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Walia A, Ladwig NR, Mak JS, Rabban JT. Prevalence of Occult Ovarian Cancer and Metastatic Breast Cancer in Ovarian Ablation Specimens of Patients With Hormone Receptor-Positive Breast Cancer: Implications for Tissue Sampling Strategies, Early Ovarian Cancer Detection and Resource Utilization. Int J Gynecol Pathol 2024:00004347-990000000-00179. [PMID: 38959394 DOI: 10.1097/pgp.0000000000001055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
Bilateral oophorectomy is one method of hormone suppression for premenopausal patients with hormone receptor-positive breast cancer. Such specimens could, in theory, harbor occult early ovarian cancer and/or metastatic breast cancer but guidelines for tissue sampling for pathologic examination remain to be addressed. Therefore, we evaluated oophorectomy specimens from 166 patients who underwent ovarian ablation for hormone receptor-positive breast cancer. Results of germline genetic testing were documented by the surgeon in only 31.3% of the pathology specimen requisition forms, whereas that information was available for 81.3% of patients elsewhere in the electronic medical records. All but 5.2% tested negative for a hereditary ovarian cancer gene pathogenic variant before oophorectomy. Complete tissue sampling was performed in 77.1% of the cases and representative sampling in the remainder. No cases of ovarian cancer were observed. Ovarian metastasis of breast cancer was identified in 9.6% of patients, all of whom were already known to have advanced-stage disease. The number of tissue cassettes per ovary required for complete tissue submission was on average three times higher than that for representative tissue sampling (P < 0.01) and ranged up to 20 cassettes per ovary when multiple follicle cysts were present. We propose that guidelines for tissue sampling in this context be defined by a combination of hereditary risk and macroscopic examination; representative sampling is reasonable for macroscopically normal ovaries in hormone receptor-positive breast cancer patients whose germline genetic testing is negative. Positive genetic test results merit complete tissue submission even if macroscopically normal. This strategy balances the goals of early ovarian cancer detection and optimal resource utilization. However, it depends on clear documentation of genetic test results. Our study demonstrates that many opportunities remain to close gaps in the communication of genetic test results by clinicians submitting oophorectomy specimens for pathologic evaluation.
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Affiliation(s)
- Anjali Walia
- School of Medicine, University of California, San Francisco, California
| | - Nicholas R Ladwig
- Department of Pathology, University of California, San Francisco, California
| | - Julie S Mak
- Cancer Risk Program, University of California, San Francisco, California
| | - Joseph T Rabban
- Department of Pathology, University of California, San Francisco, California
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Talia KL, Parra-Herran C, McCluggage WG. Macroscopic examination of gynaecological specimens: a critial and often underemphasised aspect of pathological reporting. J Clin Pathol 2024; 77:190-203. [PMID: 38373782 DOI: 10.1136/jcp-2023-208832] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/19/2023] [Indexed: 02/21/2024]
Abstract
Pathological examination of surgical specimens and compilation of a surgical pathology report comprises a series of events which includes macroscopic examination and tissue sampling, either complete or selected. This step is critical but often overlooked in the literature and not given the attention it deserves. In this review, we discuss the macroscopic examination and grossing of gynaecological pathology specimens, with reference to national and international protocols. We provide guidance as to the degree of sampling necessary in different scenarios and stress that a common-sense approach is necessary with flexibility in the degree of sampling depending on a variety of factors.
