title: Clinically significant endometrial cancer risk following a diagnosis of complex atypical hyperplasia.
abstract: OBJECTIVE
  Because of the frequent detection of carcinoma in surgical specimens after hysterectomy for endometrial complex atypical hyperplasia (CAH), it has been suggested that patients with a preoperative diagnosis of CAH be referred to gynecologic oncology for potential lymphadenectomy. However, the risk of lymph node metastasis in such patients is unknown. We sought to determine the risk of endometrial cancer and to estimate the risk of lymphatic spread in women with a preoperative diagnosis of CAH.
  
  
  METHODS
  We retrospectively reviewed the medical records of 150 consecutive patients with a preoperative diagnosis of CAH who subsequently underwent hysterectomy. Clinical characteristics and pathologic information were abstracted. Risk of lymphatic spread was modeled using previously published criteria and nomograms.
  
  
  RESULTS
  Fifty-five of the 150 patients (36.7%) had an incidental endometrial carcinoma at the time of hysterectomy. Among patients with a preoperative office biopsy compared to dilation and curettage, the rate of an incidental finding of cancer was 43.5% and 28.1%, respectively (p=0.054). Of patients with cancer, 1 (1.8%) had a grade 3 endometrial carcinoma, 4 (7.3%) had lymphovascular space involvement, and 6 (10.9%) had deep (>50%) myometrial invasion. For the 10 patients who underwent lymphadenectomy, one (10%) had lymph node metastases. Based on multiple models, the estimated risk of lymph node spread was 1.6%-2.1% for all women with a preoperative diagnosis of CAH and 4.4%-6.8% for the 55 women with endometrial cancer.
  
  
  CONCLUSIONS
  Given the high rates of underlying endometrial cancer and the potential need for lymphadenectomy, care for patients with a preoperative diagnosis of CAH desiring definitive management with hysterectomy should be referred to a gynecologic oncologist.
authors.affiliation: Department of Obstetrics and Gynecology, The University of Texas Medical School at Houston, Houston, Texas.
authors.forename: Anthony B
authors.initials: AB
authors.lastname: Costales
authors.affiliation: Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Schmeler
authors.affiliation: Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Russell
authors.initials: R
authors.lastname: Broaddus
authors.affiliation: Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Pamela T
authors.initials: PT
authors.lastname: Soliman
authors.affiliation: Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Shannon N
authors.initials: SN
authors.lastname: Westin
authors.affiliation: Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Pedro T
authors.initials: PT
authors.lastname: Ramirez
authors.affiliation: Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address: mfrumovitz@mdanderson.org.
authors.forename: Michael
authors.initials: M
authors.lastname: Frumovitz
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004714:Endometrial Hyperplasia / Q000150:complications* / Q000473:pathology; D016889:Endometrial Neoplasms / Q000209:etiology* / Q000473:pathology; D005260:Female; D006801:Humans; D007044:Hysterectomy; D008875:Middle Aged; D009367:Neoplasm Staging; D012189:Retrospective Studies; D012306:Risk
keywords: Endometrial cancer; Endometrial hyperplasia; Lymph nodes; Lymphadenectomy; Surgical staging