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Ooka R, Nanki Y, Yamagami W, Kawaida M, Nagai S, Hirano T, Sakai K, Makabe T, Chiyoda T, Kobayashi Y, Kataoka F, Aoki D. Evaluation of the role of intraoperative frozen section and magnetic resonance imaging in endometrial cancer. Int J Gynaecol Obstet 2023; 160:554-562. [PMID: 35929845 DOI: 10.1002/ijgo.14389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/03/2022] [Accepted: 07/28/2022] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate the accuracy of preoperative endometrial biopsy and magnetic resonance imaging (MRI) of endometrial cancer compared with that of intraoperative frozen section. METHODS This retrospective study included 264 patients who underwent surgery with intraoperative frozen section for endometrial cancer at our institution between 2014 and 2018. Diagnosis was determined by histologic type, grade, and myometrial invasion. Concordance rate, sensitivity, and specificity of preoperative diagnosis and intraoperative frozen diagnosis were calculated, in comparison to the final pathologic diagnosis. RESULTS Preoperative and intraoperative diagnoses showed no statistically significant difference in determining histologic type and grade (P = 0.152). Intraoperative diagnosis showed higher sensitivity for endometrioid carcinoma grade 3 and other types, and higher specificity for grade 1. For myometrial invasion, intraoperative diagnosis showed significantly higher concordance rate than preoperative MRI findings (P < 0.01). Intraoperative diagnosis showed higher sensitivity and specificity in patients with and without myometrial invasion, respectively. CONCLUSION Higher agreement between intraoperative and final diagnoses, especially in myometrial invasion, suggests that intraoperative frozen section is a good indicator for appropriate surgical procedure decision making.
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Affiliation(s)
- Reina Ooka
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiko Nanki
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Wataru Yamagami
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Miho Kawaida
- Department of Diagnostic Pathology, Keio University Hospital, Tokyo, Japan
| | - Shimpei Nagai
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Takuro Hirano
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Kensuke Sakai
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Makabe
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuyuki Chiyoda
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Yusuke Kobayashi
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
| | - Fumio Kataoka
- Department of Obstetrics and Gynecology, International University of Health and Welfare, School of Medicine, Chiba, Japan
| | - Daisuke Aoki
- Department of Obstetrics and Gynecology, Keio University School of Medicine, Tokyo, Japan
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Diniz TP, Menezes JN, Goncalves BT, Faloppa CC, Mantoan H, Kumagai LY, Badiglian-Filho L, Bovolim G, Guimaraes APG, De Brot L, Baiocchi G. Can mismatch repair status be added to sentinel lymph node mapping algorithm in endometrioid endometrial cancer? Gynecol Oncol 2023; 169:131-136. [PMID: 36580755 DOI: 10.1016/j.ygyno.2022.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To evaluate the relation between mismatch repair (MMR) status and the risk of lymph node metastasis in endometrial cancer, and whether this additional data can be incorporated to current SLN (sentinel lymph node) algorithm. METHODS We included a series of 332 women that underwent SLN mapping ± systematic lymphadenectomy from January 2013 to December 2021. Protein expressions of MLH1, MSH2, MSH6, PMS2 were examined by immuno-histochemistry and considered MMRd (deficient) when at least one protein was not expressed. RESULTS MMRd was noted in 20.8% of cases and correlated to grade 3 (p = 0.018) and presence of lymphovascular space invasion (p = 0.032). Moreover, MMRd was an independent risk factor for lymph node metastasis (OR 2.76, 95% CI 1.36-5.62). Notably, 21.7% (15/69) cases with MMRd had lymph node metastasis compared to 9.5% (25/263) of cases with MMRp (proficient) (p = 0.005). The overall and bilateral SLN detection rates were 91.9% and 75.9%, respectively. Of the 80 (24%) cases of non-bilateral SLN detection, 66.2% had low-grade tumors (G1/G2) and myometrial invasion <50%. Considering MMR status an independent prognostic factor for lymph node metastasis, a systematic lymphadenectomy (side specific or bilateral) would forgo in 53.7% (43/80) of cases with non-bilateral detection, representing 13% (43/332) of all endometroid tumors. CONCLUSION MMR status was independently related to lymph node metastasis in endometrioid EC. Moreover, MMR status may help to select patients that can forgo systematic lymphadenectomy in case of undetected SLN.
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Affiliation(s)
| | | | | | | | - Henrique Mantoan
- Department of Gynecologic Oncology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | | | | | - Graziele Bovolim
- Department of Pathology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | | | - Louise De Brot
- Department of Pathology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | - Glauco Baiocchi
- Department of Gynecologic Oncology, AC Camargo Cancer Center, Sao Paulo, Brazil.
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Iitsuka C, Asami Y, Hirose Y, Nagashima M, Mimura T, Miyamoto S, Onuki M, Ohgiya Y, Kushima M, Sekizawa A, Matsumoto K. Preoperative Magnetic Resonance Imaging versus Intraoperative Frozen Section Diagnosis for Predicting the Deep Myometrial Invasion in Endometrial Cancer: Our Experience and Literature Review. J Obstet Gynaecol Res 2021; 47:3331-3338. [PMID: 34155730 DOI: 10.1111/jog.14891] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 05/30/2021] [Accepted: 06/01/2021] [Indexed: 12/24/2022]
Abstract
AIM The present study was designed to directly compare the diagnostic performance of preoperative magnetic resonance imaging (MRI) and intraoperative frozen section (FS) diagnoses in predicting deep myometrial invasion (MI) of endometrial cancer. METHODS Using MRI findings and FS diagnoses, 194 patients with surgically staged endometrial cancer were evaluated for deep MI between 2006 and 2018. Definitive histological diagnosis of paraffin sections of excised tissues was used as the gold standard approach. RESULTS Of 194 cases, 53 (27.3%) cases were finally diagnosed as having deep MI (≥50%). There was 82% total agreement between MRI and FS diagnoses in predicting deep MI, with a kappa value of 0.54 (95% confidence interval [CI] = 0.40-0.67, moderate agreement). The sensitivity of FS diagnosis (0.66, 95% CI = 0.52-0.78) for predicting deep MI was lower than that of MRI (0.77, 95% CI = 0.63-0.87; p = 0.21), while the specificity of FS (0.98, 95% CI = 0.93-0.99) was significantly higher than that of MRI (0.88, 95% CI = 0.81-0.93; p = 0.001). Overall, the accuracy of FS (0.89, 95% CI = 0.84-0.93) was higher than that of MRI (0.85, 95% CI = 0.79-0.90), although the difference did not reach statistical significance (p = 0.23). The accuracy (0.95, 95% CI = 0.90-0.97) was very high in cases with concordant MRI and FS results. CONCLUSIONS MRI and FS showed different diagnostic characteristics for predicting deep MI, with a higher specificity observed for FS and the greatest accuracy obtained in concordant cases. Thus, our findings recommend the addition of FS diagnosis, either alone or in conjunction with MRI, to MI evaluation.
