2014 april lund lecture 3 endometrial biopsy › ... › 3.endometrial_biopsy.pdf · 4/2/14 6...
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APPROACH TO THE CORPUS BIOPSY Premalignant and Malignant Lesions
EIN and Hyperplasia
Joseph Carlson, MD, PhD
Karolinska Universitetslaboratoriet Klinisk patologi/cytologi
Good References 1. McCluggage WG. My approach to the interpretaOon of
endometrial biopsies and curePngs. J Clin Pathol. 2006 Aug;59(8):801-‐12. Review. PubMed PMID: 16873562; PubMed Central PMCID: PMC1860448.
2. Online web seminars at www.endometrium.org
3. Mazur and Kurman. Diagnosis of Endometrial Biopsies and CurePngs: A PracOcal Approach. Springer. 2004.
4. Malpica, Deavers, Euscher. Biopsy InterpretaOon of the Cervix and Corpus. Lippincoc Williams & Wilkins. 2009.
Clinical History
• Age • IndicaOon • Premenopausal: LMP, cycle length • Hormone status (HRT, p-‐piller)
Adequacy
• Inadequate: Only if no endometrial Ossue is present at all.
• Atrophy: Postmenopausal women, no finding on ultrasound, minimal Ossue is normal.
• Too licle to assess: Minimal Ossue where one would expect more (premenopausal, thickened endometrium on ultrasound, polyp or other hysteroscopic finding)
McCluggage WG. My approach to the interpretaOon of endometrial biopsies and curePngs. J Clin Pathol. 2006 Aug;59(8):801-‐12. Review. PubMed PMID: 16873562; PubMed Central PMCID: PMC1860448.
Artefacts
Can mimic papillary growth, complex architecture, atypia.
Look at benign biopsies and learn from them. As a resident, you study cancer and try to classify it.
As an acending, you study all the surrounding normal Ossues, and learn about artefacts and normal variaOon.
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Pseudopapillary artefact Artefact
Artefact Telescoping artefact
Artefact – Mimics “Oght glands”, loss of stroma
Meningioma mixed with EMBx. Neuro specimens and biopsies cut in on the same bench. This was contaminaOon.
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Non-‐endometrial Ossues
Cervix: Evaluated and described Fat: Can indicate uterine perforaOon. Should be described and signed out acutely (possible contact with clinician).
Lower uterine segment: Can resemble polyp Other: myometrium
Fat on EMBx. Can indicate perforaOon and clinician should be called.
Metaplasia
Squamous – usual and morular Mucinous Eosinophilic Tubal (ciliated cell) Papillary syncyOal
Squamous metaplasia
Should not be counted as “solid growth” Can mimic “clear cells” due to glycogen Can be due to reacOve cause (endometriOs), premalignant or malignant.
Morules can have central necrosis Morules on biopsy need follow up to exclude a malignant process.
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Mucinous metaplasia
Typically resembles endocervix Minimal atypia Classified by architecture: Simple epithelium – low risk of cancer Cribriform, papillary architecture – higher risk of cancer.
Mimics: Cervical microglandular hyperplasia
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Features typically found in endometrial mucinous metaplasia.
Cervical Microglandular Hyperplasia
Endometrial Mucinous Metaplsia
Prominent subnuclear vacuoles
PRESENT ABSENT
Luminal squamous metaplasia
ABSENT PRESENT
Stromal foam cells ABSENT PRESENT MitoOc index LOW HIGH (>3 per 10 HPF) VimenOn staining ABSENT PRESENT Reserve-‐like cells in surrounding epithelium
PRESENT ABSENT
Qiu W, Mical K: Comparison of morphologic and immunohistochemical features of cervical microglandular hyperplasia with low-‐grade mucinous adenocarcinoma of the endometrium. Int J Gynecol Pathol 2003; 22:261-‐265.
Eosinophilic metaplasia
Cuboidal cells with pink cytoplasm Architecture determines risk.
Tubal metaplasia
Associated with elevated estrogen. Common in the lower uterine segment. Low cancer risk if architecture is simple.
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Papillary syncyOal metaplasia
Menopausal women on hormone replacement therapy.
Onen associated with REPAIR. Onen overlying STROMAL BREAKDOWN. IndisOnct cell borders (syncyOum), eosinophilic cytoplasm, loss of nuclear polarity.
MUST EXCLUDE CARCINOMA
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Hyperplasia
Exclude benign mimics
1994 WHO
Terminology to avoid in the endometrium: Dysplasia CysOc hyperplasia Adenomatous hyperplasia Adenocarcinoma in situ
Hyperplasia
CombinaOon of architecture (complex, simple) and atypia (present, absent)
No atypia Atypia Simple Hormones
(1-‐2% cancer risk) RARE
Complex RARE Hysterectomy (25-‐40% cancer risk)
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“Simple with atypia” AND “Complex without atypia” are very rare! Hyperplasia -‐ Architecture
Simple: Gland to stroma raOo is maintained.
Complex: Increased gland to stromal raOo.
Simple Hyperplasia without Atypia
EssenOally an estrogen effect. No real difference from “anovulaOon” as described in lecture 1.
Regular irregular gland pacern, dilated glands. Typically diffuse – all the glands are affected by the estrogen.
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Complex Hyperplasia
Increased gland to stromal raOo. You do not need more than that!
SIMPLE ARCHITECTURE (VOLUME PERCENT STROMA HIGH)
COMPLEX ARCHITECTURE (VOLUME PERCENT STROMA LOW)
www.endometrium.org
Atypia
No atypia: Gland to stroma raOo is maintained.
Atypia: “One of the most subjecOve and problemaOc areas of gyn pathology”.
Hyperplasia -‐ Atypia
Comparison of suspected glands with background normal
Nuclear features: StraOficaOon, loss of polarity, rounding and nucleoli
Cytoplasmic: Abundant, eosinophilic, cytoplasm
Complex Atypical Hyperplasia
Typically a focal process (i.e. there are preserved normal glands in the background).
This is a reflecOon of the fact that it’s a neoplasm.
www.endometrium.org – EIN Diagnosis Library Complex Atypical Hyperplasia
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www.endometrium.org – EIN Diagnosis Library Complex Atypical Hyperplasia
www.endometrium.org – EIN Diagnosis Library Complex Atypical Hyperplasia
www.endometrium.org – EIN Diagnosis Library Complex Atypical Hyperplasia
www.endometrium.org – EIN Diagnosis Library Complex Atypical Hyperplasia
DisOncOon Between Hyperplasia and Cancer
Spectrum of changes May be impossible on small biopsies “at least atypical hyperplasia, cannot exclude grade-‐1 endometrioid carcinoma”
DisOncOon Between Hyperplasia and Cancer
1. Maze-‐like meandering glands / Rambling glands / Bridging between adjacent glands
2. Solid non-‐squamous areas 3. Cribriform areas 4. Gaping glands / mosaic pacern
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Thank you!