Dissection and reporting of the organs of the female genital tract

Transcription

1 Correspondene to: Mark K Heatley, Department of Histopathology, St James University Hospital, Bekett Street, Leeds, West Yorkshire LS9 7TF, UK Aepted 15 August 2007 Published Online First 7 September 2007 Dissetion and reporting of the organs of the female genital trat M K Heatley The aim of this artile is to provide as omprehensive a review as possible of the tehniques in use in disseting and sampling the major speimens enountered in gynaeologial pratie, whether these have originated from gynaeologial onologists or from gynaeologists who speialise in nonmalignant onditions. A brief desription of relevant histology is provided where onsidered neessary for ompleteness. Where possible I have listed material in boxes rather than providing it as free text in order to save spae and in the hope that these lists will double as heklists when disseting and desribing these speimens or finalising the report for the liniian. Obviously no list an be exhaustive and it goes without saying that any temptation to pigeonhole features of a given speimen into the neessarily limited series of options inluded should be resisted. Common tumour types (eg, adenoarinoma, transitional ell arinoma and squamous ell arinomas), and metastases, melanoma, lymphomas and leukaemias, may our at any site and have been omitted from these heklists to save spae. Finally, I have tried to avoid dupliating material provided in other lassifiation systems unless they have interesting assoiated pathologial feature, an obvious example being the assoiation between lear ell arinoma of the vagina and diethylstilboestrol (DES) exposure in utero. LYMPH NODES It may seem odd that a paper dealing with the female genital organs should begin with an aount of how lymph nodes should be handled, but it is worth desribing it at this point as these speimens may be obtained either as therapeuti lymphadenetomy speimens or as part of a sampling proedure for aners at any of the sites desribed below and the omments are therefore appliable to all these situations. The TNM system speifies that ordinarily six lymph nodes are reovered from an inguinal and 10 from a pelvi lymphadenetomy, but intriguingly the failure to ahieve the number does not alter the nodal staging. 1 It is preferable that the surgeon submits the nodes from eah group he wishes to have assessed separately, as it is often impossible to do this reliably one the anatomial landmarks have been lost when the tissue is removed from the body. Large lymph nodes may need to be setioned to fit in a assette, and more than one assette may need to be used, although several small nodes may be proessed intat together in a single assette. A reord should be made of whih node goes in whih assette (eg, first node in assette A, seond and third nodes in assette B, and so on). Every ACP best pratie lymph node is examined in its entirety unless obviously replaed by tumour when only one setion need be taken providing one is onfident that any periapsular spread has been inluded in the setion. In the report, the number of lymph nodes reovered at eah site, the number involved and a reord of whether there are extranodal deposits or evidene of extraapsular spread is inluded. It has been my pratie for many years to submit all tissue inluding that whih appears to be marosopially fat for histology. Whilst this undoubtedly inreases the lymph node ount as fat replaed nodes may be marosopially indistinguishable from fat, I have never loated tumour in these setions. VAGINA Vaginas themselves are rare speimens, as surgeons are relutant to perform vaginetomies, and when enountered as a omplete organ they are usually part of an exenteration speimen, the dissetion of whih is desribed in the setion below. The site at whih the tumour is loated should be reorded (box 1), but one is usually dependent on the liniian for this information, as most speimens from the vagina are biopsies. Some tumours our in assoiation with pre-existing onditions (eg, lear ell arinomas assoiated with exposure of the patient to DES in utero are an iatrogeni uriosity). (DES is inidentally assoiated with an inreased risk of high-grade ervial intraepithelial neoplasia (CIN) lesions. 2 ) Endometrioid arinoma related to endometriosis and muinous arinomas related to endoerviosis are desribed. EXENTERATION These speimens are usually reeived fixed, but ideally the bladder and/or retum should be inflated with formalin in the fresh state and otton-wool soaked in formalin should be introdued into the vagina. One fixed, the speimen is biseted in the sagittal plane, and both ut surfaes photographed. Essentially the desription of any lesion and the information inluded in the report follows that for eah organ identified in the speimen, as detailed below. It is also important that in addition to the dimensions of the tumour, the distanes to key surfaes or resetion margins of the overall exenteration speimen, whih are not an integral part of any inluded organ, are measured and doumented. Ideally the site from whih any bloks originate should be marked on a photograph. A note should also be made of any fistulae or radiation hanges. J Clin Pathol: first published as /jp on 7 September Downloaded from on 2 May 2018 by guest. Proteted by opyright. J Clin Pathol 2008;61: doi: /jp

2 ACP best pratie Box 1: Information to be inluded in the report of a vagina speimen Nature of speimen: vaginetomy, vagina as part of an exenteration speimen Dimensions: length, width, thikness of wall Site of lesion: anterior/posterior; upper, middle or lower third Appearane of tumour: polypoid, ulerated, pigmented (eg, in melanoma) Dimensions of tumour and distane to resetion margins Histologial type Tumour grade Assoiated intraepithelial neoplasias and their grades(vaginal intraepithelial neoplasia, ervial intraepithelial neoplasia, vulval intraepithelial neoplasia, orrelation with ytologial history may be neessary) Box 2: Information to be inluded in the report of a vulval resetion Speimen type: simple, subutaneous, radial Overall dimensions of the speimen Tissues inluded (skin, vagina, anus, subutaneous tissue, lymph nodes) and their dimensions Site of tumour: left or right, anterior or posterior, labial (minora/majora) lateral or rossing midline, periurethral, perivaginal, perianal, relation to Bartholin s glands Appearane of tumour: warty, verruous, papillary, ulerated Size of tumour: measured in its two maximal horizontal dimensions and the maximum depth of invasion if possible Appearane of tissues adjaent to the tumour: atrophy, keratosis, uleration Resetion margins of tumour: vaginal, urethral, anoretal, skin - side whih is losest to the tumour; the distane to the losest of these should be measured Invasion of strutures adjaent to the tumour Type of tumour: as well as squamous and adenoarinoma, basaloid, warty, verruous, basal ell arinoma, malignant melanoma, and tumours of skin adnexae and Bartholin s gland may our Grade of tumour: well, moderate, poor Lymphovasular invasion: present, absent Surfae dimension and depth of tumour invasion (depth of invasion is defined as the distane between the epithelial/ dermal interfae of the most superfiial dermal papilla and the deepest point of invasion; if it is not possible to give a depth of invasion (eg, due to uleration of the epithelium or improper orientation it may be helpful to the liniian to provide a thikness of the tumour that is visible) Depth of tumour-free dermis, fat, et Dysplasia/intraepithelial neoplasia: presene/absene, grade: Dysplasia in lower third: mild dysplasia vulval intraepithelial neoplasia (VIN) I, vaginal intraepithelial neoplasia (VaIN) I Dysplasia in lower two-thirds: moderate dysplasia VIN II, VaIN II Dysplasia in full thikness: severe dysplasia VIN III, VaIN III Assoiated features in the adjaent non-malignant epidermis: human-papillomavirus-assoiated features, lihen slerosus/ lihen planus, squamous hyperplasia VULVA For malignant disease The type of speimen should be reorded. It is useful to photograph and ink the margins of these speimens and I follow the international maritime onvention by painting the left side red and the right green beause it is easy to remember. The dimensions of the speimen overall and then of all the inluded tissues (skin, vagina, anus and subutaneous tissue) should be measured. The site, size and appearane of the tumour and the distane to the relevant resetion margins are reorded (box 2). Bloks A slie is made through the speimen to inlude the deepest area of invasion of the tumour and adjaent margins. It is often helpful to inlude the losest lateral and deep margin in these bloks (fig 1, a ), if neessary dividing the bloks to ensure they fit into the assette, although in large speimens this is often not possible and these will need to be separately sampled. I prefer to do this irumferentially (fig 1, b), and embed the surfae that is the true limit downward so that it is represented in the first paraffin setion. Any other resetion margins (vaginal, urethral and anal) should also be sampled (fig 1, ), and again depending on the proximity of the tumour this may be irumferential or longitudinal. Peritumoural skin preferably from all four quadrants should also be sampled to exlude or diagnose lihen slerosus or other dermatoses (fig 1, d). It is worth enouraging the surgeon to put a portion of urinary atheter in the urethra to assist in its identifiation and preserve its pateny. I identify and retrieve lymph nodes from any attahed fatty tissue and from the separately submitted lymph node groups. These are handled as for any other site. Xerography has been advoated as a means of failitating their identifiation. 3 Report In the report, speifi features that should be inluded are listed in box 2. The depth of tumour invasion and amount of tumourfree dermis should be measured mirosopially using the vernier sale or eyepiee gratiule. The International Federation of Gyneology and Obstetris (FIGO) lassifies tumours under 20 mm in diameter and less than 1 mm in depth as stage 1a1. The importane of this is that many Figure 1 Diagram showing bloking plan for vulvetomy speimens. J Clin Pathol: first published as /jp on 7 September Downloaded from on 2 May 2018 by guest. Proteted by opyright. 242 J Clin Pathol 2008;61: doi: /jp

3 ACP best pratie surgeons will undertake a groin lymph node dissetion if these dimensions are exeeded. If the surfae of the tumour is ulerated so that a depth annot be provided, I provide a thikness instead, measuring from the surfae of the speimen to the deepest point of invasion. 4 The report should also inlude details of the presene and grade of dysplasia (the term preferred by dermatologists)/vulval intraepithelial neoplasia (VIN, the term preferred by gynaeologists). I mention both systems in my report beause these may be submitted by either dermatologists or gynaeologists, both of whom may be involved in the are of the patient at different times in the natural history of the disease, even if the patient is not being managed in a speialist vulval lini. Vulva: skin removed for intraepithelial neoplasia I photograph, measure and (if they an be orientated) paint these as desribed above, and setion them at 3 mm intervals perpendiular to the muosal/epidermal surfae, marking the site of origin of eah slie on the photograph. They are all embedded with the left-hand side of eah setion in turn faing downward and the obverse surfae marked, usually with a dot of red ink to assist the histotehnologist with orientation. As a result, the first setion from eah blok is 3 mm apart. I prefer to put eah slie in an individual assette, but if there are going to be a lot I double up provided the identity of eah slie an be determined by simply looking at their image on the photographi reord. The main features to inlude in the report are the presene, extent (in terms of the number of bloks involved by VIN) and grade of any intraepithelial neoplasia (VIN I, II or III), and adequay of exision. If this is lose, I measure it. Remember, Paget disease may extend beyond the linially obvious lesion and onsequently these epidermal edges are often involved. Other omments to inlude are the presene or absene of invasive malignany or dermatoses. Vulval and vaginal biopsies (punh and wedge) The number and dimension of eah biopsy are reorded usually by the histotehnologist, although wedge biopsies may require medial input and I treat these as desribed above. At least three and preferably six levels should be ut off eah blok. I do not routinely ask for a fungal stain, though this may be helpful in a non-speifi inflammatory ondition. Remember that these speimens are obtained for a variety of dermatologial onditions and not just the exlusion or diagnosis of malignant and premalignant disease. CERVIX Cervial polyps Unless very large, when a longitudinal slie through the speimen inluding the base of the stalk is representative, all the tissue is embedded. Although it is said that endoervial polyps may give rise to hanges that are onfused with borderline nulear hange or dyskaryosis on ervial ytology, they may be assoiated with a genuine CIN lesion in the adjaent ervix (in 2.7% (95% onfidene interval (CI) 0.5% to 13.8%) of ases in a personal series). In the report, the preise origin of the tissue (endoervial, endometrial, mixed (ie, of probable lower segment origin)) and the diagnosis are given. The presene or absene of invasive malignany or any other abnormalities should also be desribed. Manhester repair These are now rare, but I would handle them as the ervix from a hysteretomy for benign disease as desribed below. Box 3: Histologial assessment of ervial punh biopsies Presene/absene of etoervial squamous epithelium, endoervial glandular epithelium and deeper tissue (ie, endoervial rypts and stroma) Presene/absene of dysplasia: squamous CIN III, II or I; epithelial abnormality of unertain signifiane; glandular dysplasia ervial intraepithelial glandular neoplasia/ adenoarinoma in situ Evidene of wart virus infetion Presene/absene of invasive malignanies Cervial punh biopsy The marosopi desription, whih is usually limited to a dimension, an be left to the histotehnology staff, though large biopsies suh as a wedge speimen may require setioning to fit into a assette. Eosin-stained formalin does not assist in orientating