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Huang SY, Chen YY, Tsai CC, Lin H, Ou YC. Evaluating resectoscopy and the levonorgestrel intrauterine system for intermenstrual bleeding associated with cesarean scar defects: A retrospective study of treatment outcomes. J Obstet Gynaecol Res 2024; 50:253-261. [PMID: 37990626 DOI: 10.1111/jog.15840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 11/12/2023] [Indexed: 11/23/2023]
Abstract
AIM To compare and evaluate the efficacy of the levonorgestrel-releasing intrauterine system (LNG-IUD) and resectoscopy remodeling procedure for intermenstrual bleeding associated with previous cesarean delivery scar defect (PCDS). METHODS A retrospective comparative study was conducted on patients with PCDS receiving LNG-IUD (levonorgestrel 20 μg/24 h, N = 33) or resectoscopy remodeling (N = 27). Treatment outcomes were compared over 1, 6, and 12 months. Outcomes in patients with a retroverted or large uterus size, defect size, and local vascularization also were evaluated. RESULTS At 12 months post-treatment, there were no significant differences between groups in efficacy rate; however, the reduction of intermenstrual bleeding days was higher in the LNG-IUD group than in the resectoscopy group (13.6 vs. 8.5 days, p = 0.015). Within the first year, both groups experienced a reduction in bleeding days, but the decrease was greater in the LNG-IUD group. Individuals exhibiting increased local vascularization at the defect site experienced more favorable outcomes in the LNG-IUD group than the resectoscopy group (p = 0.016), and who responded poorly tended to have a significantly larger uterus in the LNG-IUD group (p = 0.019). No significant differences were observed in treatment outcomes for patients with a retroverted uterus or large defect in either group. CONCLUSIONS Our findings support that the LNG-IUD is as effective as resectoscopy in reducing intermenstrual bleeding days associated with PCDS and can be safely applied to patients without recent fertility aspirations. Patients with increased local vascularization observed during hysteroscopy may benefit more from LNG-IUD intervention than resectoscopy.
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Affiliation(s)
- Szu-Yu Huang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Yi Chen
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Chang Tsai
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hao Lin
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Che Ou
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chia-Yi, Taiwan
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2
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Liu N, Lin W, Wang Y, Yao Z, Rivera-Colon G, Li Y, Carrick KS, Chen H, Lucas E, Zheng W. Predicting Progestin Therapy Response With PTEN, PAX2, and β-Catenin in Patients With Endometrioid Precancer. Int J Gynecol Pathol 2024:00004347-990000000-00133. [PMID: 38293998 DOI: 10.1097/pgp.0000000000001008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
This study investigates the predictive value of biomarkers PTEN, PAX2, and β-catenin for therapeutic outcomes in patients with atypical endometrial hyperplasia or endometrioid intraepithelial neoplasia undergoing progestin therapy. In a retrospective study of 128 patients, we analyzed a total of 351 endometrial biopsy samples and categorized outcomes into responders (absence of residual disease) and nonresponders (presence of residual disease). We found aberrant biomarker expression in pretreatment cases: 48% for PTEN, 65% for PAX2, and 36% for β-catenin. Approximately 77.3% of patients responded to progestin treatment, with nonresponders showing significantly higher initial PTEN loss (75.86% vs 39.79%, P < 0.001). Nonresponders also demonstrated significant PTEN loss (53.33% vs 20.55%, P < 0.001), PAX2 loss (57.33% vs 41.22%, P < 0.05), and β-catenin nuclear staining (53.45% vs 27.91%, P < 0.01) in follow-up samples. In addition, nonresponders exhibited lower recovery of intact PTEN and PAX2, along with higher β-catenin aberrancy in cases initially showing normal β-catenin levels. We conclude that persistent aberrant PTEN and PAX2 expression, coupled with emerging aberrant β-catenin in follow-ups, indicates a greater likelihood of treatment failure. Conversely, the absence of these aberrations suggests successful progestin therapy. Our findings highlight the utility of this 3-marker panel in assessing residual disease status and predicting progestin treatment outcomes, thus offering critical insights for patient management.
