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ACP BEST PRACTICE |
Correspondence to:
Mark K Heatley, Department of Histopathology, St James’ University Hospital, Beckett Street, Leeds, West Yorkshire LS9 7TF, UK
Accepted 15 August 2007
The aim of this article is to provide as comprehensive a review as possible of the techniques in use in dissecting and sampling the major specimens encountered in gynaecological practice, whether these have originated from gynaecological oncologists or from gynaecologists who specialise in non-malignant conditions. A brief description of relevant histology is provided where considered necessary for completeness.
Where possible I have listed material in boxes rather than providing it as free text in order to save space and in the hope that these lists will double as checklists when dissecting and describing these specimens or finalising the report for the clinician. Obviously no list can be exhaustive and it goes without saying that any temptation to pigeonhole features of a given specimen into the necessarily limited series of options included should be resisted. Common tumour types (eg, adenocarcinoma, transitional cell carcinoma and squamous cell carcinomas), and metastases, melanoma, lymphomas and leukaemias, may occur at any site and have been omitted from these checklists to save space. Finally, I have tried to avoid duplicating material provided in other classification systems unless they have interesting associated pathological feature, an obvious example being the association between clear cell carcinoma of the vagina and diethylstilboestrol (DES) exposure in utero.
 | LYMPH NODES |
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The TNM system specifies that ordinarily six lymph nodes are recovered from an inguinal and 10 from a pelvic lymphadenectomy, but intriguingly the failure to achieve the number does not alter the nodal staging.1 It is preferable that the surgeon submits the nodes from each group he wishes to have assessed separately, as it is often impossible to do this reliably once the anatomical landmarks have been lost when the tissue is removed from the body. Large lymph nodes may need to be sectioned to fit in a cassette, and more than one cassette may need to be used, although several small nodes may be processed intact together in a single cassette. A record should be made of which node goes in which cassette (eg, first node in cassette A, second and third nodes in cassette B, and so on). Every lymph node is examined in its entirety unless obviously replaced by tumour when only one section need be taken providing one is confident that any pericapsular spread has been included in the section.
In the report, the number of lymph nodes recovered at each site, the number involved and a record of whether there are extranodal deposits or evidence of extracapsular spread is included.
It has been my practice for many years to submit all tissue including that which appears to be macroscopically fat for histology. Whilst this undoubtedly increases the lymph node count as fat replaced nodes may be macroscopically indistinguishable from fat, I have never located tumour in these sections.
| VAGINA |
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Vaginas themselves are rare specimens, as surgeons are reluctant to perform vaginectomies, and when encountered as a complete organ they are usually part of an exenteration specimen, the dissection of which is described in the section below.
The site at which the tumour is located should be recorded (box 1), but one is usually dependent on the clinician for this information, as most specimens from the vagina are biopsies. Some tumours occur in association with pre-existing conditions (eg, clear cell carcinomas associated with exposure of the patient to DES in utero are an iatrogenic curiosity). (DES is incidentally associated with an increased risk of high-grade cervical intraepithelial neoplasia (CIN) lesions.2) Endometrioid carcinoma related to endometriosis and mucinous carcinomas related to endocervicosis are described.
| EXENTERATION |
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| VULVA |
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For malignant disease
The type of specimen should be recorded. It is useful to photograph and ink the margins of these specimens and I follow the international maritime convention by painting the left side red and the right green because it is easy to remember. The dimensions of the specimen overall and then of all the included tissues (skin, vagina, anus and subcutaneous tissue) should be measured. The site, size and appearance of the tumour and the distance to the relevant resection margins are recorded (box 2).
