**5. Conclusions**

The importance of a detailed preoperative diagnosis of AEH and the difficulty in defining AEH on hysteroscopic biopsy dictate careful evaluation of features associated with the finding of AEH. Occult EC cases diagnosed after hysterectomy for AEH may have some differences at preoperative diagnostic workup compared with confirmed AEH cases. In our study, the endometrial thickness and other ultrasonographic features, such as thickened endometrial stripe, a greater diameter of the lesion, an interrupted endometrial–myometrial junction, and a high vascular density at CD, along with the subjective hysteroscopic assessment by experienced clinicians are elements that can suggest the presence of occult EC in patients with a preoperative histologic diagnosis of AEH.

The results of our study should be prospectively verified on larger and prospective case series. A multicenter prospective study should be conducted based on the prospective use of an inclusive score of standardized clinical, hysteroscopic, and ultrasound features in the preoperative diagnostic pathway. This is also to select a population of patients with a pre-operative misdiagnosis of AEH who might benefit from lymph node assessment to guide adjuvant treatment.

Patients with a pre-operative misdiagnosis of AEH show post-operative histology of EC at a more advanced stage or mid- to high grade. This latter population might benefit from lymph node assessment to guide adjuvant treatment.

**Author Contributions:** Conceptualization, L.N. and L.P.; methodology, M.M. and L.N.; validation, L.M., G.P. and A.F.; formal analysis, M.M.; investigation, L.P., S.A., F.G. and A.T.; resources, P.C., A.F. and N.B.; data curation, L.P., S.A. and M.M.; writing—original draft preparation, M.M., L.N., L.P. and S.A.; writing—review and editing, L.P. and S.A.; supervision, A.F. and N.B. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted per the 1964 Declaration of Helsinki. Since this was a retrospective study with no experimental research on participants, being all the procedures performed as part of the routine care according to international recommendations, exemption from formal approval was granted by the Ethics Committee of our institution when inquired.

**Informed Consent Statement:** Written informed consent was obtained from all individual participants included in the study. All patients gave their consent to the anonymous use and publication of clinical, instrumental, and photographic data for scientific purposes.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author.

**Conflicts of Interest:** The authors declare no conflict of interest.
