Intraoperative gross examination of myometrial invasion and cervical infiltration in patients with endometrial cancer: decision-making accuracy

Evaluation of Intraoperative Assessments in the Management of Endometrial Carcinoma: A Retrospective Quality Assurance Review

Intraoperative assessment (IA) of uteri is often used to help determine whether to perform lymphadenectomy in patients with endometrial carcinoma. We sought to perform a quality assurance review of the practice of IA at our institution. In a 1-yr period, 107 hysterectomies had an IA performed. Grade of neoplasm in preoperative endometrial biopsy, neoplasm size, depth of myometrial invasion at IA, operative management, and final histologic features were recorded. Operative reports were reviewed to assess the surgeon's interpretation of the IA and the effect on surgical management. The sensitivity and specificity for IA of deep myometrial invasion (>50% myometrial thickness) compared with final histology was 76.9% and 91.1%. The positive predictive value was 71.4%, negative predictive value 93.2% and accuracy 88%. Neoplasm size was provided in 47% of cases. In 10% of patients lymphadenectomy was performed despite low-risk features. IA results were included in the operative report in 87% of cases. There were differences in 8.4% of cases between the IA diagnosis and the surgeon's operative report. IA of deep myometrial invasion is reliable at our institution. Several metrics for quality improvement have been identified as a result of this retrospective review. These include but are not limited to more reliable reporting of neoplasm size, documentation, and communication with gynecologic oncologists.

Agreement between preoperative transvaginal ultrasound and intraoperative macroscopic examination for assessing myometrial infiltration in low-risk endometrioid carcinoma

OBJECTIVE

To compare diagnostic performance of preoperative transvaginal ultrasound (TVS) and intraoperative macroscopic examination for determining myometrial infiltration in women with low-risk endometrial cancer, and to estimate the agreement between the two methods.

METHODS

This was a single-center observational study comprising women with preoperative diagnosis of well- or moderately differentiated endometrioid carcinoma of the endometrium. All women underwent preoperative TVS by a single examiner. According to the examiner's subjective impression, myometrial infiltration was stated as ≥ 50% or < 50%. Surgical staging was performed in all cases. Intraoperative macroscopic examination of the removed uterus was performed by pathologists who were unaware of the ultrasound findings, and myometrial infiltration was stated as ≥ 50% or < 50%. Definitive histological diagnosis of myometrial infiltration was made by frozen section analysis and was used as the gold standard. Sensitivity and specificity with 95% CIs were calculated for TVS and intraoperative macroscopic inspection and compared using McNemar's test. Agreement between TVS and intraoperative macroscopic inspection was estimated using Cohen's kappa index (κ) and percentage of agreement.

RESULTS

Of 209 eligible women, 152 were ultimately included. Mean (± SD) age was 60.9 ± 10.2 years, with a range of 32-91 years. Definitive histological diagnosis revealed that myometrial infiltration was < 50% in 114 women and ≥ 50% in 38 women. Sensitivity and specificity of TVS for detecting deep myometrial infiltration were 81.6% and 89.5%, respectively, whereas the respective values for intraoperative macroscopic examination were 78.9% and 90.4% (McNemar's test, P > 0.05 when comparing TVS and intraoperative macroscopic examination). Agreement between methods was moderate with κ = 0.54 (95% CI, 0.39-0.69) and percentage of agreement of 82%.

CONCLUSIONS

Although the agreement between preoperative TVS and intraoperative macroscopic examination for detecting deep myometrial infiltration was only moderate, both methods had similar accuracy when compared with frozen section histology. Preoperative TVS might reasonably be proposed as a method for assessing myometrial infiltration as an alternative to intraoperative macroscopic examination, especially when performed by an experienced examiner and image quality is not poor. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Practical issues related to uterine pathology: staging, frozen section, artifacts, and Lynch syndrome

This review covers three areas in endometrial tumor pathology: International Federation of Gynecology and Obstetrics (FIGO) staging, the use of frozen section, and Lynch syndrome. The section on FIGO staging will emphasize problems that practicing pathologists often confront, such as measuring the depth of myometrial invasion, assessing for the presence of cervical stromal invasion, detecting low-volume lymph node metastases, and recognizing synchronous endometrial and ovarian tumors and artifacts. The frozen section portion of this review will focus on the performance characteristics of intraoperative examination of the uterus to determine tumor grade and depth of myometrial invasion, including suggestions for alternative methods. The last portion of this review will provide an overview of Lynch syndrome and a discussion of the rationale and methods of screening for Lynch syndrome.