ervial biopsies in my experiene, and tehnologists have omplained that it hampers distinguishing stroma and epithelium when orientating the speimen. They have found it helpful to reeive the biopsy plaed stromal side down on filter paper, even when the speimen detahed from the paper, beause it retains a flat base. 5 6 We routinely examine six histologial levels from eah blok. The greatest yield is obtained in the first three setions, with examination of the further three levels resulting in an inrease in the grade of CIN in about 10% of ases. Arguably, therefore, fewer levels need be ut if loal arrangements allow the pathologist to be onfident that disrepanies between the biopsy and highest grade of dyskaryosis on the previous smear an be reliably identified. The ontent of the report is determined by the National Health Servies Cervial Sreening Program 6 and is summarised in box 3. All grades of CIN, inluding ungradable CIN and epithelial abnormality of unertain signifiane, should be desribed, starting with the highest. The presene of viral features suh as koiloytosis, warty features or a flat ondyloma is mentioned after the CIN. An invasive malignany may be enountered, and estimates of type and grade are possible, though it must be stressed to the liniian verbally or in writing that the biopsy may be nonrepresentative and that the adequay of exision annot usually be predited on this type of speimen. These speimens are not usually suffiiently well orientated to allow a reliable assessment of the depth of invasion and further, uleration of the surfae epithelium redues this measurement s reliability; however, an overall approximate estimation of the dimension may be useful, providing it is made lear verbally or in the report that this measurement is for guidane and may not be reliable. 6 Distintions should be made between those speimens that fail to explain the ytologial and olposopial findings beause they are tehnially inadequate, and those that are adequate but fail to aount for the referral findings. 6 J Clin Pathol: first published as /jp on 7 September Downloaded from on 2 May 2018 by guest. 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4 ACP best pratie Box 4: Information to be inluded in the report of a ervial loop exision/one biopsy speimen Cervial intraepithelial neoplasia (CIN): The speimen is measured and the number of bloks taken reorded All grades present are noted, the highest should be reorded first Are both lips are involved? Is CIN onfined to the endoervial anal? Number of bloks ontaining CIN Involvement of endoervial rypts if present Presene of CIN at speimen edges: eto, endoervial and deep lateral edges Presene of endoervial epithelium at the end of the anal Presene/absene of invasion (If three or more bloks are involved the tumour may be more than 7 mm aross) Evidene of wart virus infetion Glandular dysplasia/intraepithelial neoplasia: Grade high/low Extent Completeness of exision The UK National guidelines 6 omment that a note should be inluded in the report that glandular lesions of the ervix have a high risk of multifoality and residual disease in the form of skip lesions may persist up the anal; similarly, a note should be inluded that the presene of CIN at a speimen limit prohibits a diagnosis of miroinvasive arinoma Loop exision speimen/one These are usually performed when onfirming a ytologial or olposopi diagnosis of squamous CIN, though they are inreasingly performed for ervial intraepithelial glandular neoplasia (CIGN), to exise an etropion, and rarely to diagnose and quantify a known linial or olposopi invasive aner. Cone and large loop exision speimens of ervix These two speimen types are handled essentially in the same way. The report should indiate whether the speimen was reeived in more than one piee, and whih bloks originated from whih piee of tissue. The tissue may be painted with Indian ink and rinsed with aeti aid to ensure the ink stays on the tissue to denote the speimen edges, although diathermy artefat, if severe, may fulfil this role in some large loop speimens. Some pathologists use different olours to mark anterior and posterior surfaes, but I find the ink often runs, ausing onfusion. I do not enourage liniians to pin the piees making up a fragmented speimen on orkboard, as I find this damages the epithelial surfae. A permanent photographi reord of the speimen should be made using the digital or Polaroid amera. 6 Loop exisions should be setioned transversely at regular intervals. Use of a pre-alibrated utting board failitates this, providing the tissue is well fixed and a sharp knife suh as a skin graft blade is used. The utting board I use is prefixed at 3 mm intervals. Eah slie is turned to the right and embedded in individual assettes, and as a result the tissue is examined at equal intervals throughout. It is useful to standardise the sequene with whih bloks are proessed. If the liniian has orientated the speimen, I label Figure 2 Diagram showing bloking system and its rational for loop and one biopsy speimens. the bloks from the extreme left of the speimen (ie, surfae X) moving toward the right, and number those from the anterior lip before the posterior lip (fig 2). I mark the surfae of the blok opposite to the one I wish to have embedded downward, and thus setioned first, with red ink just in ase the tissue should turn in the proessing assette before or during opening. I prefer to put eah piee into a separate assette and mark where they have ome from on a photograph of the speimen, and only divide slies if they are too big to fit into the assette, as introduing a metal instrument into the anal damages the epithelium, espeially the olumnar epithelium. If it is neessary to do this, I squeeze the transverse aspets of the tissue slie and make the anal pout so I an insert the knife without it making ontat with and damaging the epithelium. Over the years, I have found that it is a good poliy to minimise any manipulation of these speimens, as the epithelium, partiularly if there is extensive CIN III, may be very friable and exessive handling may result in its being denuded. The system desribed above is illustrated in the diagram (fig 2) where the initial slies (1 and 2) show etoervix, but as the slies are progressively taken there is a gradual emergene of the olumnar epithelium in the rypts around the anal (3) and then the anal itself inluding the squamoolumnar juntion (4 7). The transverse (fig 2, A and B) and first lateral edges (fig 2, X) of the speimen are examined. Some pathologists turn the first blok through 180 deg before embedding it, arguing that by doing so they get a greater profile of tissue but I would suggest that the resulting setion (alpha) is merely a mirror image of the setion (beta) that is ut from the blok that follows and that unless this first blok is routinely turned through 180 deg re-embedded and a further setion (representing the edge denoted by X in fig 2) is ut, the first 3 mm of tissue are left unrepresented histologially. If the one is more than 25 mm long apial bloks are taken and embedded in the first assette(s). 