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Affiliation(s)
- Chiaki Iitsuka
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Yuka Asami
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Yusuke Hirose
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Minoru Nagashima
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Takashi Mimura
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Shingo Miyamoto
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Mamiko Onuki
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Yoshimitsu Ohgiya
- Department of Radiology, Showa University School of Medicine, Tokyo, Japan
| | - Miki Kushima
- Department of Pathology, Showa University School of Medicine, Koto Toyosu Hospital, Tokyo, Japan
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Koji Matsumoto
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
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Ferrero A, Novara L, Perotto S, Capece R, Petey F, Perrini G, Mariani LL, DE Rosa G, Biglia N, Fuso L. Could a 2D/3D US based model be helpful in the assessment of myometrial invasion at time of intraoperative frozen section? A pilot study. Minerva Obstet Gynecol 2021; 73:362-368. [PMID: 34008391 DOI: 10.23736/s2724-606x.21.04777-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The assessment of myometrial invasion is a pivotal step in the preoperative staging of endometrial cancer. Intraoperative frozen section (FS) represents a reliable tool in directing surgeon's choices. Preoperative transvaginal ultrasound (US) showed high accuracy in evaluating myometrial invasion. This study aimed to understand if the application of a standardized ultrasonographic protocol for the pre-operative evaluation of myometrial invasion can help pathologists in improving the accuracy of FS. Furthermore, the agreement between US and FS in the assessment of myometrial invasion was assessed. METHODS Sixty-six patients who underwent surgery for endometrial cancer were analyzed. Preoperative 2D/3D ultrasound was performed in all the patients. Myometrial invasion was estimated by subjective assessment and objective measurement techniques. Data from US were reported to pathologists through a prefilled form with depth and site of the maximum myometrial invasion. Diagnostic performance of US and FS were compared having the definitive histological examination as the gold standard. RESULTS Influenced by the information given by our 3D US-model, FS showed a 90% sensitivity and a 93% specificity, with a 93% PPV and an 89% NPV. The agreement with histology was strong (K=0.824). Myometrial invasion was missed at the level of the isthmus by FS just in one case. Subjective assessment was confirmed as the most reliable ultrasonographic technique in assessing myometrial invasion, with 90% sensitivity, 78% specificity, 80% PPV and 89% NPV. The agreement with histology was substantial (K=0.68). CONCLUSIONS The application of a preoperative 2D/3D US assessment would seem to help pathologists in detecting myometrial invasion in difficult areas of the uterus such as the isthmus, reducing downstaging and overtreatment.
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Affiliation(s)
- Annamaria Ferrero
- Department of Obstetrics and Gynecology, Mauriziano Hospital, Turin, Italy
| | - Lorenzo Novara
- Department of Obstetrics and Gynecology, Mauriziano Hospital, Turin, Italy
| | - Stefania Perotto
- Department of Obstetrics and Gynecology, Mauriziano Hospital, Turin, Italy
| | - Roberto Capece
- Department of Obstetrics and Gynecology, Mauriziano Hospital, Turin, Italy
| | - Francesca Petey
- Department of Obstetrics and Gynecology SC2U, Sant'Anna Hospital, Turin, Italy
| | - Gaetano Perrini
- Department of Obstetrics and Gynecology, Mauriziano Hospital, Turin, Italy
| | - Luca L Mariani
- Department of Obstetrics and Gynecology, Mauriziano Hospital, Turin, Italy
| | | | - Nicoletta Biglia
- Department of Obstetrics and Gynecology, Mauriziano Hospital, Turin, Italy -
| | - Luca Fuso
- Department of Obstetrics and Gynecology, Mauriziano Hospital, Turin, Italy
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Sentinel Lymph Node Ultra-staging as a Supplement for Endometrial Cancer Intraoperative Frozen Section Deficiencies. Int J Gynecol Pathol 2019; 38:52-58. [PMID: 28968296 DOI: 10.1097/pgp.0000000000000463] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
For endometrial cancer (EC), most surgeons rely on intraoperative frozen section (IFS) to determine the risk of nodal metastasis and necessity of lymphadenectomy. IFS remains a weak link in this practice due to its susceptibility to diagnostic errors. As a less invasive alternative, sentinel lymph node (SLN) mapping and ultra-staging have gradually gained acceptance for EC. We aimed to establish the SLN success rate, negative predictive value, and whether SLNs provide useful information for cases misdiagnosed on IFS. From 2013 to 2017, 100 patients (63 low-risk and 37 high-risk EC) underwent hysterectomy, bilateral salpingo-oophorectomy, and SLN. Among them, 56 had additional pelvic lymphadenectomy. A total of 337 SLNs were obtained in 86 cases: 55 bilaterally and 31 unilaterally. The remaining 14 cases failed because of patient obesity or leiomyoma. Pathology ultra-staging detected 2 positive SLNs from 2 patients (1 with isolated tumor cells, 1 with micrometastases). One of 773 nonsentinel pelvic nodes was positive on the contralateral hemi-pelvis in a patient who was mapped unilaterally, resulting in negative predictive value of 100%. During IFS, tumor grade and/or depth of myometrial invasion was misdiagnosed in 22 cases (22%). These errors would have resulted in under-staging in 10 high-risk patients or over-staging in 4 low-risk patients. SLNs were mapped in these misestimated patients, with one revealing metastases. SLN provides invaluable information on nodal status while detecting occult metastases in cases misdiagnosed on IFS. Our findings justify the incorporation of SLN in initial surgery for EC as an offset to IFS diagnostic errors, minimizing their negative impact on patient care.
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Moe J, McHugh JB, Udager AM, Braun TM, Helman JI, Ward BB. Intraoperative Depth of Invasion Is Accurate in Early-Stage Oral Cavity Squamous Cell Carcinoma. J Oral Maxillofac Surg 2019; 77:1704-1712. [PMID: 30878591 DOI: 10.1016/j.joms.2019.02.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/11/2019] [Accepted: 02/08/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Depth of invasion (DOI) is one predictor of nodal metastasis in oral cavity squamous cell carcinoma (OCSCC) and can facilitate the decision to complete an elective neck dissection (END) in early-stage disease with a clinically negative neck. The purpose of this study was to investigate the accuracy of DOI in intraoperative frozen specimens for T1N0 oral OCSCC. MATERIALS AND METHODS To compare the accuracy of DOI in frozen versus permanent specimens, we completed a prospective, blinded study of 30 patients with cT1N0 OCSCC who presented between October 2016 and December 2017. RESULTS DOI in frozen specimens was 96.8% accurate in predicting the need for END with a sensitivity of 90.9%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 95.2%. A strong correlation was found between DOIs in frozen and permanent specimens measured by head and neck (HN) pathologists (r = 0.96; 95% confidence interval [CI], 0.93 to 0.97), between HN pathologists using frozen specimens (r = 0.98; 95% CI, 0.95 to 0.99) and permanent specimens (r = 0.95; 95% CI, 0.91 to 0.98), and in DOIs in frozen specimens communicated intraoperatively versus measured by HN pathologist 1 (r = 0.93; 95% CI, 0.86 to 0.97) and HN pathologist 2 (r = 0.95; 95% CI, 0.89 to 0.98). Only 1 patient who did not undergo an END based on frozen specimens was undertreated owing to upgrading of the DOI in permanent specimens. CONCLUSIONS DOI in intraoperative frozen sections has an accuracy of 96.8% and may be reliably used as a clinical tool to determine the need for END in early-stage OCSCC.