Blocks
A slice is made through the specimen to include the deepest area of invasion of the tumour and adjacent margins. It is often helpful to include the closest lateral and deep margin in these blocks (fig 1, a–c), if necessary dividing the blocks to ensure they fit into the cassette, although in large specimens this is often not possible and these will need to be separately sampled. I prefer to do this circumferentially (fig 1, b), and embed the surface that is the true limit downward so that it is represented in the first paraffin section. Any other resection margins (vaginal, urethral and anal) should also be sampled (fig 1, c), and again depending on the proximity of the tumour this may be circumferential or longitudinal. Peritumoural skin preferably from all four quadrants should also be sampled to exclude or diagnose lichen sclerosus or other dermatoses (fig 1, d). It is worth encouraging the surgeon to put a portion of urinary catheter in the urethra to assist in its identification and preserve its patency.
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Report
In the report, specific features that should be included are listed in box 2. The depth of tumour invasion and amount of tumour-free dermis should be measured microscopically using the vernier scale or eyepiece graticule. The International Federation of Gynecology and Obstetrics (FIGO) classifies tumours under 20 mm in diameter and less than 1 mm in depth as stage 1a1. The importance of this is that many surgeons will undertake a groin lymph node dissection if these dimensions are exceeded. If the surface of the tumour is ulcerated so that a depth cannot be provided, I provide a thickness instead, measuring from the surface of the specimen to the deepest point of invasion.4
The report should also include details of the presence and grade of dysplasia (the term preferred by dermatologists)/vulval intraepithelial neoplasia (VIN, the term preferred by gynaecologists). I mention both systems in my report because these may be submitted by either dermatologists or gynaecologists, both of whom may be involved in the care of the patient at different times in the natural history of the disease, even if the patient is not being managed in a specialist vulval clinic.
Vulva: skin removed for intraepithelial neoplasia
I photograph, measure and (if they can be orientated) paint these as described above, and section them at 3 mm intervals perpendicular to the mucosal/epidermal surface, marking the site of origin of each slice on the photograph. They are all embedded with the left-hand side of each section in turn facing downward and the obverse surface marked, usually with a dot of red ink to assist the histotechnologist with orientation. As a result, the first section from each block is 3 mm apart. I prefer to put each slice in an individual cassette, but if there are going to be a lot I double up provided the identity of each slice can be determined by simply looking at their image on the photographic record.
The main features to include in the report are the presence, extent (in terms of the number of blocks involved by VIN) and grade of any intraepithelial neoplasia (VIN I, II or III), and adequacy of excision. If this is close, I measure it. Remember, Paget disease may extend beyond the clinically obvious lesion and consequently these epidermal edges are often involved.
Other comments to include are the presence or absence of invasive malignancy or dermatoses.
Vulval and vaginal biopsies (punch and wedge)
The number and dimension of each biopsy are recorded usually by the histotechnologist, although wedge biopsies may require medical input and I treat these as described above. At least three and preferably six levels should be cut off each block. I do not routinely ask for a fungal stain, though this may be helpful in a non-specific inflammatory condition. Remember that these specimens are obtained for a variety of dermatological conditions and not just the exclusion or diagnosis of malignant and premalignant disease.
| CERVIX |
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In the report, the precise origin of the tissue (endocervical, endometrial, mixed (ie, of probable lower segment origin)) and the diagnosis are given. The presence or absence of invasive malignancy or any other abnormalities should also be described.
Manchester repair
These are now rare, but I would handle them as the cervix from a hysterectomy for benign disease as described below.
The macroscopic description, which is usually limited to a dimension, can be left to the histotechnology staff, though large biopsies such as a wedge specimen may require sectioning to fit into a cassette. Eosin-stained formalin does not assist in orientating cervical biopsies in my experience, and technologists have complained that it hampers distinguishing stroma and epithelium when orientating the specimen. They have found it helpful to receive the biopsy placed stromal side down on filter paper, even when the specimen detached from the paper, because it retains a flat base.5 6
We routinely examine six histological levels from each block. The greatest yield is obtained in the first three sections, with examination of the further three levels resulting in an increase in the grade of CIN in about 10% of cases. Arguably, therefore, fewer levels need be cut if local arrangements allow the pathologist to be confident that discrepancies between the biopsy and highest grade of dyskaryosis on the previous smear can be reliably identified.
