Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.
Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Naples, Italy.
Am J Obstet Gynecol. 2023 Jan;228(1):22-35.e2. doi: 10.1016/j.ajog.2022.07.043. Epub 2022 Aug 4.
This study aimed to evaluate the risk of endometrial carcinoma and atypical endometrial hyperplasia in asymptomatic postmenopausal women concerning the endometrial thickness measured by stratified threshold categories used for performing subsequent endometrial sampling and histologic evaluation.
MEDLINE, Scopus, ClinicalTrials.gov, SciELO, Embase, the Cochrane Central Register of Controlled Trials, LILACS, conference proceedings, and international controlled trials registries were searched without temporal, geographic, or language restrictions.
Studies were selected if they had a crossover design evaluating the risk of atypical endometrial hyperplasia and endometrial carcinoma in postmenopausal asymptomatic women and calculated the diagnostic accuracy of transvaginal ultrasonography thresholds (at least 3.0 mm) confirmed by histopathologic diagnosis.
This was a systematic review and diagnostic test accuracy meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy and Synthesizing Evidence from Diagnostic Accuracy Tests guidelines. Endometrial thickness thresholds were grouped as follows: from 3.0 to 5.9 mm; between 6.0 and 9.9 mm; between 10.0 and 13.9 mm; and ≥14.0 mm. Quality assessment was performed using the Quality Assessment Tool for Diagnostic Accuracy Studies 2 tool. Publication bias was quantified using the Deek funnel plot test. Coprimary outcomes were the risk of atypical endometrial hyperplasia or endometrial carcinoma according to the endometrial thickness and diagnostic accuracy of each threshold group.
A total of 18 studies provided the data of 10,334 women who were all included in the final analysis. Overall, at an endometrial thickness threshold of at least 3.0 mm, the risk of atypical endometrial hyperplasia or endometrial carcinoma was increased 3-fold relative to women below the cutoff (relative risk, 3.77; 95% confidence interval, 2.26-6.32; I=74%). Similar degrees of risk were reported for thresholds between 3.0 and 5.9 mm (relative risk, 5.08; 95% confidence interval, 2.26-11.41; I=0%), 6.0 and 9.9 mm (relative risk, 4.34; 95% confidence interval, 1.68-11.23; I=0%), 10.0 and 13.9 mm (relative risk, 4.11; 95% confidence interval, 1.55-10.87; I=86%), and ≥14.0 mm (relative risk, 2.53; 95% confidence interval, 1.04-6.16; I=78%) with no significant difference among subgroups (P=.885). Regarding diagnostic accuracy, the pooled sensitivity decreased from thresholds below 5.9 mm (relative risk, 0.81; 95% confidence interval, 0.49-0.85) to above 14.0 mm (relative risk, 0.28; 95% confidence interval, 0.18-0.40). Furthermore, the specificity increased from 0.70 (95% confidence interval, 0.61-0.78) for endometrial thickness between 3.0 and 5.9 mm to 0.86 (95% confidence interval, 0.71-0.94) when the endometrial thickness is ≥14.0 mm. For 3.0 to 5.9 mm and 10.0 to 13.9 mm thresholds, the highest diagnostic odds ratios of 10 (95% confidence interval, 3-41) and 11 (95% confidence interval, 2-49), with areas under the curve of 0.81 (95% confidence interval, 0.77-0.84) and 0.82 (95% confidence interval, 0.79-0.86), respectively, were retrieved. The summary point analysis revealed that the 3.0 to 5.9 mm cutoff point was placed higher in the summary receiver operator curve space than the other subgroups, indicating increased endometrial carcinoma or atypical endometrial hyperplasia diagnosis using these cutoffs.
Both low and high endometrial thickness thresholds in postmenopausal asymptomatic women seem equally effective in detecting endometrial carcinoma and atypical endometrial hyperplasia. However, although using a 3.0 to 5.9 mm cutoff results in a lower specificity, the offsetting improvement in sensitivity may justify using this cutoff for further endometrial evaluation in patients with suspected endometrial malignancy.
本研究旨在评估分层阈值类别测量的子宫内膜厚度在无症状绝经后女性中进行后续子宫内膜取样和组织学评估时，对子宫内膜癌和非典型子宫内膜增生的风险。
MEDLINE、Scopus、ClinicalTrials.gov、SciELO、Embase、Cochrane 对照试验中心注册库、LILACS、会议论文集和国际对照试验注册库，无时间、地理或语言限制地进行了搜索。
如果研究采用交叉设计评估绝经后无症状妇女中不典型子宫内膜增生和子宫内膜癌的风险，并计算经阴道超声（至少 3.0mm）的诊断准确性，通过组织病理学诊断证实，这些研究被选中。
这是一项系统评价和诊断准确性试验荟萃分析，根据系统评价和荟萃分析诊断准确性试验和综合诊断准确性试验证据的报告项目和工具进行。将子宫内膜厚度阈值分为以下几类：3.0 至 5.9mm；6.0 至 9.9mm；10.0 至 13.9mm；和≥14.0mm。使用诊断准确性研究质量评估工具 2 工具进行质量评估。使用 Deek 漏斗图测试量化发表偏倚。主要结局是根据子宫内膜厚度和每个阈值组的诊断准确性，子宫内膜非典型增生或子宫内膜癌的风险。
18 项研究提供了 10334 名女性的数据，所有女性均纳入最终分析。总体而言，在至少 3.0mm 的子宫内膜厚度阈值下，与截点以下的女性相比，非典型子宫内膜增生或子宫内膜癌的风险增加了 3 倍（相对风险，3.77；95%置信区间，2.26-6.32；I=74%）。对于 3.0 至 5.9mm（相对风险，5.08；95%置信区间，2.26-11.41；I=0%）、6.0 至 9.9mm（相对风险，4.34；95%置信区间，1.68-11.23；I=0%）、10.0 至 13.9mm（相对风险，4.11；95%置信区间，1.55-10.87；I=86%）和≥14.0mm（相对风险，2.53；95%置信区间，1.04-6.16；I=78%）的阈值，风险程度相似，亚组间无显著差异（P=.885）。关于诊断准确性，从低于 5.9mm（相对风险，0.81；95%置信区间，0.49-0.85）的阈值到高于 14.0mm（相对风险，0.28；95%置信区间，0.18-0.40）的阈值，敏感性的汇总值降低。此外，特异性从 3.0 至 5.9mm 时的 0.70（95%置信区间，0.61-0.78）增加到≥14.0mm 时的 0.86（95%置信区间，0.71-0.94）。对于 3.0 至 5.9mm 和 10.0 至 13.9mm 的阈值，诊断优势比最高分别为 10（95%置信区间，3-41）和 11（95%置信区间，2-49），曲线下面积分别为 0.81（95%置信区间，0.77-0.84）和 0.82（95%置信区间，0.79-0.86）。汇总点分析显示，3.0 至 5.9mm 截止值在汇总接收者操作特征曲线空间中的位置高于其他亚组，表明使用这些截止值进行子宫内膜癌或非典型子宫内膜增生的诊断有增加。
绝经后无症状妇女的低和高子宫内膜厚度阈值似乎都能有效地检测子宫内膜癌和非典型子宫内膜增生。然而，尽管使用 3.0 至 5.9mm 的截止值会导致特异性降低，但敏感性的提高可能证明在疑似子宫内膜恶性肿瘤的患者中进一步进行子宫内膜评估时使用该截止值是合理的。