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Affiliation(s)
- Justine Moe
- Assistant Professor, Section of Oral and Maxillofacial Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.
| | - Jonathan B McHugh
- Professor, Department of Pathology, University of Michigan, Ann Arbor, MI
| | - Aaron M Udager
- Assistant Professor, Department of Pathology, University of Michigan, Ann Arbor, MI
| | - Thomas M Braun
- Professor, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Joseph I Helman
- Professor, Section of Oral and Maxillofacial Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Brent B Ward
- Chair, Section of Oral and Maxillofacial Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
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Role of Intraoperative Frozen Section in Defining the Extent of Surgery in Endometrial Carcinoma: An Indian Experience. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2017. [DOI: 10.1007/s40944-017-0140-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Giede C, Le T, Power P. Rôle de la chirurgie en matière de cancer de l'endomètre. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 38:S197-S207. [PMID: 28063535 DOI: 10.1016/j.jogc.2016.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Capriglione S, Plotti F, Miranda A, Lopez S, Scaletta G, Moncelli M, Luvero D, De Cicco Nardone C, Terranova C, Montera R, Angioli R. Further insight into prognostic factors in endometrial cancer: the new serum biomarker HE4. Expert Rev Anticancer Ther 2016; 17:9-18. [PMID: 27892774 DOI: 10.1080/14737140.2017.1266263] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Endometrial cancer (EC) is one of the most common gynecological cancer worldwide. To date, no good markers are routinely used in clinical practice for prognosis and monitoring. Areas covered: During the last years, an increasing interest in literature has been growing on HE4 (Human epididimis 4). Therefore, we aimed to gather all the evidence reported in literature analysing the potential prognostic value of HE4, compared to the well know tumor's features (histological type and grade, stage of disease, depth of myometrial invasion, lymphovascular space involvement and cervical involvement). Expert commentary: The analysis of data suggests that HE4 seems to have a good performance in prognosis and monitoring of the disease, helping to schedule the appropriste timing of imaging and surgery in a more individualized fashion. However, these findings surely require a validation in a larger cohorts of patients. Probably, in the next five years, prospective randomized trials will be performed to confirm the prognostic role of HE4 in EC and to find a tailored EC management strategy.
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Affiliation(s)
- Stella Capriglione
- a Department of Obstetrics and Gynaecology, Campus Bio Medico , University of Rome , Rome , Italy
| | - Francesco Plotti
- a Department of Obstetrics and Gynaecology, Campus Bio Medico , University of Rome , Rome , Italy
| | - Andrea Miranda
- a Department of Obstetrics and Gynaecology, Campus Bio Medico , University of Rome , Rome , Italy
| | - Salvatore Lopez
- a Department of Obstetrics and Gynaecology, Campus Bio Medico , University of Rome , Rome , Italy
| | - Giuseppe Scaletta
- a Department of Obstetrics and Gynaecology, Campus Bio Medico , University of Rome , Rome , Italy
| | - Michele Moncelli
- a Department of Obstetrics and Gynaecology, Campus Bio Medico , University of Rome , Rome , Italy
| | - Daniela Luvero
- a Department of Obstetrics and Gynaecology, Campus Bio Medico , University of Rome , Rome , Italy
| | - Carlo De Cicco Nardone
- a Department of Obstetrics and Gynaecology, Campus Bio Medico , University of Rome , Rome , Italy
| | - Corrado Terranova
- a Department of Obstetrics and Gynaecology, Campus Bio Medico , University of Rome , Rome , Italy
| | - Roberto Montera
- a Department of Obstetrics and Gynaecology, Campus Bio Medico , University of Rome , Rome , Italy
| | - Roberto Angioli
- a Department of Obstetrics and Gynaecology, Campus Bio Medico , University of Rome , Rome , Italy
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Intraoperative Gross Examination and Intraoperative Frozen Section in Patients With Endometrial Cancer for Detecting Deep Myometrial Invasion. Int J Gynecol Cancer 2016; 26:407-15. [DOI: 10.1097/igc.0000000000000618] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Wu Y, Zhu H, Sun J, Wang X. Accuracy of frozen section in management and prediction of lymph node metastasis in endometrial carcinoma. Gynecol Minim Invasive Ther 2015. [DOI: 10.1016/j.gmit.2015.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Karabagli P, Ugras S, Yilmaz BS, Celik C. The evaluation of reliability and contribution of frozen section pathology to staging endometrioid adenocarcinomas. Arch Gynecol Obstet 2015; 292:391-7. [PMID: 25608758 DOI: 10.1007/s00404-015-3621-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Accepted: 01/12/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the reliability and accuracy of intraoperative pathological findings, compared to permanent section (PS) and to understand contributions of frozen section (FS) to final staging in patients with endometrioid carcinomas. METHODS This is a retrospective analysis of 79 patients undergoing intraoperative FS and with endometrioid adenocarcinomas. Intraoperative pathological findings were compared with final results as to grade, depth of myometrial invasion (MI), cervical involvement, lymphovascular space invasion (LVSI) and stage. We also analyzed whether staging procedures like pelvic or para-aortic lymph node metastasis, peritoneal cytology and extension beyond of uterus were related to FS findings. Staging was based on the FIGO 2009. RESULTS FS results were agreement in 89.9 % for grade, 88.6 % for depth of MI, 100 % for cervical invasion, and 92.4 % for LVSI, compared with PS. On FS, 12, 16.6 and 44.4 % of specimens in stages of IA, IB and II became upstaged in final pathology, respectively. Of 79 cases, 5 (6.3 %) were upstaged to IIIC1, and 3 (3.8 %) were upstaged to IIIC2 because of lymph node metastasis. A significant relationship was detected between lymph node metastasis, and FS grades (p = 0.001), LVSI (p = 0.000), cervical invasion (p = 0.006) and MI (p = 0.001). CONCLUSION We consider that intraoperative FS is a useful procedure to identify poor prognostic pathological factors. While grading, depth of MI, cervical stromal invasion and LVSI on FS are significant in predicting lymph node metastasis, the existence of cervical stromal invasion and LVSI should be considered more effective parameters in the identification of metastatic endometrial cancer risks.