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5 ACP best pratie All the tissue should be submitted for histology. I resist routinely examining multiple levels, as I believe that it is uneonomi in tehnial and medial time and as experiene has shown that should it be neessary to invert the blok to examine the obverse side, it an ause tehnial diffiulties if exessive levels were taken initially. Should there be a disrepany between the previous ytologial or the olposopi diagnoses and the histologial features, or if the setion, partiularly the squamoolumnar juntion, is inomplete, I examine a single deeper level beause in 6% (95% CI 3.5% to 10.2%) of ases this has resulted in a signifiant inrease in the grade of CIN identified and in 2.5% (95% CI 1.1% to 5.7%) of ases it has allowed its identifiation for the first time. 7 Inverting the last blok (fig 2, setion 9) may be neessary to demonstrate involvement of lateral edge Y (some pathologists argue it is unneessary to do this as the presene of CIN 3 mm from any edge (eg, in setion 9) has the same prognosti signifiane as if definite margin involvement is enountered). If CIN I is present at suh a margin, reent work suggests there is no inreased risk of reurrent disease over patients with lear margins. 8 If stromal invasion is noted in two onseutive bloks (eg, fig2, setions 4 and 6) I ut further levels from these bloks, and I turn the blok preeding the first of these sine the largest tumour profile may be in the preeding slie. Thus inverting blok 3 and setioning into it may provide the best assessment of the ross-setional tumour size in tumour b (fig 2). Report The presene of CIN should be noted and all grades present reorded. I usually make a note of whih bloks are involved in brakets after the grade of CIN, as it is useful if I need to demonstrate this in a hurry at a multidisiplinary meeting, and also beause it gives a semiquantitative indiation of the extent of the disease. I also reord whether both lips are involved, if disease is onfined to the endoervial anal, as this may not be visible olposopially, or if it involves the endoervial rypts Theprognostiimportaneoftheseriteriamaysimplybethat they provide an indiation of the overall size of the area of abnormality. The ondition of the speimen edges and the presene of endoervial or squamous epithelium at the end of the anal is reorded systematially. The presene of glandular dysplasia/intraepithelial neoplasia, whih in the UK is graded as low or high grade, is reorded along similar lines (see box 4). Tumours that are visible to the naked eye are staged as 1b, 1 but, if mirosopi, the tumour should be measured using an eyepiee gratiule or the vernier stage on the side of the mirosope, 15 to establish if it exeeds the riteria for stage 1a1 tumours (7 mm aross by 3 mm deep, below originating epithelium in the rypt or intat surfae), as it may warrant aggressive surgial treatment. The dimensions should be measured on the setion showing the greatest profile. This provides two of the three dimensions ited (ie, one transverse dimension aross the setion and the depth). Even if the tumours are,7 mm aross 6 3 mm deep, the third dimension may exeed 7 mm, and Burghardt, who developed the system of examining parallel setions, advoated multiplying the greatest dimension by 1.5 to arrive at this third dimension. 16 Traditionally British pathologists have sought to establish this third dimension by multiplying the number of involved slies by their thikness. Thus in tumour b (fig 2), where three 3 mm slies are involved, this dimension is up to 9 mm, whereas tumour a with two slies involved is no more than 6 mm thik. To ensure the third dimension of the tumour is not underestimated, I turn the blok preeding the blok from whih the setion first showing tumour was ut, through 180 deg to exlude invasive tumour in it. In tumour a, this is slie 3 (fig 2) and it is not involved, onfirming that it involves only two slies, and, as eah of them is 3 mm thik, it is less than 6 mm (ie, stage 1a1). In ontrast, with respet to tumour b in fig 2, the initial setions would show tumour in slies 4 and 6, whih are in ontinuity but not in setion 3. Turning setion 3 reveals an invasive omponent suggesting invasion over three slies (up to 9 mm, and indeed the largest ross-setional dimensions would be loated as a result of this proess). This method probably overestimates the third dimensions in some ases, but is justified on the basis that tumour is better over treated than under treated. The onsequene of this method of arriving at this third dimension is that the only person who an assess what it is, is the person who ut the ase, as only he/she an be onfident as to whether the bloks were ut at 2, 3 or 4 mm intervals and if they were of equal thikness. Thus the person utting the ase should usually be deferred to when invasive tumour involving more than one ontiguous slie is enountered; this issue may ause problems espeially when aner entre pathologists are reviewing the work of others. (Note: mirosopi tumour invasion and early stromal invasion are desriptive terms that are no longer used to desribe tumours that are less than 1 mm deep 4 ). Another area of ontroversy is when several small foi of miroinvasion, none of whih is more than mm deep but whih are separated by more than 7 mm, are enountered, as in foi and d in fig 2. We will assume that foi d and e in the same slie are also separated by more than 7 mm of noninvasive tissue. The FIGO and TNM lassifiations give no advie as to how best to proeed in this senario. In my view it is illogial to stage widely separated foi that may be onfined to one or two ells as being of stage 1b and presumably therefore warranting radial surgery, whereas two foi eah 3.4 mm aross (fig 2, f and g) separated by less than 0.1 mm of tissue and thus oupying a lateral dimension of less than 7 mm are stage 1a1 and do not warrant suh treatment despite having a greater overall volume. Burghardt, in his paper, desribes adding the volume of suh tumours together, and indeed his prognosti data are based on this strategy. 17 In my experiene, most liniians appreiate this problem and judge eah ase on its merits after disussion with the patient (box 4). Deep resetion edges (the so-alled top hat) Large speimens may warrant being treated as above but on oasion it may be best to plae an inked orientation mark on the speimens to ensure the distal resetion margin is setioned first and proess them intat. In this situation, onsideration should be given to ordering levels at ut up. If this option is taken, a photograph must be available that should be marked to indiate how the speimen was orientated. Invasive tumours are typed using the World Health Organization (WHO) system, whih may be supplemented by onsulting the International Soiety of Gynaeologial Pathologists modifiation. 18 Other useful information is the presene or absene of lymphati/vasular invasion; although this does not alter the stage of the lesion some surgeons will opt for more radial surgery if it is extensive or if the primary tumour shows adenoarinomatous differentiation. Some pathologists also omment as to whether the border of the tumour is onfluent or infiltrative. J Clin Pathol: first published as /jp on 7 September Downloaded from on 2 May 2018 by guest. Proteted by opyright. J Clin Pathol 2008;61: doi: /jp