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Ganesan R, Gilks CB, Soslow RA, McCluggage WG. Survey on Reporting of Endometrial Biopsies From Women on Progestogen Therapy for Endometrial Atypical Hyperplasia/Endometrioid Carcinoma. Int J Gynecol Pathol 2022; 41:142-150. [PMID: 33935157 PMCID: PMC10284089 DOI: 10.1097/pgp.0000000000000791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Histologic assessment of response to progestogen therapy is a cornerstone of nonsurgical management of atypical hyperplasia/low-grade endometrioid carcinoma. Pathologists are required to assess whether there is ongoing preneoplastic or neoplastic change in the biopsies (often multiple) taken during therapy. There have been few studies documenting the specific histologic changes induced by therapeutic progestogens and currently there are no guidelines on terminology used in this scenario. Given the need for uniformity in reporting and the lack of guidance in the current literature, we initiated an online survey (including questions, categories of reporting, and scanned slides for assessment) which was sent to all members of British Association of Gynaecological Pathologists (BAGP) and the International Society of Gynecological Pathologists (ISGyP) with the aim to assess the variability among pathologists in reporting these specimens and to come up with a consensus-based terminology for reporting of endometrial biopsies from women on progestogen therapy for endometrial atypical hyperplasia/endometrioid carcinoma. In total, 95 pathologists participated in this survey. This manuscript elaborates on the results of the survey with recommendations aimed at promoting uniform terminology in reporting these biopsies.
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Affiliation(s)
- Raji Ganesan
- Department of Cellular Pathology, Birmingham Women’s Hospital, Birmingham, United Kingdom
| | - C Blake Gilks
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Robert A Soslow
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - W Glenn McCluggage
- Department of Pathology, Belfast Health and Social Care Trust, Belfast, United Kingdom
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4
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Inzani F, Arciuolo D, Angelico G, Santoro A, Travaglino A, D'Alessandris N, Scaglione G, Valente M, Cianfrini F, Raffone A, Zannoni GF. Assessing Post-Treatment Pathologic Tumor Response in Female Genital Tract Carcinomas: An Update. Front Oncol 2022; 12:814989. [PMID: 35223496 PMCID: PMC8866564 DOI: 10.3389/fonc.2022.814989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/05/2022] [Indexed: 01/05/2023] Open
Abstract
In the last decades, several new therapeutic strategies have been introduced in the field of gynecologic oncology. These include neoadjuvant chemotherapy for high-grade serous tubo-ovarian carcinoma, hormonal fertility-sparing strategies for endometrial cancer, pressurized intraperitoneal aerosol chemotherapy (PIPAC) for surgically incurable peritoneal metastasis, and neoadjuvant treatments for locally advanced cervical carcinomas. All these recent advances lead to the development of novel scoring systems for the evaluation of pathological response related to specific treatments. In this regard, pathological evaluation of the morphological modifications related to these treatments and the definition of a tumor regression grading score have been introduced in clinical practice in order to achieve a more efficient prognostic stratification of patients affected by gynecological malignancies. The aim of the present paper is to provide a detailed review on the post-treatment pathological scoring systems in patients affected by gynecological malignancies.