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Affiliation(s)
- Karen L Talia
- Department of Pathology, The Royal Children's Hospital and Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Carlos Parra-Herran
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - W Glenn McCluggage
- Department of Pathology, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
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Hegazy S, Brand RE, Dudley B, Karloski E, Lesnock JL, Elishaev E, Pai RK. Mutation-specific Mismatch Repair-deficient Benign Endometrial Glands in Endometrial Biopsies and Curettings Are a Biomarker of Lynch Syndrome and Associate With Endometrial Carcinoma Development. Am J Surg Pathol 2023; 47:835-843. [PMID: 37226842 DOI: 10.1097/pas.0000000000002061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Endometrial carcinoma is the most common extraintestinal cancer in Lynch syndrome (LS). Recent studies have demonstrated mismatch repair (MMR) deficiency can be detected in benign endometrial glands in LS. We performed MMR immunohistochemistry in benign endometrium from endometrial biopsies and curettings (EMCs) from a study group of 34 confirmed LS patients and a control group of 38 patients without LS who subsequently developed sporadic MLH1-deficient or MMR-proficient endometrial carcinoma. MMR-deficient benign glands were only identified in patients with LS (19/34, 56%) and were not identified in any control group patient (0/38, 0%) ( P < 0.001). MMR-deficient benign glands were identified as large, contiguous groups in 18 of 19 cases (95%). MMR-deficient benign glands were identified in patients with germline pathogenic variants in MLH1 (6/8, 75%), MSH6 (7/10, 70%), and MSH2 (6/11, 55%) but not in patients with variants in PMS2 (0/4). MMR-deficient benign glands were seen in all EMC samples (100%) but in only 46% of endometrial biopsy samples ( P =0.02). Patients with MMR-deficient benign glands were significantly more likely to have endometrial carcinoma (53%) compared with LS patients with only MMR-proficient glands (13%) ( P =0.03). In conclusion, we demonstrated that MMR-deficient benign endometrial glands are frequently identified in EMB/EMC in women with LS and are a specific marker for LS. Women with LS with MMR-deficient benign glands were more likely to have endometrial carcinoma suggesting that MMR-deficient benign glands may be a biomarker of increased risk of endometrial carcinoma development in LS.
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Affiliation(s)
| | | | - Beth Dudley
- Medicine, University of Pittsburgh Medical Center
| | - Eve Karloski
- Medicine, University of Pittsburgh Medical Center
| | - Jamie L Lesnock
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Services, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
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Carsote M, Turturea IF, Turturea MR, Valea A, Nistor C, Gheorghisan-Galateanu AA. Pathogenic Insights into DNA Mismatch Repair (MMR) Genes-Proteins and Microsatellite Instability: Focus on Adrenocortical Carcinoma and Beyond. Diagnostics (Basel) 2023; 13:diagnostics13111867. [PMID: 37296718 DOI: 10.3390/diagnostics13111867] [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: 04/04/2023] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
DNA damage repair pathways, including mismatch repair (MMR) genes, are prone to carcinoma development in certain patients. The assessment of the MMR system is widely recognized as part of strategies concerning solid tumors (defective MMR cancers), especially MMR proteins (through immunohistochemistry), and molecular assays for microsatellite instability (MSI). We aim to highlight the status of MMR genes-proteins (including MSI) in the relationship with ACC (adrenocortical carcinoma) according to current knowledge. This is a narrative review. We included PubMed-accessed, full-length English papers published between January 2012 and March 2023. We searched studies on ACC patients for whom MMR status was assessed, respectively subjects harboring MMR germline mutations, namely Lynch syndrome (LS), who were diagnosed with ACC. MMR system assessments in ACCs involve a low level of statistical evidence. Generally, there are two main types of endocrine insights: 1. the role of MMR status as a prognostic marker in different endocrine malignancies (including ACC)-which is the topic of the present work, and 2. establishing the indication of immune checkpoint inhibitors (ICPIs) in selective, mostly highly aggressive, non-responsive to standard care forms upon MMR evaluation (which belongs to the larger chapter of immunotherapy in ACCs). Our one-decade, sample-case study (which, to our knowledge, it is the most comprehensive of its kind) identified 11 original articles (from 1 patient to 634 subjects per study diagnosed with either ACC or LS). We identified four studies published in 2013 and 2020 and two in 2021, three cohorts and two retrospective studies (the publication from 2013 includes a