Garuti Giancarlo, Grossi Francesco, Centinaio Giovanna, Sita Giulia, Nalli Giulio, Luerti Massimo
Obstetrics and Gynecologic Department, Lodi Hospital, via Savoia no. 1, 26900 Lodi, Italy.
Eur J Obstet Gynecol Reprod Biol. 2007 May;132(1):101-6. doi: 10.1016/j.ejogrb.2006.04.001. Epub 2006 May 5.
To estimate the pretreatment incidence of endometrial pathology and to prospectively assess the endometrial morbidity emerging during tamoxifen intake for breast cancer.
One-hundred and forty-six menopausal breast cancer patients, candidate to receive tamoxifen underwent endometrial assessment by Transvaginal Ultrasonography (TU) before the start of therapy. A double-layered endometrial stripe measuring more than 4mm indicated hysteroscopy and endometrial biopsy. Endometrial abnormalities detected before the start of tamoxifen were treated by operative hysteroscopy or by hysterectomy; no therapy and yearly hysteroscopic follow-up was scheduled for patients showing non-atypical hyperplasias. All women were asked to undergo TU on a yearly basis; during the follow-up period, indication for hysteroscopy and endometrial biopsy were the following: (i) an endometrial lining measured above 4mm at the first time, (ii) at least a 50% increase of endometrial thickness since the last finding in patients previously assessed by hysteroscopy, (iii) a recorded vaginal bleeding, and (iv) previous findings of endometrial hyperplasia. Histopathologic result from biopsy or hysterectomy was the reference test to establish the baseline prevalence of endometrial pathology and the emerging prevalences of morbidity after 12, 24, 36, 48 and 60 months of tamoxifen therapy.
One-hundred and five patients were followed for 60 months, whereas 113, 126, 137 and 141 patients were evaluated up to 48, 36, 24 and 12 months, respectively. In 44 out of 146 patients, pretreatment TU showed an endometrium thicker than 4mm and in 31 (21.2%) of these patients abnormalities consisting of 16 endometrial polyps, seven polyps harboring simple hyperplasia, four simple hyperplasias, three atypical hyperplasias and one adenocarcinoma were found. During tamoxifen intake benign endometrial abnormalities were detected in 36 out of 114 assessable patients showing normal endometrium before the start of tamoxifen therapy (31.5%) and in seven out of 27 patients with baseline endometrial abnormalities (25.9%). Overall, an endometrial pathology emerged in 30.4% of patients during tamoxifen administration and in no patients we found an atypical lesion.
In menopausal breast cancer patients the incidence of endometrial abnormalities before the start of tamoxifen therapy is high and includes 2.7% of atypical pathology. After the diagnosis and treatment of baseline atypical lesions were accomplished, no atypical endometrial lesion emerged after the start of tamoxifen administration. Based on these findings, we believe that pretreatment assessment of endometrium is recommended in all menopausal women candidate to receive tamoxifen therapy.
评估乳腺癌患者接受他莫昔芬治疗前子宫内膜病变的发生率，并前瞻性评估他莫昔芬治疗期间出现的子宫内膜疾病。
146例绝经后乳腺癌患者，在开始治疗前接受经阴道超声检查（TU）以评估子宫内膜情况。双层子宫内膜厚度超过4mm提示需进行宫腔镜检查及子宫内膜活检。他莫昔芬治疗开始前检测到的子宫内膜异常通过宫腔镜手术或子宫切除术进行治疗；对于显示非典型增生的患者，不进行治疗，安排每年进行宫腔镜随访。所有女性均被要求每年接受TU检查；在随访期间，宫腔镜检查及子宫内膜活检的指征如下：（i）首次测量时子宫内膜厚度超过4mm；（ii）对于先前接受过宫腔镜检查的患者，自上次检查以来子宫内膜厚度至少增加50%；（iii）有阴道出血记录；（iv）先前有子宫内膜增生的检查结果。活检或子宫切除的组织病理学结果是确定子宫内膜病变基线患病率以及他莫昔芬治疗12、24、36、48和60个月后出现的疾病患病率的参考依据。
105例患者随访60个月，而分别有113、126、137和141例患者接受了48、36、24和12个月的评估。在146例患者中，44例患者治疗前的TU显示子宫内膜厚度超过4mm，其中31例（21.2%）发现异常，包括16例子宫内膜息肉、7例伴有单纯增生的息肉、4例单纯增生、3例非典型增生和1例腺癌。在他莫昔芬治疗期间，114例治疗前子宫内膜正常的可评估患者中有36例（31.5%）检测到良性子宫内膜异常，27例基线子宫内膜异常患者中有7例（25.9%）检测到良性子宫内膜异常。总体而言，30.4%的患者在他莫昔芬治疗期间出现子宫内膜病变，未发现非典型病变患者。
绝经后乳腺癌患者在开始他莫昔芬治疗前子宫内膜异常的发生率较高，其中非典型病变占2.7%。在完成基线非典型病变的诊断和治疗后，他莫昔芬治疗开始后未出现非典型子宫内膜病变。基于这些发现，我们认为所有接受他莫昔芬治疗的绝经后女性均建议进行治疗前子宫内膜评估。
