Hysteroscopy vs. Vabra in Endometrial Cancer Diagnosis: A Systematic Review of the Literature.

Endometrial cancer is the most common malignancy of the female genital tract in high-income countries. A prompt diagnosis of this condition is of utmost importance in ensuring that patients receive the best treatment strategy. The new FIGO 2023 molecular classification of endometrial cancer radically changes the current landscape of this disease's treatment and follow-up. Among the various diagnostic techniques used to identify endometrial lesions, hysteroscopy and vacuum biopsy techniques are the most employed in clinical practice. The aim of this systematic literature review is to compare the efficacy, sensitivity, specificity, and safety of these methods when employed to diagnose endometrial cancer, as well as to assess the feasibility of endometrial cancer molecular profiling on biopsy specimens. A systematic literature search of studies evaluating hysteroscopy and VABRA biopsy performance in diagnosing endometrial cancer was conducted using the main online databases (PubMed, EMBase, Cochrane Library). An additional literature search was conducted, focusing on the feasibility of endometrial cancer molecular profiling on hysteroscopic biopsy and VABRA samples, as well as on the diagnostic concordance of biopsy and final surgery specimens. Two authors performed the literature search independently, while other two authors assessed the retrieved publications' risk of bias using Begg's and Egger's tests. Twenty-four studies were included in the final report. Both techniques have shown high effectiveness in diagnosing endometrial cancer, although with important differences. Hysteroscopy provides direct visualization of the endometrium and allows clinicians to perform biopsies of suspicious lesions, but it also entails important limitations, as in the case of diffused lesions or technical difficulties, especially in nulliparous and elderly women. VABRA and other vacuum biopsy techniques, on the other hand, offer a wider sampling of endometrial tissue and are less operator-dependent but may be associated with a higher risk of failed diagnosis when compared to hysteroscopy. Hysteroscopy, especially when combined with targeted biopsies, has been proven to be a valid technique, especially in pre-surgical diagnostic workup of early-stage endometrial cancer. Vacuum techniques, although less invasive and providing larger tissue samples, do not seem to be able to completely replace hysteroscopy in diagnosing endometrial cancer but remain a valid alternative in selected cases, especially when endometrial lesions prove harder to reach and/or to identify. They may also prove useful in low resource countries in which hysteroscopy is not widely available. Based on our findings, early assessment of endometrial cancer should be carried out through hysteroscopic evaluation and targeted endometrial biopsies, ideally including molecular assessment on biopsy specimens to further guide treatment decisions. Other biopsy techniques, such as vacuum-assisted biopsy, should be reserved for specific settings in which hysteroscopy is not readily available. The ideal diagnostic approach to endometrial cancer should take multiple factors into account, such as the location and extension of the disease, patient characteristics, clinical skills, and resource availability. Further studies are needed to assess the feasibility of molecular cancer profiling on biopsy specimens, as well as cost-containment strategies which would allow equal access to targeted treatment modalities for all endometrial cancer patients worldwide.