The content of the report is determined by the National Health Services Cervical Screening Program6 and is summarised in box 3.
All grades of CIN, including ungradable CIN and epithelial abnormality of uncertain significance, should be described, starting with the highest. The presence of viral features such as koilocytosis, warty features or a flat condyloma is mentioned after the CIN.
An invasive malignancy may be encountered, and estimates of type and grade are possible, though it must be stressed to the clinician verbally or in writing that the biopsy may be non-representative and that the adequacy of excision cannot usually be predicted on this type of specimen. These specimens are not usually sufficiently well orientated to allow a reliable assessment of the depth of invasion and further, ulceration of the surface epithelium reduces this measurement’s reliability; however, an overall approximate estimation of the dimension may be useful, providing it is made clear verbally or in the report that this measurement is for guidance and may not be reliable.6
Distinctions should be made between those specimens that fail to explain the cytological and colposcopical findings because they are technically inadequate, and those that are adequate but fail to account for the referral findings.6
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Box 4: Information to be included in the report of a cervical loop excision/cone biopsy specimen
Cervical intraepithelial neoplasia (CIN):
Glandular dysplasia/intraepithelial neoplasia:
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These are usually performed when confirming a cytological or colposcopic diagnosis of squamous CIN, though they are increasingly performed for cervical intraepithelial glandular neoplasia (CIGN), to excise an ectropion, and rarely to diagnose and quantify a known clinical or colposcopic invasive cancer.
Cone and large loop excision specimens of cervix
These two specimen types are handled essentially in the same way. The report should indicate whether the specimen was received in more than one piece, and which blocks originated from which piece of tissue. The tissue may be painted with Indian ink and rinsed with acetic acid to ensure the ink stays on the tissue to denote the specimen edges, although diathermy artefact, if severe, may fulfil this role in some large loop specimens. Some pathologists use different colours to mark anterior and posterior surfaces, but I find the ink often runs, causing confusion. I do not encourage clinicians to pin the pieces making up a fragmented specimen on corkboard, as I find this damages the epithelial surface.
A permanent photographic record of the specimen should be made using the digital or Polaroid camera.6 Loop excisions should be sectioned transversely at regular intervals. Use of a pre-calibrated cutting board facilitates this, providing the tissue is well fixed and a sharp knife such as a skin graft blade is used. The cutting board I use is prefixed at 3 mm intervals. Each slice is turned to the right and embedded in individual cassettes, and as a result the tissue is examined at equal intervals throughout.
It is useful to standardise the sequence with which blocks are processed. If the clinician has orientated the specimen, I label the blocks from the extreme left of the specimen (ie, surface X) moving toward the right, and number those from the anterior lip before the posterior lip (fig 2). I mark the surface of the block opposite to the one I wish to have embedded downward, and thus sectioned first, with red ink just in case the tissue should turn in the processing cassette before or during opening. I prefer to put each piece into a separate cassette and mark where they have come from on a photograph of the specimen, and only divide slices if they are too big to fit into the cassette, as introducing a metal instrument into the canal damages the epithelium, especially the columnar epithelium. If it is necessary to do this, I squeeze the transverse aspects of the tissue slice and make the canal pout so I can insert the knife without it making contact with and damaging the epithelium. Over the years, I have found that it is a good policy to minimise any manipulation of these specimens, as the epithelium, particularly if there is extensive CIN III, may be very friable and excessive handling may result in its being denuded. The system described above is illustrated in the diagram (fig 2) where the initial slices (1 and 2) show ectocervix, but as the slices are progressively taken there is a gradual emergence of the columnar epithelium in the crypts around the canal (3) and then the canal itself including the squamocolumnar junction (4–7). The transverse (fig 2, A and B) and first lateral edges (fig 2, X) of the specimen are examined. Some pathologists turn the first block 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 section (alpha) is merely a mirror image of the section (beta) that is cut from the block that follows and that unless this first block is routinely turned through 180 deg re-embedded and a further section (representing the edge denoted by X in fig 2) is cut, the first 3 mm of tissue are left unrepresented histologically.
