What is the role of Total Corpus Endometrial Resection (TCER) in a patient with recurrent endometrial hyperplasia?

Total Corpus Endometrial Resection (TCER) in Recurrent Endometrial Hyperplasia

For patients with recurrent endometrial hyperplasia after failed progestin therapy, hysterectomy with bilateral salpingo-oophorectomy is the definitive treatment—not TCER or other endometrial ablation procedures. 1

Why TCER is Not Recommended

TCER and similar endometrial ablation techniques are not appropriate for recurrent endometrial hyperplasia because:

• Hidden malignancy risk: Approximately 10% of endometrial biopsies have false-negative results, and recurrent hyperplasia may actually represent undiagnosed endometrial cancer 1
• Incomplete tissue removal: Ablative procedures cannot guarantee complete removal of all hyperplastic tissue, leaving residual disease that can progress to cancer
• Loss of surveillance capability: After ablation, the endometrium cannot be adequately sampled for future monitoring, masking potential progression to malignancy
• No definitive cure: Unlike hysterectomy, TCER does not eliminate recurrence risk 1

Evidence-Based Management Algorithm

Step 1: Re-evaluate the Diagnosis

Before any intervention, send tissue samples to a specialized gynecologic pathologist to rule out hidden cancer or atypia that may have been missed initially, and perform immunohistochemical testing (PTEN and PAX-2) to distinguish between benign hyperplasia and other conditions 1

Obtain pelvic MRI to exclude myometrial invasion or extrauterine spread that would indicate occult malignancy 1

Step 2: Treatment Based on Patient Characteristics

For patients who have completed childbearing or are not fertility candidates:

• Hysterectomy with bilateral salpingo-oophorectomy is the definitive treatment, providing complete cure with elimination of recurrence risk 1, 2, 3
• This is particularly critical for hyperplasia with atypia, which carries the highest risk of progression to endometrial carcinoma 3

For patients desiring fertility preservation (hyperplasia without atypia only):

• Attempt alternative progestin regimens: megestrol acetate 160-320 mg/day or medroxyprogesterone acetate 400-600 mg/day 1
• Mandatory endometrial biopsy or dilation and curettage every 3-6 months during treatment 1
• Proceed to hysterectomy if hyperplasia persists after 6 months of alternative progestin therapy 1
• After completion of childbearing, strongly advise hysterectomy with bilateral salpingo-oophorectomy, as recurrence rates after successful progestin therapy reach 35% 1, 4

Step 3: Post-Treatment Surveillance

For patients who undergo fertility-sparing treatment with successful response:

• Recurrent disease occurs in approximately 35% of cases after a median time interval of 6-55 months 4
• Progestin re-treatment can be effective in most patients with recurrent disease 4
• Long-term surveillance is burdensome and carries risk of missed progression 1

Critical Contraindications to Progestin Therapy

Progestins must be avoided or used with extreme caution in patients with:

• Active or history of breast cancer 1
• Recent stroke or myocardial infarction 1
• Active pulmonary embolism or deep vein thrombosis 1
• Active smoking, particularly in women over 35 years 1

Common Pitfalls to Avoid

Do not perform TCER or endometrial ablation as these procedures:

• Cannot adequately assess for concurrent malignancy
• Prevent future endometrial sampling for surveillance
• Do not provide definitive treatment
• Are not supported by any major gynecologic society guidelines

Do not delay hysterectomy in patients with:

• Atypical hyperplasia (highest malignancy risk) 3
• Recurrent hyperplasia after 6 months of progestin therapy 1
• Completed childbearing after fertility-sparing treatment 1

Do not underestimate the risk of concurrent cancer: Women with endometrial hyperplasia, especially with atypia, are at increased risk for both concurrent and subsequent endometrial cancer 5, 3