Selected immuno-histochemical markers in curettage specimens and their correlation with final pathologic findings in endometrial cancer patients

To assess the immuno-histochemical expression of various markers in, endometrial biopsies of patients with endometrial cancer, and to correlate their expression with the final pathologic findings. Sixty-two patients with primary endometrial cancer who underwent surgical treatment were included in this study. Immuno-histochemical expression of estrogen receptor (ER), progesterone receptor (PR), p53, bcl-2, Her-2/neu and Ki-67 were assessed in curettage specimens, and review of the final pathology report from hysterectomy specimens was carried out. The expression of these markers in curettage was correlated with the final tumor characteristics obtained on hysterectomy specimens. Both ER and PR were significantly more expressed in endometrioid type (EC) than non- endometrioid type (NEC) (P value of 0.004 and 0.012). On the contrary, P53, Her-2 and Ki-67 showed higher positivity in NEC than EC (P value of 0.005, 0.025 and 0.002). Positive expression of ER and PR was significantly associated with low grade tumors and superficial myometrial invasion, whereas positive expression of Her-2 and Ki-67 was significantly associated with higher grade lesions, and deep myometrial invasion. Moreover, a statistically significant inverse relationship was observed between the positivity of P53, Her-2 and Ki-67 and the positivity of ER, PR. We found that determination of immuno-histochemical markers in curettage specimens might be helpful in predicting the final pathologic findings in patients with endometrial cancer. This might be helpful in planning the extensivity of the surgery.

Combined use of preoperative transvaginal ultrasonography and intraoperative gross examination in the assessment of myometrial invasion in endometrial carcinoma

OBJECTIVE

To evaluate the diagnostic performance of gross examination and transvaginal ultrasonography in the assessment of the depth of myometrial infiltration when they are used alone or together as a combined test.

STUDY DESIGN

The data of 219 consecutive patients with a diagnosis of endometrial cancer were evaluated retrospectively. Transvaginal ultrasound was carried out as a part of the routine preoperative work-up within three days of surgical intervention in all cases. All patients underwent hysterectomy with bilateral salpingo-oophorectomy and routine surgical staging and all uterine specimens were examined immediately after hysterectomy. The depth of myometrial invasion was classified into two groups: no or <50% invasion and ≥50% invasion. The findings of ultrasound and intraoperative gross examination were compared with the final histopathological results. The data of these two methods were integrated to evaluate the diagnostic performance of the combined test. If the results of myometrial invasion evaluation were different for the same patient, the deeper one (the depth of invasion ≥50%) was accepted.

RESULTS

Sensitivity, specificity, PPV, NPV and accuracy of preoperative ultrasonography in predicting myometrial infiltration ≥50% were 62%, 81%, 60%, 82%, and 75% respectively. The corresponding rates for intraoperative gross examination were 61%, 88%, 70%, 83% and 79%, respectively. For the combined test they were 78%, 76%, 60%, 88% and 70% respectively. There was no statistically significant difference in sensitivity and specificity between ultrasound and gross examination. The sensitivity of the combined test was significantly higher than that of ultrasound and gross examination (p=0.001 and p<0.0001, respectively). The specificity of the combined test was significantly lower than that of TVS and gross examination (p=0.008 and p<0.0001, respectively).

CONCLUSION

Combining ultrasonography and intraoperative gross examination may be a good option to assess the depth of myometrial invasion, as it has a higher sensitivity and negative predictive value in comparison to using these methods alone.

Accuracy of intraoperative gross visual assessment of myometrial invasion in endometrial cancer

OBJECTIVE

To evaluate the accuracy of gross visual assessment of myometrial invasion in endometrial carcinoma.

DESIGN

Prospective, descriptive study.

SETTING

University hospital.

POPULATION

Two hundred and fourteen consecutive patients operated between 2005 and 2008. All patients were preoperatively diagnosed with endometrial carcinoma or complex atypical hyperplasia considered by the pathologist to be at the border of highly differentiated endometrial cancer.

METHODS

Intraoperative gross visual assessment of myometrial tumor invasion (<50 or ≥50%), cervical tumor engagement and tumor diameter in millimeters were noted for all patients.

MAIN OUTCOME MEASURES

The collected data were compared with final histopathology.

RESULTS

Intraoperative gross visual assessment of myometrial tumour invasion correlated well with final histology, with an accuracy of 87%. Agreement between gross visual assessment and final histology was reached in 91% of grade 1 tumors. Additionally, we found that 98.5% of tumors with a diameter <20mm had <50% myometrial invasion, regardless of grade.

CONCLUSIONS

Intraoperative gross visual assessment of myometrial tumor invasion and tumor size measurements are simple, fast and inexpensive methods that may provide important information for the surgeon to decide upon the extent of staging when other more accurate methods are not at hand.

Laparoscopic Systemic Retroperitoneal Lymphadenectomy for Women with Low-Risk Early Endometrial Cancer