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Affiliation(s)
- Frediano Inzani
- Unità di Ginecopatologia e Patologia Mammaria, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Damiano Arciuolo
- Unità di Ginecopatologia e Patologia Mammaria, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giuseppe Angelico
- Unità di Ginecopatologia e Patologia Mammaria, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Angela Santoro
- Unità di Ginecopatologia e Patologia Mammaria, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Travaglino
- Unità di Ginecopatologia e Patologia Mammaria, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Nicoletta D'Alessandris
- Unità di Ginecopatologia e Patologia Mammaria, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giulia Scaglione
- Unità di Ginecopatologia e Patologia Mammaria, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Michele Valente
- Unità di Ginecopatologia e Patologia Mammaria, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Federica Cianfrini
- Unità di Ginecopatologia e Patologia Mammaria, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Raffone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.,Division of Gynaecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences (DIMEC), IRCCS Azienda Ospedaliero-Univeristaria di Bologna. S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gian Franco Zannoni
- Unità di Ginecopatologia e Patologia Mammaria, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Istituto di Anatomia Patologica, Università Cattolica del Sacro Cuore, Rome, Italy
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5
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Chang RJ, Rivera-Colon G, Chen H, Niu S, Carrick K, Lucas E, Gwin K, Zheng W. Navigating through perplex morphologic changes after exogenous hormone usage. Semin Diagn Pathol 2021; 39:148-158. [PMID: 34782217 DOI: 10.1053/j.semdp.2021.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/20/2021] [Indexed: 11/11/2022]
Abstract
Clinical application of exogenous hormone as a method of contraception and/or treatment of various gynecologic disorders is exceedingly common. Unfortunately, the concurrent use of these agents also complicates the interpretation of pathology specimens. Various studies have shown that morphologic changes induced by hormonal therapies are present in both non-neoplastic and neoplastic tissues within the women's reproductive tract. It is important to understand the exogenous hormone induced morphologic changes, as it helps the pathologists make the accurate diagnosis, and in turn, guide clinicians to make optimal clinical decisions. In this review, we summarize the morphologic changes in both neoplastic and non-neoplastic endometrial, cervical, and myometrial surgical specimens after hormonal therapies, particularly after progestin treatment. In the endometrium, particularly in the scenario of progestin-treated atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia (AEH/EIN), there is notoriously poor interobserver agreement and difficulty in assessing for the residual disease. We summarize current literature and propose our recommended approach in assessing these challenging endometrial biopsies, including a diagnostic algorism, the use of PAX-2, PTEN, beta-catenin immunohistochemistry panel, as well as consistency in diagnostic wording of the report. In the cervix, progestin makes dysplastic lesions appear metaplastic, thus high-grade squamous dysplastic lesions may be easily missed. Within the myometrium, lesions such as adenomyosis may show various degree of decidualization, while smooth muscle neoplasms may show apoplectic changes, and stromal lesions including endometrial stromal sarcoma may show more eosinophilic cytoplasm. All such changes may pose more or less diagnostic challenges in our daily practice. However, most are readily recognizable when we understand particular hormone related scenarios.
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Affiliation(s)
- Ruby J Chang
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Glorimar Rivera-Colon
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hao Chen
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Shuang Niu
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kelley Carrick
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Elena Lucas
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Katja Gwin
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Wenxin Zheng
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Harold C Simmons Comprehensive Cancer Center at University of Texas Southwestern Medical Center, Dallas, TX, USA.
