Background Endometrial cancer shows a trend of rejuvenation. More and more women of reproductive age in initial treatment are requesting fertility preservation. Meanwhile, with advances in molecular biology, molecular diagnosis is gradually taking a front seat in the management of early endometrial cancer.

Objective To analyze the consistency of histopathology and molecular expression between hysteroscopy-assisted segmental diagnostic scraping biopsy and surgical histopathology performed in patients with early-stage endometrial cancer, and provide references for early minimally invasive treatment.

Methods Clinical data about patients with early endometrial cancer admitted to the Department of Gynecology of the First Medical Center of Chinese PLA General Hospital from June 2020 to June 2023 were retrospectively analyzed. The consistency of main pathological features was compared between hysteroscopy-assisted segmental diagnostic scraping group and segmental diagnostic curettage alone group.

Results A total of 292 patients with a median age of 55 years (range 32-76 years) were included. There were 157 cases of hysteroscopy-assisted segmental curettage and 135 cases of segmental curettage alone. There were no statistically significant differences in age, BMI, comorbidities, menopausal status, number of deliveries, complaints at the clinic, FIGO staging, and TCGA molecular typing between the two groups; the compliance rate of pathological diagnosis in the hysteroscopy-assisted diagnostic group was significantly higher than that of the segmental curettage group alone (75.16% vs 57.04%, P=0.001). In the hysteroscopy-assisted diagnosis group, dMMR and p53abn were detected in a higher percentage of MSI-H and CNH subtypes (92.36%, 92.99%) than in the segmental curettage group (82.96%, 84.44%), and the differences were significant (P=0.014, P=0.020). The percentage of consistent Ki-67 results before and after tumor staging surgery in patients with hysteroscopy-assisted segmental diagnostic scraping was significantly higher than that of segmental diagnostic scraping alone (24.20% vs 13.33%, P=0.019); the results of cytological testing of 128 cases of hysteroscopy-assisted segmental diagnostic scraping group with abdominal rinses taken during the tumor staging surgery showed that no tumor cells were found to have disseminated into the abdominal cavity. In addition, none of the 292 patients had complications such as uterine perforation, bleeding and infection. Five patients had an objective remission rate of 100% (four CR and one PR) after hysteroscopic resection of the lesions combined with an oral high-potency progesterone treatment regimen, with a median time to complete remission of 3.7 months (3-5.7 months), and 3 of the 5 cases had live births.

Conclusion Hysteroscopy assisted curettage technology can provide more reliable molecular characteristics of tumor, which is helpful to promote the individualized diagnosis and treatment of endometrial cancer.