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All the tissue should be submitted for histology.
I resist routinely examining multiple levels, as I believe that it is uneconomic in technical and medical time and as experience has shown that should it be necessary to invert the block to examine the obverse side, it can cause technical difficulties if excessive levels were taken initially. Should there be a discrepancy between the previous cytological or the colposcopic diagnoses and the histological features, or if the section, particularly the squamocolumnar junction, is incomplete, I examine a single deeper level because in 6% (95% CI 3.5% to 10.2%) of cases this has resulted in a significant increase in the grade of CIN identified and in 2.5% (95% CI 1.1% to 5.7%) of cases it has allowed its identification for the first time.7
Inverting the last block (fig 2, section 9) may be necessary to demonstrate involvement of lateral edge Y (some pathologists argue it is unnecessary to do this as the presence of CIN 3 mm from any edge (eg, in section 9) has the same prognostic significance as if definite margin involvement is encountered). If CIN I is present at such a margin, recent work suggests there is no increased risk of recurrent disease over patients with clear margins.8
If stromal invasion is noted in two consecutive blocks (eg, fig2, sections 4 and 6) I cut further levels from these blocks, and I turn the block preceding the first of these since the largest tumour profile may be in the preceding slice. Thus inverting block 3 and sectioning into it may provide the best assessment of the cross-sectional tumour size in tumour b (fig 2).
Report
The presence of CIN should be noted and all grades present recorded. I usually make a note of which blocks are involved in brackets after the grade of CIN, as it is useful if I need to demonstrate this in a hurry at a multidisciplinary meeting, and also because it gives a semiquantitative indication of the extent of the disease. I also record whether both lips are involved, if disease is confined to the endocervical canal, as this may not be visible colposcopically, or if it involves the endocervical crypts.9–12 The prognostic importance of these criteria may simply be that they provide an indication of the overall size of the area of abnormality.13 14 The condition of the specimen edges and the presence of endocervical or squamous epithelium at the end of the canal is recorded systematically. The presence of glandular dysplasia/intraepithelial neoplasia, which in the UK is graded as low or high grade, is recorded along similar lines (see box 4).
Tumours that are visible to the naked eye are staged as 1b,1 but, if microscopic, the tumour should be measured using an eyepiece graticule or the vernier stage on the side of the microscope,15 to establish if it exceeds the criteria for stage 1a1 tumours (7 mm across by 3 mm deep, below originating epithelium in the crypt or intact surface), as it may warrant aggressive surgical treatment. The dimensions should be measured on the section showing the greatest profile. This provides two of the three dimensions cited (ie, one transverse dimension across the section and the depth). Even if the tumours are <7 mm across x 3 mm deep, the third dimension may exceed 7 mm, and Burghardt, who developed the system of examining parallel sections, advocated 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 slices by their thickness. Thus in tumour b (fig 2), where three 3 mm slices are involved, this dimension is up to 9 mm, whereas tumour a with two slices involved is no more than 6 mm thick. To ensure the third dimension of the tumour is not underestimated, I turn the block preceding the block from which the section first showing tumour was cut, through 180 deg to exclude invasive tumour in it. In tumour a, this is slice 3 (fig 2) and it is not involved, confirming that it involves only two slices, and, as each of them is 3 mm thick, it is less than 6 mm (ie, stage 1a1).
In contrast, with respect to tumour b in fig 2, the initial sections would show tumour in slices 4 and 6, which are in continuity but not in section 3. Turning section 3 reveals an invasive component suggesting invasion over three slices (up to 9 mm, and indeed the largest cross-sectional dimensions would be located as a result of this process). This method probably overestimates the third dimensions in some cases, but is justified on the basis that tumour is better over treated than under treated.
