**Clinical, Sonographic, and Hysteroscopic Features of Endometrial Carcinoma Diagnosed after Hysterectomy in Patients with a Preoperative Diagnosis of Atypical Hyperplasia: A Single-Center Retrospective Study**

**Luca Pace <sup>1</sup> , Silvia Actis 1,\* , Matteo Mancarella <sup>1</sup> , Lorenzo Novara <sup>2</sup> , Luca Mariani <sup>1</sup> , Gaetano Perrini <sup>2</sup> , Francesca Govone <sup>1</sup> , Alessandra Testi <sup>1</sup> , Paola Campisi <sup>3</sup> , Annamaria Ferrero <sup>1</sup> and Nicoletta Biglia <sup>1</sup>**


**Citation:** Pace, L.; Actis, S.; Mancarella, M.; Novara, L.; Mariani, L.; Perrini, G.; Govone, F.; Testi, A.; Campisi, P.; Ferrero, A.; et al. Clinical, Sonographic, and Hysteroscopic Features of Endometrial Carcinoma Diagnosed after Hysterectomy in Patients with a Preoperative Diagnosis of Atypical Hyperplasia: A Single-Center Retrospective Study. *Diagnostics* **2022**, *12*, 3029. https:// doi.org/10.3390/diagnostics12123029

Academic Editors: Fabio Bottari and Anna Daniela Iacobone

Received: 31 October 2022 Accepted: 30 November 2022 Published: 2 December 2022

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**Abstract:** Background: atypical endometrial hyperplasia (AEH) is a precancerous condition implying a high risk of concurrent endometrial cancer (EC), which might be occult and only diagnosed at postoperative histopathological examination after hysterectomy. Our study aimed to investigate potential differences in preoperative clinical, sonographic, and hysteroscopic characteristics in patients with AEH and postoperative diagnosis of EC. Methods: a retrospective single-center study was carried out on a case series of 80 women with AEH undergoing diagnostic workup, including ultrasonography and hysteroscopy, with subsequent hysterectomy. Women with AEH confirmed at the histopathological examination were compared with patients with a postoperative diagnosis of EC. Results: in our population, EC was diagnosed in 53 women, whereas the preoperative diagnosis of AEH was confirmed in 27 cases. At ultrasonography, women with occult EC showed greater endometrial thickness (20.3 mm vs. 10.3 mm, *p* 0.001) and size of the endocavitary lesion (maximum diameter 25.2 mm vs. 10.6 mm, *p* 0.001), and a higher prevalence of irregular endometrial-myometrial junction (40.5% vs. 6.7%, *p* 0.022) and endouterine vascularization at color Doppler (64.2% vs. 34.6%, *p* 0.017). At hysteroscopy, patients with occult EC showed a higher prevalence of necrosis (44.2% vs. 4.2%, *p* 0.001) and atypical vessels (70.6% vs. 33.3%, *p* 0.003), whereas true AEH mainly presented as a protruding intracavitary lesion (77.8% vs. 50.9%, *p* 0.029). In EC, subjective assessment by the operator was more frequently indicative of cancer (80.0% vs. 12.5%). No difference was found for clinical variables. Conclusions: occult EC in AEH may exhibit some differences in ultrasonographic and hysteroscopic patterns of presentation compared with real AEH, which could prompt a more significant suspect for the possible presence of concurrent EC at preoperative diagnostic workup.

**Keywords:** atypical endometrial hyperplasia; endometrial cancer; hysteroscopy; transvaginal ultrasound