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6
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He X, Yan L, He C, Zhu C, Mol BW, Zhang J, Huirne JAF. The effect of a hysteroscopic niche resection compared with Levonorgestrel-releasing intrauterine device on postmenstrual spotting in patients with a symptomatic niche in the uterine cesarean scar: A prospective cohort study. Eur J Obstet Gynecol Reprod Biol 2021; 265:66-73. [PMID: 34461384 DOI: 10.1016/j.ejogrb.2021.08.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/09/2021] [Accepted: 08/13/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare the effect of a hysteroscopic niche resection with a Levonorgestrel-releasing intrauterine device (LNG-IUD, 52 mg) on postmenstrual spotting duration in patients with a symptomatic niche in the uterine cesarean scar. STUDY DESIGN This prospective cohort study was conducted at the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, China. Patients with postmenstrual spotting symptomatic niches were allocated to hysteroscopy group or LNG-IUD group based on the shared medical decision-making approach, and were followed up for 1 year after treatment. MAIN OUTCOME MEASURES The primary outcome was reduced postmenstrual spotting days at 6th month after treatment. Secondary outcomes were effectiveness rate (proportion of patients with spotting days reduced by at least 50% from baseline), menstrual characteristics, menstruation satisfaction, direct medical costs, complications and side effects. RESULTS 78 out of the 82 eligible patients were included, 36 patients in both group finished 1-year follow-up. Reduced spotting days at the 6th month was 7 days in LNG-IUD group, significantly higher than 5 days in hysteroscopy group, P = 0.004; The effectiveness rate increased over time within 1 year after the insertion of LNG-IUD (63.89%, 83.33%, 88.89%, 88.89%, P for trend = 0.006), while no trend change was observed in hysteroscopy group (71.05%, 71.05%, 66.67%, 61.11%, P for trend = 0.77). The mean direct medical costs were 817[785,856] $ in the hysteroscopy group and 243[239,255] $ in the LNG-IUD group (p<0.001). 2 patients removed IUD and 2 patients reported weight gain of more than 5 kg and breast distended pain in LNG-IUD group; 2 patients got pregnant in hysteroscopy group. No serious complications were observed in both groups. CONCLUSIONS LNG-IUD is more effective in the treatment of postmenstrual spotting from the 6th month onwards than a hysteroscopic niche resection in patients with a symptomatic niche at lower direct costs.
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Affiliation(s)
- Xiaoqing He
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Li Yan
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Chuqing He
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Chenfeng Zhu
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Ben W Mol
- Department of Obstetrics and Gynecology, Monash University, 246 Clayton Road, Clayton 3168, Victoria, Australia; Aberdeen Centre for Patients's Health Research, University of Aberdeen, Aberdeen, UK
| | - Jian Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China.
| | - J A F Huirne
- Department of Obstetrics and Gynecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Centre, Location AMC and VUmc, Amsterdam, the Netherlands
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7
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Williams AT, Ganesan R. Role of the pathologist in assessing response to treatment of ovarian and endometrial cancers. Histopathology 2020; 76:93-101. [PMID: 31846531 DOI: 10.1111/his.13994] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Standardisation of pathological evaluation of tissue responses to therapy permits robust stratification of patient outcomes for management decisions and allows comparison of results across clinical trials. In gynaecological pathology there are two major areas where pathological assessment of treatment response is currently used to determine ongoing therapy. High-grade serous carcinoma (HGSC) of tubo-ovarian origin frequently presents as high-stage disease and may be managed by neoadjuvant chemotherapy with debulking surgery. The chemotherapy response score (CRS) is a reproducible, validated three-tiered morphological scoring system to assess the response of HGSC to treatment. Interobserver agreement is shown to be substantial following online training, and women with CRS3 have significantly improved progression-free and overall survival. Low-grade endometrioid endometrial cancer and atypical hyperplasia/endometrioid intraepithelial neoplasia may be managed by progestogenic therapy in women who wish to preserve fertility or for whom medical co-morbidities preclude surgical management. The response to treatment is assessed histologically in successive endometrial biopsies. The histological parameters are well described, but the pathological classification of treatment response is still under development. Pathological assessment of the response to treatment is incorporated into clinical guidelines.