retrospective and a cohort distinct section). Among these four studies, patients already confirmed to have LS (N = 643, respective 135) were found to be associated with ACC (N = 3, respective 2), resulting in a prevalence of 0.0046%, with a respective of 1.4% being confirmed (despite not having a large amount of similar data outside these two studies). Studies on ACC patients (N = 364, respective 36 pediatric individuals, and 94 subjects with ACC) showed that 13.7% had different MMR gene anomalies, with a respective of 8.57% (non-germline mutations), while 3.2% had MMR germline mutations (N = 3/94 cases). Two case series included one family, with a respective four persons with LS, and each article introduced one case with LS-ACC. Another five case reports (between 2018 and 2021) revealed an additional five subjects (one case per paper) diagnosed with LS and ACC (female to male ratio of 4 to 1; aged between 44 and 68). Interesting genetic testing involved children with TP53-positive ACC and further MMR anomalies or an MSH2 gene-positive subject with LS with a concurrent germline RET mutation. The first report of LS-ACC referred for PD-1 blockade was published in 2018. Nevertheless, the use of ICPI in ACCs (as similarly seen in metastatic pheochromocytoma) is still limited. Pan-cancer and multi-omics analysis in adults with ACC, in order to classify the candidates for immunotherapy, had heterogeneous results, and integrating an MMR system in this larger and challenging picture is still an open issue. Whether individuals diagnosed with LS should undergo surveillance for ACC has not yet been proven. An assessment of tumor-related MMR/MSI status in ACC might be helpful. Further algorithms for diagnostics and therapy, also taking into consideration innovative biomarkers as MMR-MSI, are necessary.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy & C.I. Parhon National Institute of Endocrinology, 011461 Bucharest, Romania
| | - Ionut Florin Turturea
- Department of Orthopedics and Traumatology, Cluj Emergency County Hospital, 400347 Cluj-Napoca, Romania
| | | | - Ana Valea
- Department of Endocrinology, Iuliu Hatieganu University of Medicine and Pharmacy & Clinical County Hospital, 400347 Cluj-Napoca, Romania
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Carol Davila University of Medicine and Pharmacy & Thoracic Surgery Department, Dr. Carol Davila Central Emergency University Military Hospital, 050474 Bucharest, Romania
| | - Ancuta-Augustina Gheorghisan-Galateanu
- Department of Molecular and Cellular Biology, and Histology, Carol Davila University of Medicine and Pharmacy & Department of Endocrinology, C.I. Parhon National Institute of Endocrinology, 011461 Bucharest, Romania
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Schwartz ZP, Li AJ, Walsh CS, Rimel BJ, Alvarado MM, Lentz SE, Cass I. Patterns of care and outcomes of risk reducing surgery in women with pathogenic variants in non-BRCA and Lynch syndrome ovarian cancer susceptibility genes. Gynecol Oncol 2023; 173:1-7. [PMID: 37030072 DOI: 10.1016/j.ygyno.2023.03.017] [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: 12/30/2022] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/10/2023]
Abstract
OBJECTIVES Guidelines recommend risk-reducing bilateral salpingo-oophorectomy (RRSO) for women with pathogenic variants of non-BRCA and Lynch syndrome-associated ovarian cancer susceptibility genes. Optimal timing and findings at the time of RRSO for these women remains unclear. We sought to characterize practice patterns and frequency of occult gynecologic cancers for these women at our two institutions. METHODS Women with germline ovarian cancer susceptibility gene pathogenic variants who underwent RRSO between 1/2000-9/2019 were reviewed in an IRB-approved study. All patients were asymptomatic with no suspicion for malignancy at time of RRSO. Clinico-pathologic characteristics were extracted from the medical records. RESULTS 26 Non-BRCA (9 BRIP1, 9 RAD51C, and 8 RAD51D) and 75 Lynch (36 MLH1, 18 MSH2, 21 MSH6) pathogenic variants carriers were identified. Median age at time of RRSO was 47. There were no occurrences of occult ovarian or fallopian tube cancer in either group. Two patients (3%) in the Lynch group had occult endometrial cancer. Median follow up was 18 and 35 months for non-BRCA and Lynch patients, respectively. No patient developed primary peritoneal cancer upon follow up. Post-surgical complications occurred in 9/101 (9%) of patients. Hormone replacement therapy (HRT) was rarely used despite reported post-menopausal symptoms in 6/25 (23%) and 7/75 (37%) patients, respectively. CONCLUSIONS No occult ovarian or tubal cancers were observed in either group. No recurrent or primary gynecologic-related cancers occurred upon follow-up. Despite frequent menopausal symptoms, HRT use was rare. Both groups experienced surgical complications when hysterectomy and/or concurrent colon surgery was performed suggesting concurrent surgeries should only be performed when indicated.