The consequence of this method of arriving at this third dimension is that the only person who can assess what it is, is the person who cut the case, as only he/she can be confident as to whether the blocks were cut at 2, 3 or 4 mm intervals and if they were of equal thickness. Thus the person cutting the case should usually be deferred to when invasive tumour involving more than one contiguous slice is encountered; this issue may cause problems especially when cancer centre pathologists are reviewing the work of others. (Note: microscopic tumour invasion and early stromal invasion are descriptive terms that are no longer used to describe tumours that are less than 1 mm deep4). Another area of controversy is when several small foci of microinvasion, none of which is more than 7x7x3 mm deep but which are separated by more than 7 mm, are encountered, as in foci c and d in fig 2. We will assume that foci d and e in the same slice are also separated by more than 7 mm of non-invasive tissue. The FIGO and TNM classifications give no advice as to how best to proceed in this scenario. In my view it is illogical to stage widely separated foci that may be confined to one or two cells as being of stage 1b and presumably therefore warranting radical surgery, whereas two foci each 3.4 mm across (fig 2, f and g) separated by less than 0.1 mm of tissue and thus occupying a lateral dimension of less than 7 mm are stage 1a1 and do not warrant such treatment despite having a greater overall volume. Burghardt, in his paper, describes adding the volume of such tumours together, and indeed his prognostic data are based on this strategy.17 In my experience, most clinicians appreciate this problem and judge each case on its merits after discussion with the patient (box 4).
Deep resection edges (the so-called top hat)
Large specimens may warrant being treated as above but on occasion it may be best to place an inked orientation mark on the specimens to ensure the distal resection margin is sectioned first and process them intact. In this situation, consideration should be given to ordering levels at cut up. If this option is taken, a photograph must be available that should be marked to indicate how the specimen was orientated.
Invasive tumours are typed using the World Health Organization (WHO) system, which may be supplemented by consulting the International Society of Gynaecological Pathologists’ modification.18
Other useful information is the presence or absence of lymphatic/vascular invasion; although this does not alter the stage of the lesion some surgeons will opt for more radical surgery if it is extensive or if the primary tumour shows adenocarcinomatous differentiation. Some pathologists also comment as to whether the border of the tumour is confluent or infiltrative.
The description for the dissection of hysterectomy specimens in patients with CIN or invasive cervical tumours is included in the section dealing with hysterectomies below.
Tissue trauma
Opening cone biopsy and loop excision specimens may damage the epithelium lining the endocervical canal and may also result in underestimating the dimensions of a peripherally placed invasive tumour; this practice and attempts at "clock facing" an intact specimen should be discouraged.19
I have not seen a specimen of this type for many years. They should be discouraged, since if malignant endocervical pathology is present it may render attempts to assess the presence and depth of stromal invasion impossible. Their value therefore seems to be confined to saying whether or not abnormal epithelium is present and even then it may not be possible to grade it20; this information can be extracted by a cytopathologist from a properly handled cytology specimen.
| TRANSCERVICAL ENDOMETRIAL RESECTIONS |
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| ENDOMETRIAL CURETTINGS AND PIPELLE SPECIMENS |
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Points for the histological assessment of endometrial samples are listed in box 5. It may be difficult to give any more precise estimate of the day in the cycle from which the specimen originated than early, mid or late secretory phase if the specimen has not been specially fixed in Bouins or other picric-acid-based fixative.26 The maturity of the secretory transformation in glands and stroma is assessed because dys-synchrony may indicate an underlying disturbance in hormone levels or the tissues’ response to them. The pathologist should not confine himself to a simple confirmation or exclusion of malignancy because many benign mimics have features that overlap intra-endometrial adenocarcinoma.27 If hyperplasia is present, it is worth conveying any suspicion of invasive malignancy to the clinician.28
Hyperplasia or malignancy should be considered and specifically excluded in the report if possible, or typed if present. In biopsy material I prefer to describe endometrioid adenocarcinomas as being well, moderately or poorly differentiated, rather than ascribing a FIGO grade to highlight the acknowledged variation (of between 24.6% and 55%) between the grade of endometrial cancer on sampling compared with that in the definitive resection specimen.29 FIGO recommend that serous and clear cell carcinomas be graded using the nuclear grade only,30 while the WHO regards all such tumours as being of high grade.31 I would encourage colleagues to adopt the FIGO practice, as recognising an inconsistent nuclear grade may indicate that the tumour is actually one of the mimics of these high-grade types.
