Grand Rounds

Atypical Hyperplasia Confined to Polyps: What is the Incidence of Endometrial Carcinoma?

BACKGROUND AND PURPOSE:

Incidence of endometrial carcinoma is high (approximately 40%) in women who undergo hysterectomy following a random endometrial biopsy
Jacobs et al. (BJOG, 2020) investigated the incidence of endometrial carcinoma in patients diagnosed with atypical hyperplasia confined to a polyp

Retrospective cohort study (2008 to 2016)
Participants
- Women who had hysteroscopic polyp resection
- Notes documented complete polyp removal
Data collection
- Patient characteristics: Age | BMI | Menopausal status | Hormone use | Symptoms at presentation (pre- and postmenopausal bleeding)
- Polyps reported as incidental findings or following investigation for abdominal pain or vaginal discharge were considered asymptomatic
- Histopathology results of the polyp
- Histopathology results of the uterus, in the case of hysterectomy
Polyps divided into two groups
- Benign polyps
- (Pre‐)malignant polyps: Atypical hyperplasia or endometrial carcinoma
Primary outcome
- Endometrial carcinoma

1,445 polyp resections
- Benign histopathology results: 96.2% (1,390 polyps)
- (Pre‐)malignant: 3.8% (55 polyps)
  - Atypical hyperplasia: 2.7% (39 polyps)
  - Endometrial carcinoma: 1.1% (16 polyps)
Hysterectomy (indication for (pre‐)malignant polyp pathology result for the polyp: 50 cases
- Atypical hyperplasia confined to polyp: 35 cases
- Endometrial carcinoma confined to the polyp: 15 cases
Endometrial histopathology among the 35 women with atypical hyperplasia confined to the polyp
- No additional pre-malignant changes in the endometrium: 30.8% (12 women)
- Atypical hyperplasia: 28.2% (11 women)
- Endometrial carcinoma: 30.8% (12 women)
Older age, postmenopausal status, tamoxifen use or bleeding at presentation were not associated with whether a polyp had (pre‐)malignant changes

Endometrial carcinoma was found in 30.8% of hysterectomy specimens performed for atypical hyperplasia confined to a polyp
The authors conclude that the data in this study supports a recommendation “to perform a hysterectomy and bilateral salpingo-oophorectomy for polyps with confined atypical hyperplasia in postmenopause and surgery or progestogens in premenopausal women”

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