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Affiliation(s)
- Pinar Karabagli
- Department of Pathology, Medical School of Selcuk University, Alaeddin Keykubad Campus, 42075, Selcuklu, Konya, Turkey,
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Gungorduk K, Ozdemir A, Ertas IE, Sahbaz A, Asicioglu O, Gokcu M, Solmaz U, Harma M, Uzuncakmak C, Dogan A, Sanci M. A Novel Preoperative Scoring System for Predicting Endometrial Cancer in Patients with Complex Atypical Endometrial Hyperplasia and Accuracy of Frozen Section Pathological Examination in This Context: A Multicenter Study. Gynecol Obstet Invest 2014; 79:50-6. [DOI: 10.1159/000365086] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 06/04/2014] [Indexed: 11/19/2022]
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Bell JG, Patterson DM, Klima J, Harvison M, Rath K, Reid G. Outcomes of patients with low-risk endometrial cancer surgically staged without lymphadenectomy based on intra-operative evaluation. Gynecol Oncol 2014; 134:505-9. [PMID: 25003655 DOI: 10.1016/j.ygyno.2014.06.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 06/26/2014] [Accepted: 06/28/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate clinical outcomes in patients with stage I endometrial cancer undergoing surgical management without lymphadenectomy based on intra-operative assessment for low-risk disease. METHODS Between 2000 and 2009, a total of 179 patients were surgically staged without lymphadenectomy for low-risk stage I endometrial cancer. Low-risk cancer was defined by intra-operative criteria based on both gross and frozen tissue microscopic evaluation: 1) G1 or G2 endometrioid histology; 2) myoinvasion <50%; 3) no cervical disease, and 4) no intra-abdominal metastasis. Records were reviewed for postoperative complications, pathological diagnoses, adjuvant radiation treatment, cancer recurrence, and mortality. RESULTS Morbidity, cancer recurrence, and disease-specific mortality were low. Postoperative complications occurred in 5 patients (2.8%). Nine patients (5.0%) were offered adjuvant radiation for higher risk disease diagnosed on final pathology. Radiation morbidity was minimal: grade 1 vaginal toxicity in 2 patients. Three patients (1.7%) experienced recurrent cancer with mean time to recurrence of 43.7 months. Five year overall survival was 95.8%. The five year probability of disease-specific death was 1.1%. CONCLUSION In an institution with reliable capability of pathological frozen tissue diagnosis, omission of lymph node dissection is a reasonable option in the surgical management of those patients with low-risk disease diagnosed by intra-operative factors.
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Affiliation(s)
- Jeffrey G Bell
- Riverside Methodist Hospital, 3535 Olentangy River Road, Columbus, OH 43214, United States.
| | - Diana M Patterson
- Riverside Methodist Hospital, 3535 Olentangy River Road, Columbus, OH 43214, United States
| | - Jennifer Klima
- OhioHealth Reseach Institute, 3545 Olentangy River Road, Columbus, OH 43214, United States
| | - Michelle Harvison
- Riverside Methodist Hospital, 3535 Olentangy River Road, Columbus, OH 43214, United States
| | - Kellie Rath
- Riverside Methodist Hospital, 3535 Olentangy River Road, Columbus, OH 43214, United States
| | - Gary Reid
- Riverside Methodist Hospital, 3535 Olentangy River Road, Columbus, OH 43214, United States
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Stephan JM, Hansen J, Samuelson M, McDonald M, Chin Y, Bender D, Reyes HD, Button A, Goodheart MJ. Intra-operative frozen section results reliably predict final pathology in endometrial cancer. Gynecol Oncol 2014; 133:499-505. [DOI: 10.1016/j.ygyno.2014.03.569] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 02/28/2014] [Accepted: 03/26/2014] [Indexed: 10/25/2022]
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Bogani G, Dowdy SC, Cliby WA, Ghezzi F, Rossetti D, Mariani A. Role of pelvic and para-aortic lymphadenectomy in endometrial cancer: current evidence. J Obstet Gynaecol Res 2014; 40:301-11. [PMID: 24472047 PMCID: PMC4364412 DOI: 10.1111/jog.12344] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 11/02/2013] [Indexed: 01/02/2023]
Abstract
The aim of the present review is to summarize the current evidence on the role of pelvic and para-aortic lymphadenectomy in endometrial cancer. In 1988, the International Federation of Obstetrics and Gynecology recommended surgical staging for endometrial cancer patients. However, 25 years later, the role of lymph node dissection remains controversial. Although the findings of two large independent randomized trials suggested that pelvic lymphadenectomy provides only adjunctive morbidity with no clear influence on survival outcomes, the studies have many pitfalls that limit interpretation of the results. Theoretically, lymphadenectomy may help identify patients with metastatic dissemination, who may benefit from adjuvant therapy, thus reducing radiation-related morbidity. Also, lymphadenectomy may eradicate metastatic disease. Because lymphatic spread is relatively uncommon, our main effort should be directed at identifying patients who may potentially benefit from lymph node dissection, thus reducing the rate of unnecessary treatment and associated morbidity. This review will discuss the role of lymphadenectomy in endometrial cancer, focusing on patient selection, extension of the surgical procedure, postoperative outcomes, quality of life and costs. The need for new surgical studies and efficacious systemic drugs is recommended.
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Affiliation(s)
- Giorgio Bogani
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean C. Dowdy
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - William A. Cliby
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fabio Ghezzi
- Division of Obstetrics and Gynecology, University of Insubria, Varese, and
| | - Diego Rossetti
- Division of Obstetrics and Gynecology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Andrea Mariani
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Frozen section in gynaecology: uses and limitations. Arch Gynecol Obstet 2014; 289:1165-70. [DOI: 10.1007/s00404-013-3135-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 12/16/2013] [Indexed: 01/04/2023]
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21
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Assessment of endometrial sampling as a predictor of final surgical pathology in endometrial cancer. Br J Cancer 2013; 110:609-15. [PMID: 24366295 PMCID: PMC3915129 DOI: 10.1038/bjc.2013.766] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 10/31/2013] [Accepted: 11/04/2013] [Indexed: 12/03/2022] Open
Abstract
Background: The histology and grade of endometrial cancer are important predictors of disease outcome and of the likelihood of nodal involvement. In most centres, however, surgical staging decisions are based on a preoperative biopsy. The objective of this study was to assess the concordance between the preoperative histology and that of the hysterectomy specimen in endometrial cancer. Methods: Patients treated for endometrial cancer during a 10-year period at a tertiary cancer centre were identified from a prospectively collected pathological database. All pathology reports were reviewed to confirm centralised reporting of the original sampling or biopsy specimens; patients whose biopsies were not reviewed by a dedicated gynaecological pathologist at the treating centre were excluded. Surgical pathology data including histology, grade, depth of myometrial invasion, cervical stromal involvement and lymphovascular space invasion (LVSI) as well as preoperative histology and grade were collected. Preoperative and final tumour cell type and grade were compared and the distribution of other high-risk features was analysed. Results: A total of 1329 consecutive patients were identified; 653 patients had a centrally reviewed epithelial endometrial cancer on their original biopsy, and are included in this study. Of 255 patients whose biopsies were read as grade 1 (G1) adenocarcinoma, 45 (18%) were upgraded to grade 2 (G2) on final pathology, 6 (2%) were upgraded to grade 3 (G3) and 5 (2%) were read as a non-endometrioid high-grade histology. Overall, of 255 tumours classified as G1 endometrioid cancers on biopsy, 74 (29%) were either found to be low-grade (G1–2) tumours with deep myometrial invasion, or were reclassified as high-grade cancers (G3 or non-endometrioid histologies) on final surgical pathology. Despite these shifts, we calculate that omitting surgical staging in preoperatively diagnosed G1 endometrioid cancers without deep myometrial invasion would result in missing nodal involvement in only 1% of cases. Conclusions: Preoperative endometrial sampling is only a modest predictor of surgical pathology features in endometrial cancer and may underestimate the risk of disease spread and recurrence. In spite of frequent shifts in postoperative vs preoperative histological assessment, the predicted rate of missed nodal metastases with a selective staging policy remains low.