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Affiliation(s)
- Anthony T Williams
- Department of Cellular Pathology, 1st Floor Laboratories, Birmingham Women's Hospital, Birmingham, UK
| | - Raji Ganesan
- Department of Cellular Pathology, 1st Floor Laboratories, Birmingham Women's Hospital, Birmingham, UK
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8
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Abstract
Benign endometrial calcifications with or without bone fragments are uncommon clinicopathologic findings. They can be detected during pelvic ultrasonography or as incidental pathologic findings. They have been found to be associated with infertility and menstrual anomalies in young adult patients and in symptomatic postmenopausal women with endometrial atrophy and endometrial polyps. Its exact etiology is unknown, its pathogenesis is controversial, and its clinical importance is not fully validated. We performed a retrospective review study over 7 years and found 11 (0.4%) cases of benign endometrial calcifications. The mean patient age was 45.2 years (range = 20-66 years). All of the women complained of menstrual abnormalities and 4 complained of infertility. Six had a previous procedure of abortion, 2 had oral contraceptive pills, and 4 a course of progesterone therapy. Their size and morphology varied from heterogeneous microcalcifications of variable appearances, shattered glassy chunks to detached bones. Four cases were associated with endometrial polyps, 1 with a placental site nodule, 1 with chronic endometritis, and 1 with endometrial hyperplasia. Most showed secretory endometrial tissue and ciliated cell metaplasia. Two cases showed atrophic endometrium. Etiology and pathogenesis are multifactorial and miscellaneous. Progesterone may play a role. Heterogeneous histomorphologic patterns may carry potential pitfalls. Pathologic recognition is clinically important to reassure clinicians in symptomatic postmenopausal women, alert gynecologists to a treatable albeit rare cause of infertility in younger women, and assist in patients' counselling. We also included cases of calcifications associated with endometrial malignancies to compare and contrast malignant endometrial calcifications with benign endometrial calcifications.
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Revels JW, Dey CB, Aggarwal A, London SS, Katz D, Menias C, Moshiri M. More Than Just 2 Layers: A Comprehensive Multimodality Imaging Review of Endometrial Abnormalities. Curr Probl Diagn Radiol 2019; 49:431-446. [PMID: 31307863 DOI: 10.1067/j.cpradiol.2019.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/06/2019] [Accepted: 06/25/2019] [Indexed: 11/22/2022]
Abstract
Endometrial abnormalities develop in female patients of all ages. Symptoms related to endometrial pathologies are among the most common causes of gynecologist office visits, with the radiologists playing an important role in endometrial evaluation. In some instances, the radiologist may be the first physician to note endometrial pathology. In this article, we will provide a comprehensive review of radiologic modalities utilized in the evaluation of the endometrium, as well as the imaging appearance of various endometrial disease processes.
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Affiliation(s)
| | - Courtney B Dey
- Department of Radiology, Eastern Virginia Medical School, Sentara Norfolk General Hospital, Norfolk, VA
| | - Abhi Aggarwal
- Department of Radiology, Eastern Virginia Medical School, Sentara Norfolk General Hospital, Norfolk, VA
| | - Sean S London
- Department of Radiology, University of Washington, Seattle, WA
| | - Douglas Katz
- Department of Radiology, NYU Winthrop Hospital, Mineola, NY
| | | | - Mariam Moshiri
- Department of Radiology, University of Washington, Seattle, WA
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Philip S, Taylor AH, Konje JC, Habiba M. The levonorgestrel-releasing intrauterine device induces endometrial decidualisation in women on tamoxifen. J OBSTET GYNAECOL 2019; 39:1117-1122. [PMID: 31195902 DOI: 10.1080/01443615.2019.1587600] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
There is conflicting literature on whether the levonorgestrel-releasing intrauterine system (LNG-IUS; Mirena®) induces decidualisation in the tamoxifen-treated endometrium. The expression of the decidualisation marker IGFBP-1 was measured using immunohistochemistry in endometrial biopsies and in serum (using ELISA) of 20 postmenopausal women at the start of tamoxifen-treatment for breast cancer. Ten women were then fitted with LNG-IUS and the other ten received tamoxifen-treatment only and acted as controls. Samples were taken at baseline and after 12 months. At baseline, all endometrial samples were negative for IGFBP-1 and at 12 months, IGFBP-1 was only expressed in the endometria of women fitted with the LNG-IUS, confirming the observed histological features of decidualisation. By contrast, serum IGFBP-1 concentrations were increased by tamoxifen, but not in the group receiving LNG-IUS. In conclusion, tamoxifen induces a rise in serum IGFBP-1 suggesting a systemic, possibly hepatic effect, whilst LNG abrogates this in both the liver and endometrium. Impact statement What is already known on this subject? Previous reports of the use of LNG-IUS in women on tamoxifen have provided conflicting evidence as to whether the endometrium exhibited decidualisation or not. These reports were however based solely on histological examination and lacked supporting biochemical data. What do the results of this study add? After 12 months of treatment with LNG-IUS, the endometria of women on tamoxifen show histological features of decidualisation and the presence of the decidualisation marker IGFBP-1, suggesting that levonorgestrel protects the tamoxifen-treated uterus from additional pathology by causing decidualisation. Serum levels of IGFBP-1 were expected to be a reflection of uterine production, but contrary to expectations, higher levels were identified in women on tamoxifen alone. These data suggest that an inhibition of tamoxifen-induced serum IGFBP-1 production (possibly from a hepatic source) by LNG-IUS occurred and indicates independent systemic effects of both drugs in post menopausal breast cancer patients. What are the implications of these findings for clinical practice and/or further research? This research demonstrated a mechanism for endometrial protection in women on tamoxifen. It also alerts clinicians to the fact that both tamoxifen and LNG-IUS exert systemic effects in this patient group.
