Uterus, Endometrium: Diagnosis

Uterus, Endometrium: Diagnosis
The depth of invasion of endometrial carcinoma image into the myometrium is an important predictor of the likelihood of metastasis. The deepest extent of invasion image is confirmed by frozen section.
This extensive endometrial carcinoma fills the uterine cavity image and extends into the cervix image. Frozen section evaluation of the cervix to confirm involvement is important for staging.
SURGICAL/CLINICAL CONSIDERATIONS
Goal of Consultation
  • Determine if carcinoma is present with features indicating need for further staging
Change in Patient Management
  • Surgeon may perform pelvic &/or paraaortic lymph node dissections if endometrial carcinoma with the following features is present
    • Grade II or III
    • Invasion beyond 50% of myometrial thickness
    • Cervical involvement
Clinical Setting
  • Diagnosis of carcinoma or endometrial intraepithelial neoplasia (EIN) will usually have been made with a prior biopsy
  • Occasionally, atypical findings during surgery at time of routine hysterectomy may prompt intraoperative consultation
SPECIMEN EVALUATION
Gross
  • Orient uterus according to anterior and posterior aspects
  • Outer surface of uterus is inspected for areas suspicious for direct tumor invasion or serosal implants
    • Any suspicious areas should be differentially inked
  • Open uterus along lateral edges using scissors
  • Inspect (but do not touch) endometrial lining for gross evidence of carcinoma
    • Pale yellow-tan heaped-up and firm areas
  • Make serial transverse incisions at 5 mm intervals from mucosal surface to, but not through, serosa
    • Specimen should be kept intact to maintain orientation
  • Myometrial invasion grossly appears as effacement of normal myometrial texture
    • Carcinoma often presents as tan-yellow- white homogeneous mass replacing normal myometrium
    • Depth of invasion can sometimes be determined grossly
  • Surfaces of ovaries and fallopian tubes are carefully inspected
    • Ovaries are serially sectioned and inspected for any mass lesions
Frozen Section
  • Section of the area of suspected deepest invasion is frozen
  • Areas of suspected cervical, fallopian tube, or ovarian involvement may be evaluated by frozen section as well
MOST COMMON DIAGNOSES
Endometrial Carcinoma
  • ˜ 50% of cases
  • Endometrial lining may appear heaped-up
    • Carcinomas are typically pale yellow to tan and friable
  • Histologic types
    • Endometrioid: Most common type, composed of glands lined by columnar epithelium
    • Clear cell: High-grade carcinoma with variable cytoplasmic clearing, tubulocystic glands with hobnailed cells, and stromal hyalinization
    • Serous: High-grade carcinoma composed of slit-like glandular spaces lined by highly atypical cells with prominent nucleoli
    • Carcinosarcoma: Any of the above carcinomas with a malignant mesenchymal (stromal) component
  • Grade
    • Grade II or III is an indication for staging biopsies
  • Depth of invasion
    • Uterine wall is serially sectioned to identify greatest depth of invasion that can be seen grossly
    • Myometrial invasion is detected by effacement of normal myometrial texture
Endometrial Stromal Sarcoma
  • Usually diffusely infiltrative
  • Lymphovascular invasion can be seen as worm-like masses in myometrium
  • Irregular nests or tongues of malignant stromal cells or solid growth pattern
Endometrial Polyp
  • ˜ 10-15% of cases
  • Usually, broad-based finger-like projection from endometrial wall
  • Central portion consists of fibrous stroma, and surface is covered by endometrium
Adenomyosis
  • ˜ 10% of cases
  • Normal endometrium is deeply embedded within myometrium
    • Can mimic invasion when involved by carcinoma
  • Consists of thick, trabeculated muscle fibers with small, pinpoint hemorrhages
Endometrial Intraepithelial Neoplasia (EIN)
  • Generally not grossly evident
  • Closely packed glands with intervening stroma
REPORTING
Frozen Section
  • In cases of EIN or atypical hyperplasia, frozen section diagnosis of “at least EIN in 1 examined section” is appropriate with a note deferring further classification to more extensive sampling of endometrium
  • If carcinoma is present, the following features are reported
    • Type (endometrioid, clear cell, serous, or carcinosarcoma)
    • Grade
    • Depth of invasion
    • Cervical involvement
    • Serosal, ovarian, or fallopian tube involvement
  • Attempted diagnosis of type of carcinoma and depth of invasion should be made for each case
  • If cervix and adnexa are grossly negative, this should be reported
Reliability for Carcinoma
  • Grade is accurate in 67-96% of cases
  • Depth of invasion is accurate in 85-95% of cases
  • Cervical involvement is accurate in 65-96% of cases
  • False-positive diagnoses
    • In ˜ 9% of cases, > 50% myometrial invasion is reported but not confirmed on permanent sections
  • False-negative results
    • In ˜ 10% of cases, myometrial invasion is not reported but is found on permanent sections
PITFALLS
Carcinomatous Involvement of Adenomyosis
  • Depth of invasion can be difficult to determine when adenomyosis is present
Lymphovascular Invasion vs. Myometrial Invasion
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Jul 7, 2016 | Posted by in PATHOLOGY & LABORATORY MEDICINE | Comments Off on Uterus, Endometrium: Diagnosis

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