In my experience it is rare to be able to assess the tissue for evidence of lymphatic or vascular permeation, and myometrium is rarely included in samples except in high-grade or high-stage tumours. Care should be taken in assessing endocervical fragments especially if they are involved by tumour, as they may either be the primary source of a cancer that has infiltrated upward into the uterus or secondarily involved by a low-lying endometrial tumour.
Neither endometrial biopsy32 nor imaging33 alone is sufficient investigation in postmenopausal bleeding, and a combination of biopsy and transvaginal ultrasound or hysteroscopy is advised34–36 since less than 50% of the cavity is sampled in most patients, even with dilation and curettage.37 38
I comment on the presence of plasma cells, eosinophils, lymphoid follicles and granulomata if I find them, but I am reluctant to exclude endometritis if they are absent because significant pelvic inflammatory disease, including infection with Neisseria gonorrhoeae and Chlamydia trachomatis, may have no histological evidence of endometritis.39 If inflammatory cells are absent, a stromal reaction may herald the onset of plasma cell endometritis.40
Endometrial polyps
Ideally these should be removed intact under hysteroscopic control, but in many centres they are removed piecemeal by curettage. The fragments should be weighed and the largest measured. The presence of any areas of necrosis should be noted.
Except for very large polyps or those that are obviously fibroid polyps, they should be examined entirely, as they are said to have twice the risk of harbouring hyperplasia and the same risk of developing carcinoma as non-polypoidal endometria,41 although these cancers are often of low stage and grade.42 Up to 13% of usual endometrial polyps,43 and nine of 29 patients with polyps showing atypical complex hyperplasia, have been found to have a carcinoma in the adjacent endometrium at hysterectomy.44
A recent review dealing with the reporting of endometrial biopsy specimens has been provided.45
Myomectomy
I usually count the number of fibroids submitted and give their range of dimensions. Each should be sectioned and one block from each submitted.46 If the fibroid shows any atypical features, additional blocks should be examined. I continue to describe the lesions as fibroids when issuing a report to convey to everyone reading it, particularly the patient if they ask to see the report, that there are no histological concerns about how the lesion will behave, but also include the term leiomyoma to satisfy the fastidious.
Although an argument has been advanced for not examining macroscopically normal hysterectomy specimens histologically, in a series of 139 specimens, one case of CIN (0.7%, 95% CI 0.1% to 4.0%), a condition that in the UK would warrant follow-up with repeat cytology,47 was detected. Most pathologists therefore are reluctant to abandon some histological examination of these specimens. The following technique is primarily designed to be used for specimens in which no or only benign anatomical pathology is expected, and aims to gather the maximum information from the minimum number of blocks, while leaving the specimen in such a condition that it is possible to return to it, to take further meaningful blocks should this be necessary. However, it is readily adaptable for use in malignant conditions.47
Preparation of specimen on receipt in laboratory
If possible, a period of fixation before opening is to be encouraged, as this minimises distortion due to fixation. I am reluctant to inject formalin through the cervical os. I believe that it traumatises the canal and if any intra-epithelial neoplasia is present the abnormal epithelium may be sloughed and damaged, limiting histological assessment.48 Junior medical staff and technologists may prefer to mark the anterior midline of the specimen with ink, paint or a pin. A 20–25 mm length of the cervix should be partially or completely amputated by a transverse cut followed by a single anterior midline incision in the uterus from fundus to the lower resection line (fig 3). If the cavity is not exposed, it may be opened by inserting scissors into the lumen of the cavity at the lower uterine segment and cutting upward. Pieces of pre-soaked tissue are placed in the incisions to ensure adequate fixation. If large fibroids are to be incised this is preferably done from the serosa, and these too should be stuffed with paper or cotton wool.