6 ACP best pratie The desription for the dissetion of hysteretomy speimens in patients with CIN or invasive ervial tumours is inluded in the setion dealing with hysteretomies below. Tissue trauma Opening one biopsy and loop exision speimens may damage the epithelium lining the endoervial anal and may also result in underestimating the dimensions of a peripherally plaed invasive tumour; this pratie and attempts at lok faing an intat speimen should be disouraged. 19 Box 5: Histologial assessment of endometrial samples Phase of yle (proliferative, seretory, menstrual), inative, atrophi, postmenopausal) Inflammation/stromal reation if present Hyperplasia (disordered proliferative endometrium, simple or omplex arhitetural hyperplasia with/without ytologial atypia), intraepithelial neoplasia Malignany (endometrial adenoarinoma should be typed and graded) Vasular lymphati and myometrial invasion if present Endoervial urettings I have not seen a speimen of this type for many years. They should be disouraged, sine if malignant endoervial pathology is present it may render attempts to assess the presene and depth of stromal invasion impossible. Their value therefore seems to be onfined to saying whether or not abnormal epithelium is present and even then it may not be possible to grade it 20 ; this information an be extrated by a ytopathologist from a properly handled ytology speimen. TRANSCERVICAL ENDOMETRIAL RESECTIONS The tissue must be weighed, as this may have prognosti signifiane for the patient. 21 Sine these an be abundant speimens it may be reasonable to sample the material rather than submitting it in total. I reviewed the follow-up of over 200 suh speimens that had been submitted in total, and none (95% CI 0% to 1.9%) was assoiated with a diagnosis of hyperplasia or arinoma; this is perhaps not surprising sine the patients are sreened 22 to ensure they are suitable for suh treatment, usually having one or more hysterosopy and endometrial samplings followed by a prolonged ourse of medial treatment, suh as systemati or loal progestogen, before the transervial resetion of the endometrium (TCRE)! Those ases in the literature where invasive arinoma has first been enountered at TCRE have usually ourred in women whose prior biopsy was obtained with diffiulty, was inadequate or was inonlusive, 23 or where arinoma was present extensively throughout the tissue making its detetion in a sampled speimen likely. 24 There has been a single ase of endometrial intraepithelial neoplasia diagnosed at endometrial resetion. 25 ENDOMETRIAL CURETTINGS AND PIPELLE SPECIMENS The volume of tissue should be estimated. This an be done by using a ruler to measure the aggregated sample size, but like many pathologists I prefer to use a semiquantitative method that ombines ease of use with an immediate estimate of the amount of tissue one should expet on the slide. If less than one-quarter of the assette base is oupied by tissue I desribe the sample as santy, and if more than one-quarter is oupied but it an all be aommodated in one assette I regard it as moderate. Tissue requiring more than one assette is designated bulky and is weighed. The presene of identifiable polyps and their longest dimension is reorded and an estimate of the proportion of tissue omposed of muus or blood is made. I usually examine all the material histologially. Points for the histologial assessment of endometrial samples are listed in box 5. It may be diffiult to give any more preise estimate of the day in the yle from whih the speimen originated than early, mid or late seretory phase if the speimen has not been speially fixed in Bouins or other piri-aid-based fixative. 26 The maturity of the seretory transformation in glands and stroma is assessed beause dyssynhrony may indiate an underlying disturbane in hormone levels or the tissues response to them. The pathologist should not onfine himself to a simple onfirmation or exlusion of malignany beause many benign mimis have features that overlap intra-endometrial adenoarinoma. 27 If hyperplasia is present, it is worth onveying any suspiion of invasive malignany to the liniian. 28 Hyperplasia or malignany should be onsidered and speifially exluded in the report if possible, or typed if present. In biopsy material I prefer to desribe endometrioid adenoarinomas as being well, moderately or poorly differentiated, rather than asribing a FIGO grade to highlight the aknowledged variation (of between 24.6% and 55%) between the grade of endometrial aner on sampling ompared with that in the definitive resetion speimen. 29 FIGO reommend that serous and lear ell arinomas be graded using the nulear grade only, 30 while the WHO regards all suh tumours as being of high grade. 31 I would enourage olleagues to adopt the FIGO pratie, as reognising an inonsistent nulear grade may indiate that the tumour is atually one of the mimis of these high-grade types. In my experiene it is rare to be able to assess the tissue for evidene of lymphati or vasular permeation, and myometrium is rarely inluded in samples exept in high-grade or high-stage tumours. Care should be taken in assessing endoervial fragments espeially if they are involved by tumour, as they may either be the primary soure of a aner that has infiltrated upward into the uterus or seondarily involved by a low-lying endometrial tumour. Neither endometrial biopsy 32 nor imaging 33 alone is suffiient investigation in postmenopausal bleeding, and a ombination of biopsy and transvaginal ultrasound or hysterosopy is advised sine less than 50% of the avity is sampled in most patients, even with dilation and urettage. I omment on the presene of plasma ells, eosinophils, lymphoid folliles and granulomata if I find them, but I am relutant to exlude endometritis if they are absent beause signifiant pelvi inflammatory disease, inluding infetion with Neisseria gonorrhoeae and Chlamydia trahomatis, may have no histologial evidene of endometritis. 39 If inflammatory ells are absent, a stromal reation may herald the onset of plasma ell endometritis. 40 Endometrial polyps Ideally these should be removed intat under hysterosopi ontrol, but in many entres they are removed pieemeal by urettage. The fragments should be weighed and the largest J Clin Pathol: first published as /jp on 7 September Downloaded from on 2 May 2018 by guest. Proteted by opyright. 246 J Clin Pathol 2008;61: doi: /jp