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Turan T, Oguz E, Unlubilgin E, Tulunay G, Boran N, Demir OF, Kose MF. Accuracy of frozen-section examination for myometrial invasion and grade in endometrial cancer. Eur J Obstet Gynecol Reprod Biol 2013; 167:90-5. [DOI: 10.1016/j.ejogrb.2012.11.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 08/14/2012] [Accepted: 11/21/2012] [Indexed: 11/29/2022]
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Kumar S, Medeiros F, Dowdy SC, Keeney GL, Bakkum-Gamez JN, Podratz KC, Cliby WA, Mariani A. A prospective assessment of the reliability of frozen section to direct intraoperative decision making in endometrial cancer. Gynecol Oncol 2012; 127:525-31. [PMID: 22940491 DOI: 10.1016/j.ygyno.2012.08.024] [Citation(s) in RCA: 100] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 08/17/2012] [Accepted: 08/22/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the reliability of intraoperative frozen sections (IFSs) for surgical staging of endometrial cancer (EC). METHODS Data were collected prospectively on 784 consecutive patients with EC who were undergoing a hysterectomy at our institution from January 1, 2004, to December 31, 2008. The need for surgical staging was decided through IFS using 4 variables: tumor size, histologic grade, histologic subtype, and depth of myometrial invasion (MI). The IFS results were compared with the permanent paraffin sections (PSs) to assess for discordances. RESULTS In 30 of the 784 cases (4%), the PS pathology report was amended with discordant results. In addition, a definitive diagnosis of the 4 parameters was deferred to PS in 53 cases (7%), of which 30 (4%) were concordant and 23 (3%) were discordant. IFS-related deviations from the prescribed surgical algorithm occurred in 10 cases (1.3%; 95% confidence interval, 0.6%-2.3%). Of these 10 cases, 3 were amendments after PS review and 7 were IFS deferrals for definitive PS interpretation. CONCLUSIONS Clinically significant discordance between IFS and PS occurred in only 1.3% of cases. Despite skepticism expressed in the medical literature, IFS provides highly reliable data to guide intraoperative treatment decisions at institutions with sufficient pathologic expertise.
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Affiliation(s)
- Sanjeev Kumar
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Lax S, Tamussino K, Prein K, Lang P. Schnellschnittdiagnostik bei Erkrankungen des weiblichen Genitaltrakts. DER PATHOLOGE 2012; 33:430-40. [DOI: 10.1007/s00292-012-1597-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Akbayir O, Corbacioglu A, Numanoglu C, Goksedef BPC, Guraslan H, Akagunduz G, Sencan F. Combined use of preoperative transvaginal ultrasonography and intraoperative gross examination in the assessment of myometrial invasion in endometrial carcinoma. Eur J Obstet Gynecol Reprod Biol 2012; 165:284-8. [PMID: 22819271 DOI: 10.1016/j.ejogrb.2012.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 06/07/2012] [Accepted: 07/02/2012] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Ozgur Akbayir
- Istanbul Kanuni Sultan Suleyman Research and Teaching Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey
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Turan T, Karadag B, Karabuk E, Tulunay G, Ozgul N, Gultekin M, Boran N, Isikdogan Z, Kose MF. Accuracy of Frozen Sections for Intraoperative Diagnosis of Complex Atypical Endometrial Hyperplasia. Asian Pac J Cancer Prev 2012; 13:1953-6. [DOI: 10.7314/apjcp.2012.13.5.1953] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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MAVROMATIS IOANNISD, ANTONOPOULOS CONSTANTINEN, MATSOUKIS IOANNISL, FRANGOS CONSTANTINOSC, SKALKIDOU ALKISTIS, CREATSAS GEORGE, PETRIDOU ELENITH. Validity of intraoperative gross examination of myometrial invasion in patients with endometrial cancer: a meta-analysis. Acta Obstet Gynecol Scand 2012; 91:779-93. [DOI: 10.1111/j.1600-0412.2012.01406.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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28
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Savelli L, Testa AC, Mabrouk M, Zannoni L, Ludovisi M, Seracchioli R, Scambia G, De Iaco P. A prospective blinded comparison of the accuracy of transvaginal sonography and frozen section in the assessment of myometrial invasion in endometrial cancer. Gynecol Oncol 2012; 124:549-52. [DOI: 10.1016/j.ygyno.2011.11.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 11/09/2011] [Accepted: 11/11/2011] [Indexed: 10/15/2022]
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Intraoperative frozen section is essential for assessment of myometrial invasion but not for histologic grade confirmation in endometrial cancer: a ten-year experience. Arch Gynecol Obstet 2011; 285:1415-9. [DOI: 10.1007/s00404-011-2135-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 10/27/2011] [Indexed: 10/15/2022]
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Loubeyre P, Undurraga M, Bodmer A, Petignat P. Non-invasive modalities for predicting lymph node spread in early stage endometrial cancer? Surg Oncol 2011; 20:e102-8. [DOI: 10.1016/j.suronc.2011.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Accepted: 01/19/2011] [Indexed: 11/25/2022]
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Yanazume S, Saito T, Eto T, Yamanaka T, Nishiyama K, Okadome M, Ariyoshi K. Reassessment of the utility of frozen sections in endometrial cancer surgery using tumor diameter as an additional factor. Am J Obstet Gynecol 2011; 204:531.e1-7. [PMID: 21420065 DOI: 10.1016/j.ajog.2011.01.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2010] [Revised: 12/09/2010] [Accepted: 01/31/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this study was to improve the reliability of frozen section with the use of tumor diameter (TD) as an additional factor and intraoperatively to identify a subgroup of early endometrial cancers that would not require lymphadenectomy. STUDY DESIGN Data for 228 patients who underwent surgery with frozen section were analyzed retrospectively. Lymphadenectomy was performed in 86% of patients; the nodes were positive in 8%. RESULTS The accuracy of frozen section for myometrial invasion, grade, and low-risk prediction significantly increased with decreasing TD (P = .036) and was 98%, 95%, and 95%, respectively, when the TD was ≤3 cm. Patients with a TD of ≤2 cm and patients with a TD of 2-3 cm who had low-risk predictors had no nodal metastasis; patients with a TD of 2-3 cm who had intermediate-high risk predictors and a TD of >3 cm with any level of risk predictors were at risk of nodal metastases. CONCLUSION When the TD was ≤3 cm, the low-risk group that is defined by frozen section can be predicted accurately and safely to remain lymph-node metastasis free.