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Affiliation(s)
- Sarah Philip
- Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester , Leicester , UK.,Department of Obstetrics & Gynaecology, Royal Berkshire Hospital NHS Foundation Trust , Reading , UK
| | - Anthony H Taylor
- Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester , Leicester , UK.,Department of Molecular and Cell Biology, University of Leicester , Leicester , UK
| | - Justin C Konje
- Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester , Leicester , UK.,Department of Obstetrics and Gynaecology, Sidra Medical and Research Centre , Doha , Qatar
| | - Marwan Habiba
- Reproductive Sciences Section, Department of Cancer Studies and Molecular Medicine, University of Leicester , Leicester , UK.,Department of Health Sciences, Centre for Medicine , Leicester , UK.,Department of Obstetrics & Gynaecology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust , Leicester , UK
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12
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Hanley KZ, Birdsong GG, Mosunjac MB. Recent Developments in Surgical Pathology of the Uterine Corpus. Arch Pathol Lab Med 2017; 141:528-541. [PMID: 28353387 DOI: 10.5858/arpa.2016-0284-sa] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
There have been several updates recently on the classification of uterine tumors. Endometrial carcinomas have traditionally been divided into 2 types, but some are difficult to classify and do not fit readily into either of the currently recognized categories. The Cancer Genome Atlas Research Network has recently defined 4 new categories of endometrial cancer on the basis of mutational spectra, copy number alteration, and microsatellite instability, which might provide independent prognostic information beyond established risk factors. The Society of Gynecologic Oncology, moreover, now recommends systematic screening of every patient with endometrial cancer for Lynch syndrome. The new definition of high-grade endometrial stromal sarcoma disregards the number of mitotic figures as a primary diagnostic criterion and instead specifies moderate atypia still resembling stromal origin but lacking the pleomorphism of undifferentiated uterine sarcoma; these tumors also harbor a JAZF1-SUZ12 gene rearrangement. Mitotic count, atypia, and coagulative necrosis are the main histologic criteria that define leiomyosarcoma. Determining the type of necrosis can be very challenging in patients receiving various treatment modalities for symptomatic fibroids before myomectomy, since key histologic features of ischemic-type necrosis are often absent. Ancillary stains including p16, p53, MIB-1, trichrome, and reticulin may be helpful in tumors harboring necrosis that is difficult to classify. Minimally invasive gynecologic surgeries have introduced histologic artifacts that complicate the diagnosis. It is essential to recognize these as procedure-related artifacts to avoid upstaging tumors and triggering unnecessary adjuvant treatment.