7 ACP best pratie Box 6: Information to be inluded in the report of uterus and ervix speimens Marosopi desription Weight Measurements inluding length, transverse and anteroposterior dimension State of serosa, adhesions, haemosiderin deposits (powder burns), gritty areas suggesting alifiation Vaginal muosa Cervix: Configuration of os slitlike/ parous, irular/ nulliparous Condition of epithelial surfaes (eg, surgial trauma and sarring, polyps, ulers, erosions and large ysts) Uterus: Depth of endometrium Presene of polyps, ysti hange Maximum depth of anterior and posterior myometrium Presene/absene of fibroids, site (submuosal, intramural, subserosal), distortion of avity/ervial anal The dimensions of the largest should be reorded along with the presene of nerosis, haemorrhage, alifiation Presene of previous surgery (eg, sars from Caesarian setion, evidene of myometomy or transervial resetion of the endometrium) Other distortion (eg, biornuate appearane) Presene or absene of adnexa Length and diameter of Fallopian tubes Dimensions and any abnormalities of ovaries Presene of ysts, adhesions, powder burns and whih adnexa they affet Mirosopi desription Cervix: Koiloytosis Glandular or squamous CIN Invasive arinoma (give dimensions) Any other signifiant abnormalities Endometrium: Phase of yle, atrophi, postmenopausal Any signifiant abnormalities (eg, hyperplasia, endometritis) Polyps Hyperplasias Myometrium: Adenomyosis Confirmation that there is no atypia or oagulative type nerosis in the smooth musle masses Fallopian tubes: Any signifiant abnormalities, inluding interruptions or the presene of lips or rings Ovaries: Any signifiant abnormalities suh as funtional or aquired ysts, endometriosis or neoplasia measured. The presene of any areas of nerosis should be noted. Exept for very large polyps or those that are obviously fibroid polyps, they should be examined entirely, as they are said to have twie the risk of harbouring hyperplasia and the same risk of developing arinoma as non-polypoidal endometria, 41 although these aners are often of low stage and grade. 42 Up to 13% of usual endometrial polyps, 43 and nine of 29 patients with polyps showing atypial omplex hyperplasia, have been found to have a arinoma in the adjaent endometrium at hysteretomy. 44 A reent review dealing with the reporting of endometrial biopsy speimens has been provided. 45 Myometomy I usually ount the number of fibroids submitted and give their range of dimensions. Eah should be setioned and one blok from eah submitted. 46 If the fibroid shows any atypial features, additional bloks should be examined. I ontinue to desribe the lesions as fibroids when issuing a report to onvey to everyone reading it, partiularly the patient if they ask to see the report, that there are no histologial onerns about how the lesion will behave, but also inlude the term leiomyoma to satisfy the fastidious. HYSTERECTOMY Although an argument has been advaned for not examining marosopially normal hysteretomy speimens histologially, in a series of 139 speimens, one ase of CIN (0.7%, 95% CI 0.1% to 4.0%), a ondition that in the UK would warrant follow-up with repeat ytology, 47 was deteted. Most pathologists therefore are relutant to abandon some histologial examination of these speimens. The following tehnique is primarily designed to be used for speimens in whih no or only benign anatomial pathology is expeted, and aims to gather the maximum information from the minimum number of bloks, while leaving the speimen in suh a ondition that it is possible to return to it, to take further meaningful bloks should this be neessary. However, it is readily adaptable for use in malignant onditions. 47 Preparation of speimen on reeipt in laboratory If possible, a period of fixation before opening is to be enouraged, as this minimises distortion due to fixation. I am relutant to injet formalin through the ervial os. I believe that it traumatises the anal and if any intra-epithelial neoplasia is present the abnormal epithelium may be sloughed and damaged, limiting histologial assessment. 48 Junior medial staff and tehnologists may prefer to mark the anterior midline of the Figure 3 Cut up of normal uterus. A length of the ervix is amputated by a transverse ut followed by a single anterior midline inision in the uterus from fundus to the lower resetion line. J Clin Pathol: first published as /jp on 7 September Downloaded from on 2 May 2018 by guest. Proteted by opyright. J Clin Pathol 2008;61: doi: /jp

8 ACP best pratie Figure 6 Cut up of normal uterus. Cutting in the sagittal plane until the inferior avity is no longer visible. speimen with ink, paint or a pin. A mm length of the ervix should be partially or ompletely amputated by a transverse ut followed by a single anterior midline inision in the uterus from fundus to the lower resetion line (fig 3). If the avity is not exposed, it may be opened by inserting sissors into the lumen of the avity at the lower uterine segment and utting upward. Piees of pre-soaked tissue are plaed in the inisions to ensure adequate fixation. If large fibroids are to be inised this is preferably done from the serosa, and these too should be stuffed with paper or otton wool. Following fixation, the speimen is weighed and measured (box 6). If the uterus was opened by the surgeon or before undergoing partial fixation it may beome distorted and only the weight and length an be reliably assessed. The speimen is orientated beause the posterior serosal refletion is inferior to the superior refletion and beause the ovaries are situated posterior to the Fallopian tubes. In subtotal speimens, I ink the inferior (ervial/lower segment) resetion line firstly to mark the limit, but mainly beause when it omes to examining the setions it is a onvenient reminder that it is a subtotal speimen and not one that has been inadequately sampled or from whih slides are missing. Beause of the risk of trauma to the anal epithelium, I would disourage probing of the ervial anal. The prior amputation of the ervix provides a flat base on whih it an sit on the benh allowing bloks from anterior and posterior lips of the ervix to be taken in one set of slies using a large knife. I take a full thikness blok from both anterior and posterior lip. Histologial examination of mid line bloks in the ervix from a hysteretomy speimen in whih there is no previous reason to suspet in-situ or invasive neoplasia ombines the optimum yield of linially relevant lesions with an eonomi bloking poliy I also take a thin sliver of the posterior peritoneal refletion as a sreening test to exlude endometriosis from patients who have no history or morphologial evidene of the ondition, embedding it with the posterior lip (fig 4). I feel justified in doing this beause although it adds little to the use of resoures and manpower in the laboratory in 3% (95% CI 1.5% to 6.1%) of hysteretomy speimens from patients with adenomyosis or endometriosis, this was the only site where endometriosis was observed so that its identifiation may be the only explanation for preoperative or indeed postoperative symptoms. If there was more onvining evidene of endometriosis I would of ourse blok the area formally, along with any adhesions and the left and right parametrial tissue or ornua. Endometriosis may our in the ornual serosa in 2.9% of ases (95% CI 1.4% to 5.9%), although eah ase was assoiated with endometriosis in the posterior refletion or adnexa. There may be no need to return Figure 5 Cut up of normal uterus. Parallel slies of the uterine orpus ut in the sagittal plane. Figure 7 ornua. Benign onditions 248 Cut up of normal uterus. Cutting oronally out through the J Clin Pathol 2008;61: doi: /jp J Clin Pathol: first published as /jp on 7 September Downloaded from on 2 May 2018 by guest. Proteted by opyright. Figure 4 Cut up of normal uterus. A thin sliver of the posterior peritoneal refletion is taken.

