An audit of Endometrial Pathology cases referred to

NGOCDr Paul Cross

Consultant Cellular PathologistQueen Elizabeth Hospital

Gateshead

Background• Endometrial cancer is one of the commonest

female malignancies, and is on the increase• In the North of England Cancer guidelines, it

outlines that for the northern part of the region:– All cases of suspected or proven endometrial

cancer should be discussed at the NGOC MDT (based at the QEH Gateshead)

– Cases of Grade 1 or 2 endometrial cancer can be treated at Cancer Units

– Cases of Grade 3 of special type (i.e. High grade serous, clear cell, carcinosarcoma) should be treated at the NGOC Cancer centre

WRCFI 2008

MDT review basis• As far as is known all cases of

suspected/proven endometrial malignancy are referred to the NGOC for MDT discussion

• Most cases are routinely reviewed by an NGOC Pathologist for NGOC MDT discussion

• Cases from South Tyneside, Durham Sunderland, Northumbria, QEH are routinely reviewed.

• Cases from Newcastle and Carlisle are reviewed if required (but are always shown by a base pathologist via a TC link for the NGOC MDT discussion)

Study - 1• It appeared that at MDT

review/discussion some cases had the original diagnosis amended, sometimes significantly in that it would affect patient management

• The purpose of the audit was to review all cases referred to the NGOC MDT for discussion of possible/proven endometrial cancer in 2010

Study - 2

• All cases referred to the NGOC MDT (GYREF) for the calendar year 2010 were identified from the QEH Pathology laboratory computer

• All such cases were then ordered by SNOMED code for endometrial pathology

• Cases of non-epithelial uterine malignancy (e.g. Endometrial stromal tumour) were excluded

Results - 1

• In 2010, 506 cases were referred for central pathology review for the NGOC MDT

• Of these 206 (40.7%) were cases of suspected/proven endometrial cancer

• Of these 206, 121 related to biopsies classed as complex atypical hyperplasia (CAH) or worse (23.9% overall, and 58.7% of endometrial cases overall)

Review vs original biopsy diagnosis

(n=121) CAH CAH?G1 G1 G2 G3 SPECIAL TYPE

CAH(n=28)

12 7 4 4 1 (HG SEROUS)

CAH?G1(n=19)

10 6 2 1 (HG SEROUS)

G1(n=30)

27 2 1 (HG SEROUS)

G2(n=20)

18 2 (HG SEROUS X2)

G3(=11)

10 1 (CLEAR CELL)

SPECIAL TYPE(n=13)

13 (HG SEROUS 6, CARCINOSARCOMA 4, CLEAR CELL 3)

Outcome where known on hysterectomy vs biopsy review

diagnosis(n=90) CAH G1 G2 G3 SPECIAL

TYPE

CAH(n=4)

3 1

G1(n=43)

36 5 2

G2(n=20)

2 16 1 1 (HG SEROUS)

G3(n=14)

11 3 (CARCINOSACRCOMA 3)

SPECIAL TYPE(n=9)

9 (HG SEROUS 6, CLEAR CELL 3)

Results• Of the 121 original biopsies, on review 91

(75.2%) were fully agreed with• Two main areas of disagreement on review

were:– i) identification of special type (esp HG serous)

carcinoma (6 cases uplifted, 5 HG serous)(5% overall)

– ii) confident separation of CAH from grade 1 (or worse) endometrial cancer (of 28 cases originally diagnosed as CAH, 11 were uplifted to G1 or G2, and 5 to G3 or special type. Of the 19 CAH?G1 group, 8 were uplifted to G1 or G2, and 1 to special type (HG serous) (42.5% of these two groups overall)

WHO classification – a problem?

• Endometrial hyperplasia– Hyperplasia (typical)

• Simple hyperplasia without atypia• Complex hyperplasia without atypia

(adenomatous without atypia)

– Atypical Hyperplasia• Simple complex hyperplasia (rare)• Complex atypical hyperplasia (adenomatous

with atypia)

• “Atypia” refers to cytological atypia

Why does it matter?• CAH, G1 or G2 tumours are typically

treated with a simple hysterectomy• G3 or special type typically would

require hysterectomy, nodal sampling and may require other omental/peritoneal biopsies

• Washings taken in all cases, but do not affect FIGO staging (under FIGO 2009)

• Understaging (if it can be avoided) may mean a second surgery for the woman

CAH vs G1 endometrial cancer• Features favouring endometrial G1 cancer

are:– Complex back-to-back glands with scanty intervening stroma– Cribriform glands/complex meandering lumina– Intra-glandular bridging– Complex/multi-layered/papillary epithelial projections– Solid non-squamous non-morular areas– Necrosis (glandular +/- stroma)– Bizarre nuclei– Foamy stromal macrophage groups– Often little/no normal endometrium– Invasion (seldom seen!)– High grade features (true clear cell areas, HG serous features, CS )

Back - to - back glands

Cribriform glands

necrosis

Solid areas

Foamy macrophages

HG endometrial cancer• Main types HG serous, clear cell and

carcinosarcoma• This audit highlights HG serous as an issue• Features of HG serous are

– Marked cytological atypia of cells on surface of papillary projections– Papillary areas with slit-like spaces– Tufting/stratification of cells– Secondary papillary projections/bridging between papillae– May have psammoma bodies (not diagnostic, but found in ~30-50%

of cases)– may be seen as an “in situ” change not associated with invasion

What does this audit highlight?• Endometrial pathology is common, and

getting more so• Diagnosis of hyperplasia is problematic,

but neoplasia can (in many cases) be confidently separated from hyperplasia

• Features of special types (esp HG serous) must not be overlooked

• Features which may help in diagnosis of these two areas can be re-iterated to help in diagnosis

• Intend to re-audit in future to assess any future trends