Introduction: There is no consensus on the extent of lymphadenectomy and the appropriate patients for lymphadenectomy in low-risk patients with endometrial cancer. This study aimed to evaluate the feasibility and effectiveness of laparoscopic lymphadenectomy for low-risk patients with endometrial cancer. Materials and Methods: From January 2004 to May 2008, we reviewed the medical records of 28 patients with low-risk, endometrial cancer; endometrioid type, grade 1 or 2, and with a depth of myometrial invasion of less than one-half of the myometrium. All patients underwent laparoscopically-assisted staging surgery. Results: The median age and body mass index were 56 years (range, 28 to 75) and 25.5 kg/m2 (range, 21.3 to 37.2). The median operating time, estimated blood loss, and length of hospital stay were 142 minutes (range, 110 to 410), 215 mL (range, 100 to 700), and 7 days (range, 3 to 19), respectively. No conversion to laparotomy was noted. The median number of harvested lymph nodes was 21 (range, 10 to 48) pelvic nodes and 12 (range, 4 to 21) para-aortic nodes. One (3.6%) patient presented pelvic lymph node metastasis and 2 (7.1%) presented isolated para-aortic lymph node metastasis. The complication rate was 14.3%. No recurrence in the vaginal vault, distant metastasis, port site metastasis was noted up to the last follow-up. Conclusion: Systemic pelvic and para-aortic lymphadenectomy should be considered in all low-risk patients with endometrial cancer until it is concluded to be clinically insignificant through large-scale prospective research in the future. However, it will be difficult to explain statistical differences in survival rates according to lymphadenectomy, because the increase of the survival rate resulting from lymphadenectomy will fall within the margin of statistical error. Key words: Endometrial cancer, Laparoscopy, Lymphadenectomy

The accuracy of frozen pathology at time of hysterectomy in patients with complex atypical hyperplasia on preoperative biopsy

OBJECTIVE

The purpose of this work was to estimate the accuracy of frozen pathologic analysis, compared with final pathological diagnosis in patients with a preoperative diagnosis of endometrial complex atypical hyperplasia (CAH).

STUDY DESIGN

We performed a retrospective review of frozen and final pathology in patients with a preoperative diagnosis of CAH from January 1987 through August 2004. Clinical and pathological information was obtained from patient charts.

RESULTS

We identified 23 of 41 patients with diagnosis of CAH who had a frozen section. Nine of the frozen pathology results (39.1%) correlated with the final pathological diagnosis. In 14 of 23 of the cases (60.8%), the frozen and final pathology reports disagreed. Eight of 14 patients initially diagnosed with CAH by frozen section (57%) were diagnosed with endometrial adenocarcinoma on final pathology.

CONCLUSION

Our data suggest that intraoperative frozen analysis of the endometrium is not a reliable indicator of final pathology in patients with a preoperative diagnosis of CAH.

The Endometrium

Context.—Endometrial tissue specimens are commonly encountered in daily practice. It is well known that a number of problematic diagnostic scenarios occur relative to these specimens.

Objective.—To emphasize practical aspects of endometrial specimen handling and reporting, with selected comments on common diagnostic pitfalls, including (1) the diagnosis of endometrial intraepithelial carcinoma in atrophic endometrial biopsy specimens, (2) evaluation of adequacy of endometrial sampling specimens, (3) problems in diagnosing and measuring the depth of myometrial invasion in endometrial carcinoma, (4) the question of metastasis versus independent primaries in concurrent carcinomas of endometrium and one or both ovaries, (5) the problematic differential diagnoses between type 1 (primarily endometrioid) and type 2 (primarily serous) adenocarcinomas, and (6) atypical hyperplasia and proposed classification systems for its replacement.

Data Sources.—Published literature, consensus statements, and personal experience.

Conclusions.—A systematic approach to the handling and reporting of endometrial specimens reduces the potential for omission and error. Recognition of diagnostic pitfalls and practical approaches to their resolution help improve quality.

Preoperative and intraoperative assessment of myometrial invasion and histologic grade in endometrial cancer: role of magnetic resonance imaging and frozen section

The objective of this study was to determine the value of myometrial invasion by magnetic resonance imaging (MRI), histologic typing and grading by endometrial biopsy, and the intraoperative evaluation of both parameters by frozen section in the evaluation of endometrial cancer. The preoperative and intraoperative records of 180 patients with endometrial cancer were used to compare the preoperative endometrial biopsy, the myometrial invasion by MRI, and the intraoperative frozen sections, with the final histopathologic findings. The preoperative endometrial biopsy gave us the tumor histologic type and grade. MRI gave us the depth of myometrial invasion. The evaluation of intraoperative frozen sections gave us the tumor histologic type, the tumor grade, and also the myometrial invasion. Patients were classified as low risk (grade 1 and 2, and myometrial invasion <50%) and high risk (grade 3 or myometrial invasion >50%). Standard statistical calculations were used. Evaluation of the tumor grade by preoperative biopsy has a sensitivity and a specificity of 75% and 95%, respectively. Evaluation of the tumor grade by intraoperative biopsy has a sensitivity and a specificity of 40% and 98%, respectively. Evaluation of the depth of myometrial invasion with MRI has a sensitivity and a specificity of 79% and 82%, respectively. Evaluation of the depth of myometrial invasion with intraoperative frozen sections has a sensitivity and a specificity of 74% and 95%, respectively. Evaluation of all four of the parameters together has a sensitivity and a specificity of 80% and 82%, respectively with a kappa of 0.621. In our opinion, the combination of preoperative biopsy and intraoperative frozen section is the best way to decide whether a lymphadenectomy is necessary with a low rate of understaging patients. MRI would have a fringe benefit in these patients.