9 ACP best pratie Figure 9 Cut up of normal uterus. One blok is taken from eah of the anterior and posterior wall, inluding the endometrium, myometrium and serosa. Figure 10 Cut up of normal uterus. Standard endometrial myometrial bloks with fibroids. J Clin Pathol 2008;61: doi: /jp Figure 11 Cut up of normal uterus. Standard endometrial myometrial bloks with fibroids. to a speimen in whih adenomyosis is unexpetedly enountered histologially to exlude serosal endometriosis20 and ertainly, in my experiene, no patient with adenomyosis has been found to have endometriosis onfined to the posterior refletion (95% CI 0% to 4.2%). I examine parallel slies of the uterine orpus in the sagittal plane (fig 5). I ontinue utting in the sagittal plane until the inferior avity is no longer visible (fig 6) and then ut oronally out through the ornua (fig 7) so that I an exlude polyps or small aners at this point marosopially (fig 8). In routine ases, I take one blok eah from the anterior and posterior wall inluding the endometrium, myometrium and serosa (fig 9). The ornua and lower segment/upper ervial anal are speifially examined histologially, only in ases of hyperplasia or ovarian-aquired ysts. Bloks from the three largest fibroids inluding the interfae with myometrium are taken from uteri where the fibroids all have a typial marosopi appearane,3 with more extensive sampling of fibroids with an atypial marosopi appearane suh as areas of nerosis, softening, haemorrhage or alifiation. It may be possible to inlude some or all of these in the standard endometrial myometrial bloks (figs 10 and 11). In ases of suspeted neoplasia in a uterine smooth musle lesion, one blok Figure 12 Cut up of normal uterus. The adnexa are detahed from the main speimen. 249 J Clin Pathol: first published as /jp on 7 September Downloaded from on 2 May 2018 by guest. Proteted by opyright. Figure 8 Cut up of normal uterus. Continued utting through the ornua for marosopial exludion of polyps or small aners.

10 ACP best pratie Figure 13 Cut up of normal uterus. The ovaries are slied at 3 4 mm intervals through the full thikness in the sagittal plane. Figure 14 Cut up of normal uterus. Two omplete slies are taken from eah ovary. Figure 15 Cut up of normal uterus. Bloks of any other marosopi abnormalities are taken. for every 1 or 2 m of maximum dimension is usually reommended. I detah the adnexa from the main speimen (fig 12) before opening the endometrial avity, and slie the ovaries at 3 4 mm intervals through the full thikness in the sagittal plane (fig 13) and take two omplete slies from eah ovary (fig 14). Further bloks of any other marosopi abnormalities are taken (fig 15) and, in partiular, thik-walled ysts should be sampled at one blok per 10 mm diameter. I prefer to sample the uterine adnexa in ontinuity if submitted intat, rather than disseting the tube from the aompanying ovary and soft tissue. In an audit series, 40 of 354 (11.3%, 95% CI 8.4% to 15.0%) patients with endometriosis were desribed as having endometriosis in the peri-adnexal soft tissues; in seven (2%, 95% CI 1.0% to 4.0%) of these patients it was the only site of endometriosis. Very oasionally a aesarian hysteretomy is performed either eletively beause of a malignany (in whih ase the speimen is handled aording to the relevant setion below) or as an emergeny following an obstetri ompliation. The speimen is largely handled following the above protool, with attention to the presene of any laerations or inisions, and whether or not they are sutured. Setions of these and the full thikness of the wall, inluding the plaenta and deidua, are reommended. If giant setions are unavailable, it may be neessary to divide the slie into several bloks marking their origin on a photograph or diagram. It may be neessary to refer to a protool for handling plaental and oasionally, unfortunately, fetal speimens. Speimens removed for malignant onditions are effetively handled as outlined above, but with a more extensive desription and sampling to reflet the anatomial position of the tumour. Hysteretomy for arinoma of the endometrium In the ase of endometrial tumours, the exat loation within the avity should be desribed, though it should be remembered that large lesions might extend over a ombination of these sites. Although the dimensions of the tumour are traditionally measured in three dimensions, from a staging perspetive the most important dimensions are the depth of marosopi extension into the myometrium at the point at whih the tumour extends losest to the serosal surfae and the minimal depth of myometrium unaffeted by tumour, as this allows alulation of the perentage of the thikness of the wall that is infiltrated by tumour; this is a key feature of FIGO staging. Involvement of the ervix, ornua, Fallopian tubes and ovaries should be onfirmed or exluded. The presene or absene of previous surgery (eg, sars from Caesarian setion) may be important as it may provide a point of weakness that failitates tumour invasion. 51 In some parts of the world, these speimens are examined peroperatively to guide the surgeon as to the need to undertake lymph node resetions. However, at least one study has suggested that this results in a higher grade and stage being provisionally assigned to the tumour than is the ase in the final report (p,0.0001). 52 This ould reflet aution on the part of the pathologist who is anxious to ensure that there is no risk of patients being under-treated on the basis of his/her frozen setion opinion. 53 Bloks are taken to onfirm the diagnosis, establish the grade of tumour, espeially endometrioid adenoarinoma, and to establish its stage. Although riteria for grading and staging are well defined, their appliation is not neessarily easy or reproduible. J Clin Pathol: first published as /jp on 7 September Downloaded from on 2 May 2018 by guest. Proteted by opyright. 250 J Clin Pathol 2008;61: doi: /jp

