Hysteroscopic morphology as a bridge between diagnosis and fertility preservation in endometrial cancer

To the Editor, Li and Duan present an insightful and practice-oriented review on the application of hysteroscopic morphology in the diagnosis and fertility-preserving management of endometrial cancer (EC). By synthesizing classic lesion architecture and vascular pattern recognition with modern adjuncts – including narrow-band imaging, 5-aminolevulinic acid photodynamic diagnosis, molecular classification, and artificial intelligence (AI) – the authors convincingly frame hysteroscopy as both a diagnostic tool and a component of individualized conservative therapy[1]. A key strength of the review is the systematic translation of hysteroscopic visual features into clinically actionable information. Distinct surface morphologies (nodular, polypoid, papillary, necrotic) and atypical vascular patterns (glomerular versus cerebroid) are discussed as real-time indicators of tumor differentiation and biological behavior. Such pattern-based assessment aligns with earlier quantitative evidence demonstrating high diagnostic accuracy of hysteroscopy for EC and atypical hyperplasia when correlated with histopathology[2]. For surgeons, this reinforces the value of targeted biopsy and structured hysteroscopic assessment over blind sampling, particularly in younger patients where diagnostic precision directly influences fertility-sparing eligibility. The authors also highlight growing evidence that combining hysteroscopic lesion resection with progestin-based therapy improves complete remission rates and shortens time to response, while subsequent use of assisted reproductive technology enhances pregnancy and live-birth outcomes[1]. These conclusions are consistent with recent high-quality systematic reviews showing meaningful reproductive success after conservative management in carefully selected early-stage EC patients[3]. Importantly, the review appropriately emphasizes stringent selection criteria – grade 1 endometrioid histology, stage IA disease without myometrial invasion, and commitment to close surveillance – echoing current international guidelines[4]. Several points merit further emphasis for safe clinical translation. First, integration of molecular classification into hysteroscopic decision-making is essential. Contemporary frameworks derived from The Cancer Genome Atlas demonstrate that p53-abnormal tumors carry poor prognosis and are generally unsuitable for fertility-sparing strategies, whereas POLE-mutated and p53-wild-type tumors may be more amenable to conservative approaches[5]. Second, although concerns regarding hysteroscopy-related peritoneal dissemination persist, cumulative evidence indicates no adverse impact on survival when the procedure is appropriately performed, supporting its continued use within standardized protocols[6]. Third, AI-assisted hysteroscopic interpretation is promising, but widespread adoption will require external validation, explainability, and transparent reporting to avoid algorithm-driven overtreatment or inappropriate fertility preservation. Overall, this review effectively integrates “clinical artistry” with emerging technology, offering a coherent framework for personalized, fertility-preserving care in EC. Future prospective studies combining hysteroscopic morphology, molecular risk stratification, and standardized conservative treatment protocols will be crucial to define long-term oncologic safety and reproductive benefit. This commentary was developed in line with the principles of the TITAN 2025 guideline, aiming to support transparent and responsible interpretation of technology-enhanced surgical evidence[7].