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Affiliation(s)
- Shintaro Yanazume
- Gynecology Service, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
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Total Laparoscopic Hysterectomy in Early-Stage Endometrial Cancer Using an Intrauterine Manipulator: Is It a Bias for Frozen Section Analysis? Case-Control Study. J Minim Invasive Gynecol 2011; 18:184-8. [DOI: 10.1016/j.jmig.2010.11.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 11/13/2010] [Accepted: 11/17/2010] [Indexed: 11/23/2022]
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Çelik Ç, Özdemir S, Esen H, Balc O, Ylmaz O. The Clinical Value of Preoperative and Intraoperative Assessments in the Management of Endometrial Cancer. Int J Gynecol Cancer 2010; 20:358-62. [DOI: 10.1111/igc.0b013e3181cff1f3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Assessment of gross examination and frozen section of uterine specimen in endometrial cancer patients. Arch Gynecol Obstet 2010; 282:685-9. [DOI: 10.1007/s00404-010-1387-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2009] [Accepted: 02/01/2010] [Indexed: 11/25/2022]
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Wang X, Zhang H, Di W, Li W. Clinical factors affecting the diagnostic accuracy of assessing dilation and curettage vs frozen section specimens for histologic grade and depth of myometrial invasion in endometrial carcinoma. Am J Obstet Gynecol 2009; 201:194.e1-194.e10. [PMID: 19564019 DOI: 10.1016/j.ajog.2009.05.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2008] [Revised: 01/04/2009] [Accepted: 05/06/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We sought to investigate clinical factors affecting accuracy of dilation and curettage (D&C) and frozen section diagnosis of endometrial cancer. STUDY DESIGN Clinical parameters affecting concordance of D&C or frozen section compared with final hysterectomy pathology were analyzed in 218 patients with endometrial cancer. RESULTS The overall concordance of grade between D&C and final hysterectomy findings was 35.2% (62/176). The following factors increased accuracy of D&C: depth of uterus cavity > or = 9 cm (P = .043), deep (> 50%) myometrial invasion (P = .03), P53 positivity (P = .023), grade 2 (P = .01), and grade 3 (P = .048). When comparing frozen section with final hysterectomy findings, the concordance was 69% (58/84) in tumor grade and 87% (67/77) in myometrial invasion. Postmenopausal bleeding (P = .004) and less resistance index of endometrial lesion blood flow (P = .005) increased efficacy of grade diagnosis by frozen section. CONCLUSION Discordance with hysterectomy assessment was most common for women with D&C or frozen section diagnoses of low-grade superficial cancers.
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Affiliation(s)
- Xipeng Wang
- Department of Obstetrics and Gynecology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Fotiou S, Vlahos N, Kondi-Pafiti A, Zarganis P, Papakonstantinou K, Creatsas G. Intraoperative gross assessment of myometrial invasion and cervical involvement in endometrial cancer: Role of tumor grade and size. Gynecol Oncol 2009; 112:517-20. [DOI: 10.1016/j.ygyno.2008.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2008] [Revised: 11/05/2008] [Accepted: 11/09/2008] [Indexed: 10/21/2022]
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Giede KC, Yen TW, Chibbar R, Pierson RA. Significance of concurrent endometrial cancer in women with a preoperative diagnosis of atypical endometrial hyperplasia. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2008; 30:896-901. [PMID: 19038073 PMCID: PMC2891955 DOI: 10.1016/s1701-2163(16)32969-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Our objectives were (1) to review the rate of concurrent endometrial cancer in patients with a preoperative diagnosis of atypical endometrial hyperplasia (AEH); (2) to determine the proportion of patients with concurrent endometrial cancer who have high-risk disease; and (3) to re-evaluate our surgical management of AEH. METHODS We performed a retrospective chart review of all patients who had surgery on the basis of a preoperative diagnosis of atypical endometrial hyperplasia between January 2001 and December 2006. Demographic data, the method of preoperative diagnosis, postoperative grade of tumour, and other postoperative findings were recorded. When applicable, this included cancer stage, lymph node status, and presence of lymphovascular space invasion. In postoperative review, patients were considered to be high risk if they had disease beyond the uterus or a combination of other risk factors. RESULTS Of 70 patients, 25 (35.7%) were found to have concurrent endometrial cancer. This was higher than the commonly accepted rate of 25% (P = 0.03). Of the 25 patients upgraded, 4 (16%) had high-risk cancer on final pathologic evaluation. CONCLUSION Simple hysterectomy in women with AEH may result in inadequate surgical management. Simple methods are required to identify patients with a preoperative diagnosis of AEH who may harbour significant cancers.
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Affiliation(s)
- Kurt Christopher Giede
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Saskatchewan, Saskatoon SK
| | - Tin-Wing Yen
- Faculty of Medicine University of Saskatchewan, Saskatoon SK
| | - Rajni Chibbar
- Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon SK
| | - Roger A Pierson
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Saskatchewan, Saskatoon SK
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Jha UP, Swasti. Using Intra-Operative Frozen Section (IFS) in Gynaecological Oncology. APOLLO MEDICINE 2008. [DOI: 10.1016/s0976-0016(11)60489-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Egle D, Grissemann B, Zeimet AG, Müller-Holzner E, Marth C. Validation of intraoperative risk assessment on frozen section for surgical management of endometrial carcinoma. Gynecol Oncol 2008; 110:286-92. [PMID: 18653219 DOI: 10.1016/j.ygyno.2008.05.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 04/24/2008] [Accepted: 05/15/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study aimed to evaluate the accuracy of risk assessment in intraoperative frozen section (IFS) in order to direct surgical management and also attempted to validate the clinical significance of using five variables for classification as low- or intermediate high-risk endometrial carcinoma in routine practice. PATIENTS AND METHODS Charts of 410 patients who underwent surgery for endometrial cancer between January 1992 and December 2003 were retrospectively reviewed, and risk assignment on the basis of IFS was compared with final pathological reports. Clinical relevance of risk assessment and its surgical consequences were studied on the basis of patient survival data. RESULTS In 303 (95%) of 318 cases, IFS-assessed risk corresponded with that estimated from final paraffin sections, giving a positive predictive value of 99% and a negative predictive value of 92%. Unrecognized lymphovascular invasion in IFS was the main factor responsible for the discrepancies between the two examinations. Survival analysis showed a highly significantly better outcome for patients with low-risk as compared to intermediate high-risk carcinomas for recurrence-free (RFS) and overall survival (OS). However, survival in patients with intermediate high-risk carcinomas who underwent lymphadenectomy (LNE) was not significantly improved as compared to those who did not. Moreover, in multivariate analysis lymph node involvement did not emerge as a variable with significant impact on survival. Age, tumor stage and intraoperatively assessed risk were seen to be independent prognosticators in this study (p<0.0001). CONCLUSION Our data show that IFS, when performed by experienced gynecopathologists, is a reliable and applicable tool in estimating risk in endometrial cancer and that systematic LNE seems to not be superior to radiotherapy with regard to patient survival.
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Affiliation(s)
- Daniel Egle
- Department of Obstetrics and Gynecology, Innsbruck Medical University, Innsbruck, Austria.