11 ACP best pratie Box 7: Speial features in hysteretomy speimens for endometrial aner Exat loation: anterior or posterior myometrium, fundus, straddling the lower uterine segment/upper endoervial anal, left or right hand side, originating in the ornua, manner of growth (eg, polypoid, solid) Size: superior inferior, anterior posterior, left to right Bloks should inlude the lower segment, ornua and all three planes to define distane to the serosa Type, grade (FIGO grade for endometrioid arinoma; NB squamous areas are not inluded in this grading system; nulear grading for poor prognosis type disease) Presene of haemorrhage/nerosis Edge well defined, infiltrative, assoiated adenomyosis Lymphovasular invasion Bakground endometrium Depth of maximum extension into the myometrium and the minimal depth of myometrium unaffeted by tumour (ie, is tumour onfined to the inner or outer half of the myometrium); serosal involvement Extension of tumour into the lower uterine segment/ervial epithelium and stroma Adnexa, as above Assoiated hormone-produing lesions, suh as theomas Assoiated arinomas (eg, of ovary) Immunophenotype: oestrogen reeptor, progesterone reeptor, p53 Pending a formal internationally agreed system, endometrial stromal saromas and leiomyosaromas if onfined to the uterus are in pratie ut like hysteretomy speimens for epithelial malignanies and similar staging information provided As a minimum, a full thikness blok of eah lip of the ervix should be submitted and if there is tumour in the anal, entrapped in muus or adherent to the surfae the entire anal should be sampled (fig 16, a). 56 I blok the entire anal up front as it saves time, and I ut levels if there is any unertainty as to the involvement of stroma. In addition, I take a blok aross the juntion of the lower uterine segment and upper endoervial anal sine tumour extension into the ervix upstages the tumour to FIGO stage 2 (fig 16, b). These bloks may have to be divided into two or more piees to ensure they fit in the proessing assette. There is urrently some debate in the UK as to how endometrial tumours should be sampled. The traditional pratie has been to ut serial slies in the sagittal plane (fig 16, ), selet that with the greatest depth of tumour infiltration marosopially, and submit the entire slie. In its minimum data set The Royal College of Pathologists 57 has advoated setioning in the oronal plane. Although there is researh to suggest that examination of whole mount transverse setions allows the depth of penetration to be most readily visualised, 58 the President of the British Assoiation of Gynaeologial Pathologists has written to the President of The Royal College of Pathologists reommending that future editions of the ollege s doument revert to the sagittal system (T P Rollason, personal ommuniation, 2007). I suspet that the key point is to remember that the uterus is a threedimensional organ, and that sine the uterine wall an be invaded in any on those planes, a tehnique that examines them Figure 16 Diagram showing bloking system for malignant uterus. all is required. My own pratie is to follow the traditional method, but one the avity begins to peter out (fig 16, d), I rotate the speimen and make transverse setions. I take transverse bloks for histologial assessment at the point at whih tumour infiltrates most deeply into the left and right lateral myometrium (fig 16, d), sine in 13.9% (95% CI 8.4% to 21.9%) ases the right, left or both lateral myometrial bloks have been found to have been invaded. There is also debate as to the best method of examining the ornua. I prefer to ut in an essentially oronal plane as I feel it allows me to inspet the surfae of the endometrium out as far as the isthmus of the tube, and reassure myself as to its involvement (fig 16, e). The myometrium anterior and posterior to the endometrium myometrium juntion an then be trimmed bak so the speimen an be examined in a standard proessing assette. Others prefer to take transverse setions aross the tube at its insertion, moving proximally and progressively sampling more of the juntion of endometrium and myometrium (fig 16f). I feel this method removes the opportunity for a thorough visual inspetion of the ornual endometrium and reprodues information available in the setions taken from the proximal Fallopian tube that will be sampled in any ase, but would onede that from the point of view of staging tumours, there is probably little between the two tehniques and it is a matter of hoie. I found that in 29 of 101 ases (28.7%, 95% CI 20.8% to 38.2%) one or other or both ornua were involved. Although these bloks oasionally revealed a greater proportion of myometrium infiltrated by tumour than in the orpus, in no ase (0%, 95% CI 0% to 3.7%) did it alter the stage of the tumour. Fallopian tubes, ovaries and lymph nodes are sampled as desribed above. Endometrial tumours are typed aording to the WHO lassifiation, 31 but this is not exhaustive and distint entities have sine been introdued into pratie. The tumours are staged aording to the method of the International Union Against Caner 1 ; this also provides a two-stage system for grading endometrioid arinomas based on an appraisal of arhitetural appearane and nulear grade. The assessment of the arhitetural grade requires an assessment of the tumour that has a solid non-glandular onfiguration EXCLUDING the squamous areas; this is not an easy thing to do, but one an draw some omfort from the findings of a morphometri study J Clin Pathol: first published as /jp on 7 September Downloaded from on 2 May 2018 by guest. Proteted by opyright. J Clin Pathol 2008;61: doi: /jp