We would like to thank our colleagues and the Munich Tumor Center for their comments.
It is in the nature
of things that statements such as those published in our update of the recommendations
for the diagnosis
and treatment of endometrial cancer are usually presented in an abridged form which
cannot reflect all
the nuances and the analysis. The basis for the carefully compiled statements will
be explained in
detail in the background texts of the upcoming S3 guideline for which funding has
just been
approved.
Ad 1.)
As Kolben et al. correctly stated, endometrial cancer is found in at least 10 % of
cases with
post-menopausal bleeding. Endometrial hyperplasia is diagnosed in a further 10 %,
which – if it is
atypical endometrial hyperplasia – constitutes a relevant precancerous lesion and
is also an important
indication of pathological estrogen production (steroid hormone-producing tumor).
A cancer probability
of 10 % is sufficient to justify histological investigation. In breast examinations,
histological
investigations are already carried out if the cancer probability is 2 %. The Uterus
Commission is
familiar with the publications cited by Kolben et al. However, we consider the paper
by Jacobs et al.
(2011) [1] to be more relevant. Jacobs et al. reported that 20 % of
endometrial cancers were not detected in ultrasound investigations of endometrial
thickness (cut-off
< 5 mm; n = 30 664); however, 58 women required histological investigation to detect
one case of
endometrial cancer or atypical endometrial hyperplasia. The sensitivity and specificity
of the method
“bleeding in the post-menopausal period” is thus much higher. We therefore intend
to stick with our
recommendation. We agree with Kolben et al. that Pipelle biopsy is a suitable procedure
for histological
investigation. Pipelle biopsy is the standard method used in many countries and is
usually carried out
on an outpatient basis in doctorsʼ practices without complications and without the
need for anesthetics.
This will be a very important issue for the S3 guideline, and it can be conjectured
that the
fractionated curettage method still very much favored in Germany will become less
important.
Ad 2.)
The Uterus Commission wrestled for a long time as it attempted to find a better wording.
“Atypical
bleeding in perimenopausal women” is definitively too vague. We can definitely envisage
using another
wording, such as the one proposed by Kolben et al., and explaining it in greater detail
in the
accompanying background text compiled as part of the work on the S3 guideline. As
we cannot provide such
a differentiated approach in these short recommendations (What does “therapy resistant”
mean?, What does
“persistent” mean?), we would like to stick with the current wording. Here again,
Pipelle biopsy carried
out in doctorsʼ offices is usually quite sufficient for sampling.
We would like to thank our colleagues Kolben, Dannecker and Kürzl for their considered
comment and for
the opportunity this provided to offer a more differentiated consideration of these
issues.