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Because of the risk of trauma to the canal epithelium, I would discourage probing of the cervical canal. The prior amputation of the cervix provides a flat base on which it can sit on the bench allowing blocks from anterior and posterior lips of the cervix to be taken in one set of slices using a large knife. I take a full thickness block from both anterior and posterior lip. Histological examination of mid line blocks in the cervix from a hysterectomy specimen in which there is no previous reason to suspect in-situ or invasive neoplasia combines the optimum yield of clinically relevant lesions with an economic blocking policy.49 50 I also take a thin sliver of the posterior peritoneal reflection as a screening test to exclude endometriosis from patients who have no history or morphological evidence of the condition, embedding it with the posterior lip (fig 4). I feel justified in doing this because although it adds little to the use of resources and manpower in the laboratory in 3% (95% CI 1.5% to 6.1%) of hysterectomy specimens from patients with adenomyosis or endometriosis, this was the only site where endometriosis was observed so that its identification may be the only explanation for preoperative or indeed postoperative symptoms. If there was more convincing evidence of endometriosis I would of course block the area formally, along with any adhesions and the left and right parametrial tissue or cornua. Endometriosis may occur in the cornual serosa in 2.9% of cases (95% CI 1.4% to 5.9%), although each case was associated with endometriosis in the posterior reflection or adnexa. There may be no need to return to a specimen in which adenomyosis is unexpectedly encountered histologically to exclude serosal endometriosis20 and certainly, in my experience, no patient with adenomyosis has been found to have endometriosis confined to the posterior reflection (95% CI 0% to 4.2%).
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Specimens removed for malignant conditions are effectively handled as outlined above, but with a more extensive description and sampling to reflect the anatomical position of the tumour.
Hysterectomy for carcinoma of the endometrium
In the case of endometrial tumours, the exact location within the cavity should be described, though it should be remembered that large lesions might extend over a combination of these sites. Although the dimensions of the tumour are traditionally measured in three dimensions, from a staging perspective the most important dimensions are the depth of macroscopic extension into the myometrium at the point at which the tumour extends closest to the serosal surface and the minimal depth of myometrium unaffected by tumour, as this allows calculation of the percentage of the thickness of the wall that is infiltrated by tumour; this is a key feature of FIGO staging. Involvement of the cervix, cornua, Fallopian tubes and ovaries should be confirmed or excluded. The presence or absence of previous surgery (eg, scars from Caesarian section) may be important as it may provide a point of weakness that facilitates tumour invasion.51
In some parts of the world, these specimens are examined peroperatively to guide the surgeon as to the need to undertake lymph node resections. 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 case in the final report (p<0.0001).52 This could reflect caution 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 section opinion.53
Blocks are taken to confirm the diagnosis, establish the grade of tumour, especially endometrioid adenocarcinoma, and to establish its stage. Although criteria for grading and staging are well defined, their application is not necessarily easy or reproducible.54 55
As a minimum, a full thickness block of each lip of the cervix should be submitted and if there is tumour in the canal, entrapped in mucus or adherent to the surface the entire canal should be sampled (fig 16, a).56 I block the entire canal up front as it saves time, and I cut levels if there is any uncertainty as to the involvement of stroma. In addition, I take a block across the junction of the lower uterine segment and upper endocervical canal since tumour extension into the cervix upstages the tumour to FIGO stage 2 (
TOP
LYMPH NODES
VAGINA