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A Practical Approach to Intraoperative Consultation in Gynecological Pathology. Int J Gynecol Pathol 2008; 27:353-65. [DOI: 10.1097/pgp.0b013e31815c24fe] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ortashi O, Jain S, Emannuel O, Henry R, Wood A, Evans J. Evaluation of the sensitivity, specificity, positive and negative predictive values of preoperative magnetic resonance imaging for staging endometrial cancer. Eur J Obstet Gynecol Reprod Biol 2008; 137:232-5. [DOI: 10.1016/j.ejogrb.2007.02.029] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2005] [Revised: 01/17/2007] [Accepted: 02/14/2007] [Indexed: 11/30/2022]
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Chi DS, Barakat RR, Palayekar MJ, Levine DA, Sonoda Y, Alektiar K, Brown CL, Abu-Rustum NR. The incidence of pelvic lymph node metastasis by FIGO staging for patients with adequately surgically staged endometrial adenocarcinoma of endometrioid histology. Int J Gynecol Cancer 2008; 18:269-73. [PMID: 18334008 DOI: 10.1111/j.1525-1438.2007.00996.x] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The seminal Gynecologic Oncology Group study on surgical pathologic spread patterns of endometrial cancer demonstrated the risk of pelvic lymph node metastasis for clinical stage I endometrial cancer based on tumor grade and thirds of myometrial invasion. However, the FIGO staging system assigns surgical stage by categorizing depth of myometrial invasion in halves. The objective of this study was to determine the incidence of pelvic lymph node metastasis in endometrial cancer based on tumor grade and myometrial invasion as per the current FIGO staging system. We reviewed the records of all patients who underwent primary surgical staging for clinical stage I endometrial cancer at our institution between May 1993 and November 2005. To make the study cohort as homogeneous as possible, we included only cases of endometrioid histology. We also included only patients who had adequate staging, which was defined as a total hysterectomy with removal of at least eight pelvic lymph nodes. During the study period, 1036 patients underwent primary surgery for endometrial cancer. The study cohort was composed of the 349 patients who met study inclusion criteria. Distribution of tumor grade was as follows: grade 1, 80 (23%); grade 2, 182 (52%); and grade 3, 87 (25%). Overall, 30 patients (9%) had pelvic lymph node metastasis. The incidence of pelvic lymph node metastasis in relation to tumor grade and depth of myometrial invasion (none, inner half, and outer half) was as follows: grade 1-0%, 0%, and 0%, respectively; grade 2-4%, 10%, and 17%, respectively; and grade 3-0%, 7%, and 28%, respectively. We determined the incidence of pelvic nodal metastasis in a large cohort of endometrial cancer patients of uniform histologic subtype in relation to tumor grade and a one-half myometrial invasion cutoff. These data are more applicable to current surgical practice than the previously described one-third myometrial invasion cutoff results.
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Affiliation(s)
- D S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York 10021, USA.
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Ali A, Black D, Soslow RA. Difficulties in Assessing the Depth of Myometrial Invasion in Endometrial Carcinoma. Int J Gynecol Pathol 2007; 26:115-23. [PMID: 17413976 DOI: 10.1097/01.pgp.0000233165.56385.0b] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The depth of myometrial invasion (DMI) is one of the most important prognostic indicators and determinants of therapy in endometrial cancer. There are well-documented problems in recognizing DMI. We examined 100 previously diagnosed endometrioid endometrial carcinomas in hysterectomy specimens, reassessed DMI, and explored morphological features that complicated appraisal of myometrial invasion. The DMI was different from the original measurement in 29% of cases. Twelve percent of all cases (40% of cases with measurement discrepancies) involved differences in the assignment of invasion categories (noninvasive, < or =50% myometrial invasion, and >50% myometrial invasion). Nearly all endometrial cancers originally diagnosed as invasive were considered noninvasive on review. We examined whether the distribution of stromal metaplasia, noninvasive patterns (exophytic tumors, irregular endomyometrial junctions, and adenomyosis), and myometrial invasion patterns were different in cases with and without measurement discrepancies. Irregular endomyometrial junctions, exophytic tumors, and adenomyosis tended to coexist and were more common in the cases with DMI discrepancies. Although there seemed to be a relationship between smooth muscle metaplasia and exophytic tumors, it did not appear that smooth muscle metaplasia was significantly more common in cases with measurement difficulties. However, cases with extensive smooth muscle metaplasia posed problems with assessment of myometrial invasion. Patterns of myometrial invasion other than the conventional destructive pattern were sufficiently uncommon as to not impact on DMI measurement in large numbers of cases. Measuring the DMI is usually uncomplicated, but additional scrutiny should be paid to cases involving exophytic tumors, irregular endomyometrial junctions, adenomyosis, and extensive stromal smooth muscle metaplasia.
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Affiliation(s)
- Asya Ali
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Case AS, Rocconi RP, Straughn JM, Conner M, Novak L, Wang W, Huh WK. A Prospective Blinded Evaluation of the Accuracy of Frozen Section for the Surgical Management of Endometrial Cancer. Obstet Gynecol 2006; 108:1375-9. [PMID: 17138769 DOI: 10.1097/01.aog.0000245444.14015.00] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To prospectively evaluate in a blinded fashion the accuracy of frozen section in endometrial cancer. METHODS Sixty patients with endometrial cancer or complex atypical hyperplasia were consecutively enrolled. Intraoperatively, a frozen section was obtained, processed, and stored for interpretation by blinded pathologists. Final pathologic diagnosis was conducted in the usual fashion with the pathologists blinded to frozen results. Histologic grade and myometrial invasion on frozen section was correlated with final pathology. RESULTS Median age was 61 years (range, 39-82 years). Fifty-seven percent of patients were white, and mean body mass index was 40 mg/kg2. Depth of invasion on frozen correlated with final pathology in 67% (95% confidence interval [CI] 55-79%). Twenty-eight percent (95% CI 17-39%) of patients were upstaged from frozen to final. Patients with no invasion on frozen were upstaged in 46% (95% CI 28-64%). Histologic grade on frozen correlated with final pathology in 58% (95% CI 46-70%); 38% (95% CI 26-50%) of patients were upgraded by final grade. Patients with frozen grade 1 histology or less were upgraded in 61% (95% CI 45-77%). Clinically relevant upstaging occurred in 11 patients (18%) (95% CI 8-28%). CONCLUSION Frozen section for histologic grade and depth of myometrial invasion in endometrial cancer correlates poorly with final pathology. Because a large number of patients are potentially understaged with the use of frozen section with a subsequent risk of over and under treatment, we recommend consideration of comprehensive surgical staging for all patients with endometrial cancer. LEVEL OF EVIDENCE II-2.
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Affiliation(s)
- Ashley S Case
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama.