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Affiliation(s)
| | | | - Marina B Mosunjac
- From the Department of Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, Georgia (Dr Hanley); and the Department of Pathology and Laboratory Medicine, Grady Memorial Hospital, Atlanta, Georgia (Drs Birdsong and Mosunjac)
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13
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Association of baseline bleeding pattern on amenorrhea with levonorgestrel intrauterine system use. Contraception 2016; 94:556-560. [PMID: 27364099 DOI: 10.1016/j.contraception.2016.06.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/19/2016] [Accepted: 06/21/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aims to evaluate the effect of baseline bleeding patterns on rates of amenorrhea reported at 12 months in levonorgestrel (LNG) 52 mg intrauterine system (IUS) users. We also assessed the effect of baseline bleeding patterns at 3 and 6 months postinsertion. STUDY DESIGN In this secondary analysis of the Contraceptive CHOICE Project, we included participants who had an LNG-IUS inserted within 1 month of enrollment and continued use for 12 months. Using 12-month telephone survey data, we defined amenorrhea at 12 months of use as no bleeding or spotting during the previous 6 months. We used chi-square and multivariable logistic regression to assess the association of baseline bleeding pattern with amenorrhea while controlling for confounding variables. RESULTS Of 1802 continuous 12-month LNG-IUS users, amenorrhea was reported by 4.9%, 14.8% and 15.4% of participants at 3, 6 and 12 months, receptively. Participants with light baseline bleeding or short duration of flow reported higher rates of amenorrhea at 3 and 6 months postinsertion (p<.03), while LNG-IUS users with heavy or prolonged flow were less likely to report amenorrhea at 3 and 6 months (p<.03). In a multivariable analysis, participants with self-reported heavy bleeding at baseline were less likely to report amenorrhea at 12 months than those who reported moderate bleeding (ORadj, 0.36; 95% CI, 0.16-0.69). CONCLUSION Women with heavier menstrual bleeding are less likely than women with moderate flow to report amenorrhea following 12 months of LNG-IUS use. IMPLICATIONS Baseline heavy menstrual flow reduces the likelihood of amenorrhea with LNG-IUS use, information that could impact contraceptive counseling. Anticipatory counseling can improve method satisfaction and continuation, an important strategy to continue to reduce unintended pregnancy and abortion rates.
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Association of Cervical Microglandular Hyperplasia With Exogenous Progestin Exposure. J Low Genit Tract Dis 2016; 20:162-4. [DOI: 10.1097/lgt.0000000000000176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Endometrial Synovial-like Metaplasia Associated With Levonorgestrel-releasing Intrauterine System. Int J Gynecol Pathol 2015; 34:570-5. [DOI: 10.1097/pgp.0000000000000183] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gallos ID, Devey J, Ganesan R, Gupta JK. Predictive ability of estrogen receptor (ER), progesterone receptor (PR), COX-2, Mlh1, and Bcl-2 expressions for regression and relapse of endometrial hyperplasia treated with LNG-IUS: a prospective cohort study. Gynecol Oncol 2013; 130:58-63. [PMID: 23603367 DOI: 10.1016/j.ygyno.2013.04.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Revised: 04/08/2013] [Accepted: 04/10/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To test the predictive ability of immunohistochemical estrogen receptor(ER), progesterone receptor (PR), COX-2, Mlh1, and Bcl-2 expressions for predicting the outcomes of regression and relapse in women with endometrial hyperplasia treated with the Levonorgestrel-releasing intrauterine system (LNG-IUS). METHODS We recruited prospectively all women diagnosed with complex or atypical complex hyperplasia that underwent treatment with LNG-IUS from August 1998 until September 2008. Immunohistochemistry was performed with conventional methods and recorded using a semi-quantitative score (Q score) by two blinded assessors. Women were followed with endometrial biopsies to record regression and relapse. The biomarker predictive ability was analysed using the Cox proportional hazards model. RESULTS The median follow-up was 72.1 months (IQR 59.1-89.8). The Q score agreement between assessors was 82.6% (K statistic=0.801 ± 0.036). The majority of study participants initially regressed to normal endometrium following LNG-IUS therapy (n = 164 regressed; n = 10 persisted). From the 164 women that regressed with LNG-IUS we were able to assess 152 women for relapse from which 18 relapsed. We found a weak association for persisted endometrial hyperplasia with ER and PR expressions with Q score on the 5th and 10th centiles. No associations were found for COX-2, Mlh1 and Bcl-2 protein expressions for regression and for any of the biomarkers for relapse. CONCLUSION We found that poor expression of ER and PR is weakly associated with persisting endometrial hyperplasia and COX-2, Mlh1, and Bcl-2 expressions are not predictive. None of the biomarkers is predictive for relapse in women with endometrial hyperplasia treated with LNG-IUS.
