Endometrial Ablation: Malignancy Following Ablation,

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Endometrial Ablation: Malignancy Following Ablation,Myth or Reality?

A.H. DeCherney

Department of Obstetrics and Gynecology

UCLA School of Medicine, Los Angeles, CA, USA

Originally, when ablation of the endometrium was initiated as a technique, approximately 15 years ago, there was no real concern over the relationship between this procedure and eventual endometrial carcinoma. Since that time a number of concerns have been voiced. These include:

a)does the carbonized material left in the uterus serve as a nidus for the formation of carcinoma,

b)will endometrial ablation mask the ability of the patient to present, if she develops carcinoma subsequently,

c)can pre-malignant lesions, such as complex endometrial hyperplasia with atypia, be treated with endometrial ablation. All three of these areas are controversial in the formation and context of the concept as well as the execution.

Most concerns involving the remaining carbonized material causing a nidus for carcinoma, have been pretty much set to rest. There is no evidence that the ablation procedure in any way initiates a carcinomatas event.

On the other hand, there is a fair amount of concern that if a patient undergoes an endometrial ablation over the years, if she develops an endometrial carcinoma, since early detection is based primarily on bleeding, this will be diagnosed too late and the patient will be converted from a Stage I carcinoma of the endometrium to a Stage III or Stage IV at the time of diagnosis. This is a real concern. All of the endometrium is not ablated at the time of the procedure. There are remaining nests of endometruim and these can provide a sight of origin for endometrial carcinoma in the future. Since frequently the lower uterine segment is ablated, there is no chance for blood to regress and therefore the patient has lost her ability to present early in the development of her endometrial cancer.

This requires a number of initiatives, the first being sounding of the uterus at the time of the first visit to make sure that there is some canal present so bleeding can be detected. If patients post ablation goes onto estrogen replacement therapy they should be placed on estrogen and progesterone, and these patients require careful monitoring post menopause with ultrasound in order to assess endometrial thickening.

On the other hand one would think that the chances for carcinoma are diminished since these patients have decreased amounts of endometrial tissue to undergo malignant transformation. Certainly as newer estrogens (SERMs) come onto the market place that do not stimulate the endometrium, these will be the most desirable treatment in these individual cases.

The most controversial area surrounds the use of the endometrial ablation in patients that have both simple and complex hyperplasia. Although there is some evidence that some of these patients go on to progress t0 carcinoma of the endometrium after ablation, consensus is that since we know from hysterectomy specimens there are areas left after the most thorough ablations and since these are pre-malignant lesions, in a certain percentage of cases, these patients should not be treated in this fashion. Especially in light of the fact that monitoring is at best poor in any patient that undergoes an endometrial ablation as far as endometrial carcinoma is concerned.

So, malignancy does not cause ablation. It could mask the symptoms of the developing endometrial carcinoma, but should not be considered a treatment for even the most low grade of malignancies or for that matter, pre-malignant conditions as well.

References

1. Brooks PG, Serden SP: Hysteroscopic findings after unsuccessful D&C for abnormal uterine bleeding. Am J Obstet Gynecol 158:1354-1358, 1998.

2. Cooper KG, Parkin DE, Garratt AM, Grant AM. Two-Year Follow Up of Women Randomised to Medical Management or Transcervical Resection of the Endometrium for Heavy Menstrual Loss: Clinical and Quality of Life Outcomes. Br J Obstet Gynecol 1990;106:258-265.

3. Magos AM, Baurmann R, Lochwood GM, Tunrbull AC. Experience with the first 250 endometrial resections for menorrhagia. Lancet 1991;337:1074-80.

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