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Affiliation(s)
- Zachary P Schwartz
- Kaiser Permanente Panorama City Medical Center, Division of Gynecologic Oncology, 13640 Roscoe Blvd., Panorama City, CA 91402, USA.
| | - Andrew J Li
- Cedars-Sinai Medical Center, Samuel Oschin Cancer Center, 127 S. San Vicente Blvd., 7th Floor, Los Angeles, CA 90048, USA.
| | - Christine S Walsh
- University of Colorado Cancer Center, 1665 Aurora Court, Aurora, CO 80045, USA.
| | - B J Rimel
- Cedars-Sinai Medical Center, Samuel Oschin Cancer Center, 127 S. San Vicente Blvd., 7th Floor, Los Angeles, CA 90048, USA.
| | - Monica M Alvarado
- Kaiser Permanente Southern California Regional Genetic Services, 393 E. Walnut St. 6 SW, Pasadena, CA 91188, USA.
| | - Scott E Lentz
- Kaiser Permanente Los Angeles Medical Center, Gynecology Oncology Department, 4950 W., Sunset Blvd., Los Angeles, CA 90027, USA.
| | - Ilana Cass
- Dartmouth Hitchcock Medical Center, Department of Obstetrics and Gynecology, 1 Medical, Center Drive, Lebanon, NH 03756, USA.
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Umemiya M, Horikawa N, Kanai A, Saeki A, Ida K, Makio S, Yoshida T, Tsuji M, Gou R, Tani H, Usui T, Kosaka K. Endometrial Cancer Diagnosed at an Early Stage during Lynch Syndrome Surveillance: A Case Report. Case Rep Oncol 2023; 16:634-639. [PMID: 37933313 PMCID: PMC10625814 DOI: 10.1159/000531837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/21/2023] [Indexed: 11/08/2023] Open
Abstract
Lynch syndrome is an autosomal dominant inherited disorder caused by a germline pathogenic variant in DNA mismatch repair genes, resulting in multi-organ cancer. Annual transvaginal ultrasonography and endometrial biopsy are recommended for endometrial cancer surveillance in patients with Lynch syndrome in several guidelines; however, evidence is limited. Here, we present the case of a 51-year-old woman with endometrial cancer who underwent robot-assisted laparoscopic simple hysterectomy at an early stage detected by Lynch syndrome surveillance. The patient was a 51-year-old gravida zero woman without any medical history or symptoms. Her sister suffered from bladder, breast, rectal, and endometrial cancer and was diagnosed with Lynch syndrome using a hereditary cancer panel test (VistaSeq®). During gynecologic surveillance, the patient's endometrial cytology was classified as Papanicolaou class III. Therefore, she underwent endometrial curettage with hysteroscopy and was diagnosed with atypical endometrial hyperplasia. Robot-assisted hysterectomy was performed with a final pathological diagnosis of endometrial cancer (endometrioid carcinoma, Grade 1), stage 1A. She has remained disease-free for more than 12 months. Owing to advances in genetic medicine, prophylactic and therapeutic surgeries for hereditary cancers are increasing. To achieve an early diagnosis and treatment of Lynch syndrome-associated cancers, the importance of Lynch syndrome surveillance should be more widely recognized.
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Affiliation(s)
- Maki Umemiya
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Naoki Horikawa
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Ami Kanai
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Ayaka Saeki
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Kohei Ida
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Satoru Makio
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Teruki Yoshida
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Mitsuru Tsuji
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Rei Gou
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Hirohiko Tani
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
| | - Takeshi Usui
- Department of Genetics, Shizuoka General Hospital, Shizuoka, Japan
- Shizuoka Graduate University of Public Health, Shizuoka, Japan
| | - Kenzo Kosaka
- Department of Obstetrics and Gynecology, Shizuoka General Hospital, Shizuoka, Japan
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Lim N, Hickey M, Young GP, Macrae FA, Kelly C. Screening and risk reducing surgery for endometrial or ovarian cancers in Lynch syndrome: a systematic review. Int J Gynecol Cancer 2022; 32:646-655. [PMID: 35437274 PMCID: PMC9067008 DOI: 10.1136/ijgc-2021-003132] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Lynch syndrome is a hereditary cancer syndrome caused by mismatch repair gene mutations, and female carriers are at an increased risk of endometrial and ovarian cancer. The best approach to screening is not yet clear and practice varies across countries and centers. We aimed to provide evidence to inform the best approach to screening and risk reduction. Methods A systematic search of the literature was conducted (Medline, Embase, PubMed). Studies evaluating the following were included: women with Lynch syndrome (by mismatch repair mutation or Amsterdam II criteria), screening methods for endometrial and/or ovarian cancer, intervention included endometrial biopsy, transvaginal ultrasound, or serum cancer antigen 125 (CA-125), outcomes