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Affiliation(s)
- Ioannis D Gallos
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham Women's Hospital, Birmingham B15 2TG, UK.
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Boyd C, McCluggage WG. Unusual morphological features of uterine leiomyomas treated with progestogens. J Clin Pathol 2011; 64:485-9. [DOI: 10.1136/jcp.2011.089664] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundUterine leiomyomas are extremely common in surgical pathology practice and in the vast majority there are no issues in diagnosis. Progestogens are widely prescribed drugs for a variety of indications, including abnormal uterine bleeding, and are often given to women with leiomyomas but the pathological features of leiomyomas treated with progestogens are poorly described.MethodsWe report the pathological features in eight cases of uterine leiomyomas in women who had been treated with oral progestogens or a progestogen-containing intrauterine device; all cases were received in consultation because the features raised concern for leiomyosarcoma, smooth muscle tumour of uncertain malignant potential or a benign leiomyoma with unusual features. Additionally, we reviewed a series of cases of uterine leiomyomas (n=99) in women who exhibited progestogenic effects in the endometrium.ResultsThe morphological features in the consult cases, which were widespread and marked and which varied somewhat from case to case, included small and/or large areas of infarct-type necrosis (sometimes mimicking coagulative tumour cell necrosis) with surrounding increased cellularity, mitotic activity, nuclear pyknosis, cytoplasmic eosinophilia, epithelioid morphology, stromal oedema, haemorrhage, and myxoid change and infiltration by CD56 positive granulated lymphocytes. Sometimes the features resulted in an almost deciduoid appearance. Similar features were present to a minor degree in significant numbers of the additional series of cases.ConclusionsPathologists should be aware of these progestogen-associated features when reporting uterine leiomyomas whether or not the clinician has indicated that the woman is taking progestogens since otherwise a diagnosis of leiomyosarcoma or smooth muscle tumour of uncertain malignant potential may be rendered. Useful features in suggesting a benign leiomyoma, in addition to recognition of the morphological features described which, in combination, are characteristic of progestogens, are the lack of true nuclear atypia and the low mitotic activity away from the abnormal areas.
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Scarselli G, Bargelli G, Taddei GL, Marchionni M, Peruzzi E, Pieralli A, Mattei A, Buccoliero AM, Fambrini M. Levonorgestrel-releasing intrauterine system (LNG-IUS) as an effective treatment option for endometrial hyperplasia: a 15-year follow-up study. Fertil Steril 2011; 95:420-2. [DOI: 10.1016/j.fertnstert.2010.07.1044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 06/18/2010] [Accepted: 07/07/2010] [Indexed: 10/19/2022]
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Thiryayi SA, Rana DN, Wadehra V. Dense deposits in cervical cytology samples of patients fitted with intrauterine contraceptive devices. Diagn Cytopathol 2009; 37:897-8. [PMID: 19217040 DOI: 10.1002/dc.21019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- S A Thiryayi
- Manchester Cytology Centre, Manchester Royal Infirmary, Manchester, United Kingdom.
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The effectiveness of a levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of endometrial hyperplasia—A long-term follow-up study. Eur J Obstet Gynecol Reprod Biol 2008; 139:169-75. [DOI: 10.1016/j.ejogrb.2008.02.022] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Revised: 12/14/2007] [Accepted: 02/23/2008] [Indexed: 11/23/2022]
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