Diagnosis of Endometrial Biopsies and Curettings

Diagnosis of Endometrial Biopsies and Curettings

Michael T. Mazur RobertJ. Kurman Diagnosis of Endometrial Biopsies and Curettings A Practical Approach With 209 Illustrations t Springer Science+Business Media, LLC

Michael T. Mazur, M.D. Crouse Irving Memorial Hospital State University of New York Health Science Center Syracuse, NY 13210 USA RobertJ. Kurman, M.D. Departments of Gynecology and Obstetrics and Pathology The Johns Hopkins Hospital and The Johns Hopkins University School of Medicine Baltimore, MD 21287 USA Library of Congress Cataloging-in-Publication Data Mazur, Michael T. Diagnosis ofendometrial biopsies and curettings : a practical approach I Michael T. Mazur, RobertJ. Kurman. p. cm. Includes bibliographical references and index. 1. Endometrium-Histopathology. I. Kurman, RobertJ. 11. Tit1e. [DNLM: 1. Endometrium-pathology. 2. Uterine Diseases-pathology. WP 400 M476d 1994] RG318.M39 1994 618.1'407 - dc20 DNLMIDLC for Library of Congress 94-10428 CIP Printed on acid-free paper. ISBN 978-1-4757-3945-9 ISBN 978-1-4757-3943-5 (ebook) DOI 10.1007/978-1-4757-3943-5 1995 Springer Science+Business Media New York Origina11y published by Springer-Verlag New York, Inc. in 1995. Softcover reprint of the hardcover 1 st edition 1995 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher Springer Science+Business Media, LLC except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrievai, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even ifthe former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Production coordinated by Chemow Editorial Services, Inc. and managed by Theresa Komakj manufacturing supervised by Gail Simon. Typeset by Asco Trade Typesetting Ltd., Hong Kong. 9 8 765 432 1

Preface The ineentive for writing this book eame from a short course, "Endometrial Biopsy Interpretation," that we presented for five years at the United States and Canadian Aeademy of Pathology. The enthusiastie response we reeeived from this endeavor prompted us to eonsider writing a praetieal text on the histologie interpretation of these speeimens, whieh are eommonly eneountered in the surgieal pathology laboratory but are given short shrift in standard texts. Several gyneeologie pathology textbooks, such as Blaustein's Pathology ojthe Female Genital Tract, 4th ed. (1994), deseribe the morphologie features and classifieation ofbenign and malignant endometriallesions, but little attention is given to the subtle differenees between physiologie ehanges and pathologie eonditions and the artifaets of biopsy and proeessing. In addition, mieroseopie findings that ean be safely ignored beeause they have no clinieal bearing are gene rally not diseussed in standard texts. It is our impression that it is preeisely these areas that present most of the diffieulties in daily praetiee, more so, in fact, than the diagnosis of a malignant tumor. This text is not a referenee or atlas that deseribes pathologie euriosities that one might never eneounter in a lifetime of praetiee. Instead, we attempt to provide a logieal approach to formulating a pathologie diagnosis from the diverse array offragmented, often seant pie ces oftissue and blood reeeived in the laboratory. As such, the material is presented in a less traditional fashion. Conventional histopathologie classifieations remain an integral part of the text, but the various ehapters foeus on a clinieally oriented approach to the mieroseopie diagnosis of eommon problems. For example, the individual ehapters address the clinieal questions and speeifies of reporting the findings, aspeets that vary aeeording to the patient's age and the clinieal eireumstanees. One important subjeet is that of ehanges in the endometrium indueed by breakdown and bleeding, independently of the underlying pathology. These alterations are highly prevalent in endometrial biopsies and are often misinterpreted, so they are deseribed in detail. The updated World Health Organization classifieation of endometrial hyperplasia is based on the distinetion of atypieal and non-atypieal hyperplasia. This topie is espeeially important, sinee eytologie atypia is the eritieal prognostie feature in their behavior, yet the eharaeteristies of what eonstitutes aty-

VI Preface pia are not weh appreciated. Metaplasia and other benign changes can mimic hyperplasia and carcinoma, so the text focuses on these lesions in detail. Clinical management of endometrial carcinoma is greatly influenced by the histologie evaluation of the curettings. Accordingly, the discussion of endometrial carcinoma considers not only the differential diagnosis, but also the grading of carcinoma and the distinction of endometrial from endocervical primary tumors. Trophoblast presents unique problems in diagnosis. This is largely because the pathologist lacks experience with the diverse morphologie array of trophoblastic changes in benign and malignant lesions. Gestational trophoblastic disease is rare in routine practice. Furthermore, trophoblast of abortion specimens, including the trophoblast of the implantation site, usually receives little scrutiny. Two chapters have been included to cover this complex subject, one devoted to physiologie and one to neoplastic conditons. Almost ah the illustrations used in this text are from biopsies, and some show artifact and distortion, as occurs in routine specimens. We intentionally use this less-than-perfect material, since it better illustrates the problems that the pathologist faces in the interpretation of these specimens. Since this monograph is not a reference text or atlas, we suggest reading it in its entirety in order to appreciate the clinically oriented problemsolving approach that we advocate. We hope that the reader finds this approach informative, useful, and enjoyable. Michael T. Mazur RobertJ. Kurman

Contents Preface... v Chapter Introduction... Chapter 2 Normal Endometrium and Infertility Evaluation... 7 Chapter 3 Pregnancy, Abortion, and Ectopic Pregnancy.. 33 Chapter 4 Gestational Trophoblastic Disease... 63 Chapter 5 Dysfunctional Uterine Bleeding... 89 Chapter 6 Effects of Hormones... 109 Chapter 7 Endometritis... 131 Chapter 8 Polyps... 146 Chapter 9 Endometrial Hyperplasia and Epithelial Cytoplasmic Change... 160 Chapter 10 Endometrial Carcinoma... 184 Chapter 11 Other Tumors.................................. 219 Chapter 12 Methods ofendometrial Evaluation... 244 Index... 255