1 endometrial cancers on D&C were upgraded to Grade 2 (or Grade 3 in 2% to 3% of cases) while 4% were downgraded at final pathology. In summary, pre-operative FIGO Grade 1 endometrioid endometrial cancer correlates in 80% to 85% of cases with the grade on the final hysterectomy specimen. The difference between pipelle biopsy and D&C does not warrant extra anesthesia. Changing from the three-grade FIGO system to a binary system does not improve accuracy sufficiently to warrant replacing the FIGO system, which is currently in use worldwide. However, molecular tests may have greater potential to support the binary system in the future (Clarke & Gilks, 2010). In a review of Stage III cases treated at our institution, we found that less than half were suspected preoperatively (Denschlag et al., 2007). A recent French multicentre study on sentinel lymph node mapping, found that 29% of tumors thought to be grade 1 preoperatively or intraoperatively, were upgraded to grade 2 or 3 or at final histology and 7% of patients thought to have type I tumors had type 2 endometrial cancer at definitive histology (Ballester et all 2010).

#### **4.2 Conclusion**

Identifying metastatic lymph nodes by currently available imaging techniques is only as sensitive as flipping a coin (50%). Assessing risk factors for metastatic lymph nodes, such as depth of myometrial invasion and cervical involvement, is most accurate with MRI, reaching at least 85% (in study circumstances) for both risk factors. Pre-operative assessment of Grade 1 tumors correlates with the final grade in 80% to 85% of cases.

This means that approximately one patient in five is underestimated pre-operatively for risk factors that include depth of myometrial invasion and/or cervical involvement and/or tumor grade. Consequently, tailoring surgery based on pre-operative assessment alone is not adequate.

## **5. Intra-operative assessment**

#### **5.1 Palpation of lymph nodes**

Intra-operative palpation of pelvic or para-aortic lymph nodes will reveal only 39% of the metastatic lymph nodes (Mariani et al., 2000). Creasman et al. (1987) have already shown that 37% of metastatic lymph nodes are smaller than 2mm. So neither pre-operative imaging nor intra-operative palpation is accurate enough to dispense with surgical excision.

## **5.2 Gross inspection**

104 Cancer of the Uterine Endometrium – Advances and Controversies

**4. Pre-operative assessment of grade and histological subtype of the disease** 

In addition to a TVS, a patient with post-menopausal bleeding needs a tissue diagnosis. This can be done by pipelle biopsy (office endometrial biopsy) or dilatation and curettage (D&C). The sensitivity of pipelle biopsy in detecting endometrial cancer is 99.6%. The sensitivity of D&C is similar; it serves as the diagnostic procedure when pipelle biopsy is not feasible or is inadequate (Dijkhuizen et al., 2000). After the diagnosis of endometrial cancer is made, preoperative assessment of the aggressiveness of the disease is very important to tailor the surgery. Patients with a high-grade endometrial cancer have a 15% to 20% risk of having metastatic lymph nodes (Creasman et al., 1987). Therefore, the ability to grade the tumor

A D&C reflects the final FIGO grade more accurately than a pipelle biopsy. Leitao et al., (2009) reported a higher grade at the time of hysterectomy in 8.7% of patients when the diagnosis was made with a D&C, compared to 17.4% with a pipelle biopsy. Obermaier et al. (1999) found that 20% of Grade 1 endometrial cancers on D&C were upgraded to Grade 2 (or Grade 3 in 2% to 3% of cases) while 4% were downgraded at final pathology. In summary, pre-operative FIGO Grade 1 endometrioid endometrial cancer correlates in 80% to 85% of cases with the grade on the final hysterectomy specimen. The difference between pipelle biopsy and D&C does not warrant extra anesthesia. Changing from the three-grade FIGO system to a binary system does not improve accuracy sufficiently to warrant replacing the FIGO system, which is currently in use worldwide. However, molecular tests may have greater potential to support the binary system in the future (Clarke & Gilks, 2010). In a review of Stage III cases treated at our institution, we found that less than half were suspected preoperatively (Denschlag et al., 2007). A recent French multicentre study on sentinel lymph node mapping, found that 29% of tumors thought to be grade 1 preoperatively or intraoperatively, were upgraded to grade 2 or 3 or at final histology and 7% of patients thought to have type I tumors had type 2 endometrial cancer at definitive

Identifying metastatic lymph nodes by currently available imaging techniques is only as sensitive as flipping a coin (50%). Assessing risk factors for metastatic lymph nodes, such as depth of myometrial invasion and cervical involvement, is most accurate with MRI, reaching at least 85% (in study circumstances) for both risk factors. Pre-operative assessment

This means that approximately one patient in five is underestimated pre-operatively for risk factors that include depth of myometrial invasion and/or cervical involvement and/or tumor grade. Consequently, tailoring surgery based on pre-operative assessment alone is

Intra-operative palpation of pelvic or para-aortic lymph nodes will reveal only 39% of the metastatic lymph nodes (Mariani et al., 2000). Creasman et al. (1987) have already shown that 37% of metastatic lymph nodes are smaller than 2mm. So neither pre-operative imaging

nor intra-operative palpation is accurate enough to dispense with surgical excision.

of Grade 1 tumors correlates with the final grade in 80% to 85% of cases.

accurately on the diagnostic sample, be it a pipelle biopsy or a D&C, is crucial.

**4.1 Pathology** 

histology (Ballester et all 2010).

**5. Intra-operative assessment** 

**5.1 Palpation of lymph nodes** 

**4.2 Conclusion** 

not adequate.

Assessment of the depth of myometrial invasion of an endometrial cancer by gross visual examination has been studied in three prospective studies (ranging from 148 to 403 patients). Compared to definite hystopathological findings, sensitivity varies from 71% to 79% and specificity from 93% to 96%. Evaluation of cervical involvement by gross inspection has never been studied (Loubreyre et al., 2011).