evaluated were number of cancers and/or endometrial hyperplasia. Results A total of 18 studies of Lynch syndrome carriers which screened for endometrial cancer using transvaginal ultrasound and/or hysteroscopy/endometrial biopsy revealed an incidence of 3.9% at the time of screening. Most (64.1%) endometrial cancers detected were from screening, with the balance detected in symptomatic women at the first screening visits, regular review, or between screening intervals. In mismatch repair carriers, the overall sensitivity of endometrial screening was 66.7%, and the number needed to screen ranged between 4 and 38 (median 7). The sensitivity of endometrial biopsy was 57.1% and the number needed to screen was 23–380 (median 78). The sensitivity of transvaginal ultrasound was 34.4% and the number needed to screen was 35–973 (median 170). Fourteen studies which screened for ovarian cancer using transvaginal ultrasound and/or CA-125 revealed an incidence of 1.3% at the time of screening and 42.9% of ovarian cancers were detected at asymptomatic screening. The sensitivity of ovarian screening was 54.6%, and the number needed to screen was 9–191 (median 23) in mismatch repair carriers. Thirteen studies reported 5.8% incident endometrial cancers and 0.5% ovarian cancers at time of risk reducing surgery. Conclusions There is limited evidence to support screening for endometrial and ovarian cancer in Lynch syndrome and data on mortality reduction are not available. Further prospective, randomized trials comparing targeted screening methods are needed. Risk reducing surgery remains the most reliable way to reduce endometrial and ovarian cancer risk in Lynch syndrome.
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Affiliation(s)
- Natalie Lim
- The University of Melbourne Melbourne Medical School, Melbourne, Victoria, Australia
| | - Martha Hickey
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Graeme P Young
- Cancer Research, Flinders Health and Medical Research Institute, Flinders University College of Medicine and Public Health, Bedford Park, South Australia, Australia
| | - Finlay A Macrae
- Department of Medicine, The University of Melbourne Medicine at Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Christabel Kelly
- Department of Gastroenterology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
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Hegazy S, Brand RE, Dudley B, Karloski E, Bhargava R, Elishaev E, Pai RK. DNA mismatch repair-deficient non-neoplastic endometrial glands are common in Lynch syndrome patients and are present at a higher density than in the colon. Histopathology 2021; 79:573-583. [PMID: 33847404 DOI: 10.1111/his.14386] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 12/27/2022]
Abstract
AIMS The hallmark of Lynch syndrome (LS) is DNA mismatch repair protein (MMR) deficiency. Recently, MMR deficiency in non-neoplastic colonic crypts has been identified as a novel indicator of LS. We aimed to determine whether MMR-deficient non-neoplastic endometrial glands can distinguish patients with and without LS, and to compare the level of MMR deficiency in the normal endometrium and colon in LS patients. METHODS AND RESULTS We evaluated the immunohistochemical expression of MMR proteins in the normal endometrial mucosa from 64 patients, including 34 patients with confirmed LS (17 with endometrial cancer and 17 without cancer), 30 patients with endometrial cancer without LS (10 with tumours with MLH1 promoter hypermethylation and 20 with MMR-proficient tumours), and in the normal colonic mucosa from 30 LS patients. MMR-deficient non-neoplastic endometrial glands were identified in 47% of LS patients and in no patients without LS (P < 0.001). MMR-deficient non-neoplastic glands were more often identified in LS patients with endometrial cancer (65%) than in those without endometrial cancer (29%) (P = 0.04). In contrast to what was seen in the normal colon, MMR-deficient glands in the normal endometrium were seen as large, contiguous groups, ranging in number from two to 101 (87% versus 45%, P = 0.02). MMR-deficient glands were identified at a higher density in the endometrium than in the colon in LS patients (median number of MMR-deficient glands, 22 versus two, P = 0.02). CONCLUSIONS Our findings indicate that MMR-deficient non-neoplastic endometrial glands constitute an indicator of LS, and that MMR-deficient glands in the endometrium are present in a pattern of contiguous large groups.
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Affiliation(s)
- Shaymaa Hegazy
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Randall E Brand
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Beth Dudley
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Eve Karloski
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rohit Bhargava
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Esther Elishaev
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Reetesh K Pai
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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