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Abstract
This review analyzes current pitfalls in pretreatment staging of endometrial and cervical carcinoma with magnetic resonance imaging (MRI) based on a critical review of the literature. Technical, patient, and tumor-related characteristics were analyzed to improve further staging of uterine neoplasm with MRI. For endometrial carcinoma staging, contrast-enhanced dynamic imaging appears essential to avoid false-positive findings for deep myometrial invasion by better delineating tumor from normal myometrium. However, leiomyomas, adenomyosis, and grade 3 tumors provide difficulties in staging for pathologists and radiologists. Slice orientation perpendicular to the long axis of the cervical channel might improve false-negative findings for deep stromal invasion on T2-weighted images in endometrial and cervical cancer. Contrast-enhanced sequences do not improve diagnosis of parametrial or vaginal invasion in cervical cancer. Assessment of lymph node invasion by any imaging modality has limited sensitivity in detecting lymph node metastasis smaller than 5 mm. Knowledge of diagnostic criteria is critical to avoid false-negative findings for bladder wall invasion. Higher spatial resolution with dedicated multichannel pelvic phase array coils, smaller fields of view and section thickness, and careful comparison of T2-weighted and contrast-enhanced sequences are strategies that might avoid misinterpretation of pelvic MRI in staging uterine neoplasm.
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Affiliation(s)
- K Kinkel
- Institut de Radiologie, Clinique et fondation des Grangettes, 7, chemin des Grangettes, CH-1224 Chêne-Bougeries, Geneva, Switzerland.
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Pentenero M, Gandolfo S, Carrozzo M. Importance of tumor thickness and depth of invasion in nodal involvement and prognosis of oral squamous cell carcinoma: a review of the literature. Head Neck 2006; 27:1080-91. [PMID: 16240329 DOI: 10.1002/hed.20275] [Citation(s) in RCA: 271] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Oral mucosa squamous cell carcinoma (OSCC) has locoregional evolution, with frequent neck involvement (the most important parameter for prognosis). There are still many doubts concerning the best way to approach N0 neck disease in early-stage lesions (T1 and T2). Many parameters have been studied to identify N0 patients with a high likelihood of harboring occult node metastases or of having them develop. METHODS A review of the studies analyzing "tumor thickness"/"depth of invasion" in predicting regional metastases and survival was undertaken. RESULTS The literature suggests that "tumor thickness"/"depth of invasion" is a reliable parameter for predicting regional nodal involvement and survival in OSCC. CONCLUSIONS Authors are in substantial agreement regarding the reliability of tumor thickness. The lack of comparable study groups, measurement techniques, and cut-off values points to the need for further studies so as to reach a consensus and to develop therapy protocols that include tumor thickness.
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Affiliation(s)
- Monica Pentenero
- Department of Biomedical Sciences and Human Oncology, Oral Medicine Section, University of Turin, Clinica Odontostomatologica, Sezione di Patologia e Medicina Orale, Corso Dogliotti 38, 10126 Torino, Italy.
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Abstract
The use of frozen section has greatly impacted on the care of the gynaecological oncology patient. Frozen section allows intraoperative evaluation to distinguish benign from malignant tumors in order to tailor the extent of surgery necessary. Frozen section diagnosis in gynaecological oncology is sufficiently sensitive and specific for clinical use. Generally, the false negative rate is low and the false positive rate is negligible. Deferred diagnoses or incompatible frozen section diagnosis is usually due to technical limitations especially for the mucinous ovarian tumors. This review summarises the available literature on the accuracy, limitations and role of frozen section for individual gynaecological tumors.
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Affiliation(s)
- M Moodley
- Division of Gynecological Oncology, Nelson R Mandela School of Medicine, Durban, South Africa.
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Frumovitz M, Singh DK, Meyer L, Smith DH, Wertheim I, Resnik E, Bodurka DC. Predictors of final histology in patients with endometrial cancer. Gynecol Oncol 2005; 95:463-8. [PMID: 15581947 DOI: 10.1016/j.ygyno.2004.07.016] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the usefulness of preoperative tumor grade and intraoperative assessment of gross depth of myometrial invasion as "predictors" of final grade, final depth of myometrial invasion and surgical stage in patients with "low-risk" endometrial cancer. METHODS We retrospectively compared preoperative histology and intraoperative gross depth of invasion with final pathologic evaluation on hysterectomy specimens. For patients traditionally considered intraoperatively to be "low-risk" for lymph node metastasis (grade 1 or 2 adenocarcinoma with less than 50% myometrial invasion), "predictors" combining preoperative histology and intraoperative gross depth of myometrial invasion were established; that is, a preoperative biopsy of grade 1 adenocarcinoma with an intraoperative gross depth of myometrial invasion of 30% was assigned the predictor IbG1 (Stage Ib, grade 1). These predictors were then compared to final grade and surgical stage. Sensitivity, specificity, and positive predictive value were then calculated. RESULTS A total of 153 patients had both a preoperative biopsy and intraoperative assessment of gross depth of invasion. Twenty-four patients had the IaG1 predictor; eight had stage IaG1 on final pathologic evaluation (sensitivity, 0.50; specificity, 0.88; positive predictive value, 0.33). Eight patients had the IaG2 predictor; none had stage IaG2 on final pathologic evaluation (sensitivity, 0; specificity, 0.95; positive predictive value, 0). Eighty-nine patients had the IbG1 predictor; forty-six had stage IbG1 on final pathologic evaluation (sensitivity, 0.72; specificity, 0.52; positive predictive value, 0.52). Thirty-two patients had the IbG2 predictor; 11 had stage IbG2 on final pathologic evaluation (sensitivity, 0.46; specificity, 0.84; positive predictive value, 0.34). CONCLUSION A clinically significant number of patients will have more advanced disease than predicted by preoperative or intraoperative prognostic factors. These predictors should not be relied on in the staging of endometrial cancer.
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Affiliation(s)
- Michael Frumovitz
- The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA
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Hernandez E. Comment on "The impact of complete surgical staging on adjuvant treatment decisions in endometrial cancer". Gynecol Oncol 2004; 95:776; author reply 776-7. [PMID: 15582010 DOI: 10.1016/j.ygyno.2004.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2004] [Indexed: 10/26/2022]
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Abstract
Endometrial carcinoma is the most common malignant tumor of the female genital tract in the Western world. Approximately 80% of cases are well- to moderately differentiated (endometrioid) adenocarcinomas, which are confined to the uterine corpus at diagnosis, and thus most can be cured. Conversely, high-grade (ie, clear cell and serous) carcinomas account for only 15% to 20% of cases and show marked nuclear atypia. These tumors usually invade the myometrium and may extend beyond the uterus at the time of hysterectomy. In addition to clinical and morphological differences, these 2 groups of endometrial carcinomas differ in their pathogenesis. Whereas prognosis in the latter group is generally poor, the pathologist's role in establishing the outcome in the former group is crucial. Furthermore, it has become progressively apparent that both groups overlap to some extent, making the dualistic model a guideline at best. Over the last 2 decades, several studies have demonstrated the prognostic importance of various key surgical and pathological parameters, including histological type, histological grade, surgical-pathological stage, depth of myometrial invasion, vascular invasion, and cervical involvement. This review presents the most important prognostic factors of endometrial carcinomas from the pathologist's viewpoint, and attempts to clarify existing conflicts in the classification and diagnosis of these tumors.
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Affiliation(s)
- Jaime Prat
- Department of Pathology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
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