Narrow Band Imaging Diagnosis And The Clinical Effect Of The Treatment Of Endometrial Lesions

Objective: The study aim at evaluating the value of narrow band imaging(NBI) hysteroscopy in the diagnosis and treatment of endometrial lesions. Ordinary white light(WL) and NBI hysteroscopy were used respectively to observe endometrial lesions and compare concordance between visual identification and a pathological diagnosis of endometrial lesions, so as to estimate whether the use of NBI hysteroscopy was a powerful means of detecting tiny or atypical nidus and improved the accuracy of the sensitivity and negative predictive value in diagnosing endometrial lesions; Summarizing the blood vessels and mircostructures on different types of endometrial lesions with NBI hysteroscopy improve qualitative diagnosis and detection of high risk or low risk hyperplasia; Evaluating the reliability of lesions’ definition and scope estimate whether the use of NBI hysteroscopy could guide intraoperative resection in order to reduce the number of false negative and recurrence. Hysteroscopy findings with WL and NBI were compared with histologic, which was considered the gold standard.Methods: From March 2014 to February 2015, a total of 181 patients with suspected endometrial lesions were examined with hysteroscopy equipped with the white light in addition to NBI in Obstetrics and Gynecology Affiliated Hospital of Dalian Medical University. Observing comprehensively, taking a picture and biopsy when Hysteroscopy findings suspected positive lesions. Using the pathological diagnosis as the gold standard, we evaluated the two mode of accuracy, sensitivity, specific, negative predictive value and positive predictive value of NBI hysteroscopy in detecting high risk and low risk hyperplasia. Of the 4 cases of stage-Ⅰor suspected endometrial carcinoma who desired to conceive underwent resection of the lesions with NBI hysteroscopy and summarized the pregnant and recurrent rates.Results: 1. The clinical characteristics of patients with endometrial lesionsThe enrolled 88 patients with endometrial lesions had a mean age of 44.67±6.94 years and a course of 1-72 months whose endometrium was 4 mm- 33 mm.There are 42 patients cases in high-risk hyperplasia(18 cases of endometrial cancer, 24 cases of endometrial atypical hyperplasia), 46 cases of low-risk hyperplasia(34 cases of complex hyperplasia and 12 cases of simple hyperplasia); 20 cases of normal endometrium, 42 cases of endometrial polyps and 31 cases of other benign lesions(inflammation, sub mucous myoma). 2. Comparison of visualization of silhouette between ordinary white light and NBI hysteroscopyThe score of NBI and white light hysteroscopy in visualization were 3.50±0.620 and2.97±0.906, respectively. Visualization of silhouette of endometrial lesions and the micro-vessels by NBI hysteroscopy were clearer than the ordinary WL hysteroscopy(χ2=43.945,P=0.000). 3. Comparison of concordance with pathological diagnosis between ordinary white light and NBI hysteroscopyThe accuracy, sensitivity and specificity of NBI and WL hysteroscopy in predicting hyperplasia and cancer was 95.58%(173/181) and 83.98%(152/181)( χ2= 19. 239 P=0.000); 97.73%(86/88) and 81.82%(72/88)( χ2=12.129,P=0.000); 93.55%(87/93) and 86.02%(80/93)( χ2=2.767,P=0.096),respectively.NBI hysteroscopy showed significantly higher accuracy and sensitivity for the detection of endometrial lesions. 4. Classification of endometrial lesions’ micro-vessels with NBI hysteroscopyWe divided the overall micro-vessels of endometrial lesions into the following four types. Type Ⅰ: flat endometrial mucosa with no evident vascular network or new growth with vascular axis,such as normal proliferative endometrium, Polyp(71/93); TypeⅡ: dilatation of superficial vascular network and equable vessels with expanded, enlarged and irregular distribution, such as Low-risk hyperplasia, myoma and Atrophic polyp(29/46);TypeⅢ: expanded、tortuous and stenosed vessels with uneven venation with variable diameter, such as atypical hyperplasia(19/24);TypeⅣ: atypical vessels with interrupted, naked, papillary and coiling, such as Endometrial cancer(16/18). 5. Using micro-vascular type with NBI hysteroscopy diagnosing high-risk hyperplasia and low-risk hyperplasiaAccording to the micro-vascular characteristics of endometrial lesions in NBI mode can be divided into high-risk hyperplasia(type Ⅲ- Ⅳ) and low-risk hyperplasia(type Ⅱ). The accuracy, sensitivity and specificity,kappa index of micro-vascular characteristics(type Ⅲ- Ⅳ) in NBI mode and W L hysteroscopy in predicting hyperplasia and cancer were 88.95% and 79.56%( χ2=6.018.P=0.014); 95.24% and 57.14%( χ2=16.800, P=0.000); 87.05% and 86.33%(χ2=0.031.P=0.860)(80/93)( χ2=2.767,P=0.096);0.726 and 0.431, respectively. Micro-vascular characteristics in NBI hysteroscopy showed significantly higher accuracy and sensitivity for the detection of endometrial lesions. There was no significantly difference in diagnosing endometrial polyps and submucous myoma between the two methods. 6. Resection of the lesions with NBI hysteroscopy and follow-upOf the 4 cases of stage-Ⅰ or suspected endometrial carcinoma who desired to conceive underwent resection of the lesions with NBI hysteroscopy, combined Levonorgestrel-releasing intrauterine system. following up for 3- 6 months, 2 cases turns out normal endometrium,1 case turns out low-risk hyperplasia(complex endometrial hyperplasia), 1 case turns out atypical hyperplasia and overall patients without recurrence.Conclusions:1. Visualization of silhouette of endometrial lesions and the micro-vessels by NBI hysteroscopy were clearer than the ordinary WL hysteroscopy;2. NBI hysteroscopy can increase the detection rate of endometrial endometrial lesions significantly.NBI hysteroscopy can increase the detection of cancer and atypical endometrial hyperplasia;3.Different types of endometrial lesions with different micro-vascular characteristics: type Ⅲ- Ⅳ helps to identify high-risk hyperplasia(the atypical hyperplasia display typeⅢand endometrial cancer display type Ⅳ), type Ⅱ helps to identify low-risk hyperplasia, type Ⅰhelps to identify the normal endometrium and endometrial polyps;4. Micro-vascular characteristics with. NBI hysteroscopy can recognise the tiny and atypical lesions so that guide intra-operative biopsy and lesion resection accurately. Micro-vascular characteristics in NBI hysteroscopy showed significantly higher accuracy and sensitivity for the detection of endometrial lesions. There was no significantly difference in diagnosing endometrial polyps and submucous myoma between the two methods;5. NBI may improve clinical outcomes of stage-Ⅰ endometrial carcinoma. However, it’s not sure to the function of using LNG-IUD after surgery to pregnancy and recurrence.