Endometrioid adenocarcinomas of the uterine corpus in women younger than 50 years of age can be divided into two distinct clinical and pathologic entities based on anatomic location

Mixed High-Risk Endometrial Carcinoma Initially Presented With Atypical Squamous Cells of Undetermined Significance (ASC-US) Cytology: Lessons to Be Learned

Endometrial carcinoma represents the most common gynecologic malignancy, affecting mainly postmenopausal women. Early detection and proper management may allow not only a successful treatment but also an acceptable quality of life. Although its usual clinical manifestations, such as vaginal bleeding or a mass stuck out of the cervix, often arouse medical concern, in some cases, there is a dilemma regarding the differential diagnosis of endocervical cancer. Additionally, tumors arising from and confined to the uterine isthmus may often pose a greater diagnostic challenge. Defining the primary origin of the carcinoma is of paramount importance as the treatment plan may be widely different in these two scenarios. Magnetic Resonance Imaging (MRI), markers, and biopsy with immunohistochemistry could facilitate the diagnostic process, but the final diagnosis may even be made from the final surgical specimen in such demanding cases. We present the case of a mixed-type, stage IIIC2, endometrial carcinoma arising from the lower uterine segment initially suspected from atypical squamous cells of undetermined significance (ASC-US) cytology.

Grade 3 endometrioid adenocarinoma of the lower uterine segment diagnosed 6 weeks after a term delivery: A case report and literature review

Background

Endometrial cancer is the most common gynaecological malignancy in Australian women. Less than 5% of cases occur in women under 40 years of age and it is rarely associated with pregnancy. Most cases associated with pregnancy are diagnosed after first trimester loss. Only 14 cases of endometrial cancer diagnosed post-partum are reported in the literature. These cases were diagnosed up to 15 months post-partum. The histopathological classification was low grade in 12 patients and high grade in two patients.

Case

We describe a 37 year old woman, who presented after her second vaginal delivery (at 37 weeks of gestation) with suspected retained products of conception (RPOC). She had a dilation and curettage leading to the diagnosis of endometrial cancer six weeks post-partum. She underwent a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and bilateral sentinel node biopsy. Histopathology confirmed a stage 1B grade 3 endometrioid adenocarcinoma located in the lower uterine segment with widespread lymph-vascular invasion and no other evidence of malignancy. She is planned to complete six cycles of adjuvant carboplatin/ paclitaxel chemotherapy, followed by pelvic external beam radiotherapy.

Discussion

We report the second case of a high-grade endometrial cancer diagnosed post-partum. The bulk of this tumour was in the lower segment of the uterus, which together with the fundal placenta, likely permitted the pregnancy progressing to term. Endometrial cancer should be considered a rare cause of abnormal post-partum bleeding. Curettage and histopathology examination is recommended in cases that do not resolve with conservative measures to exclude this rare complication.

Imaging-based definition of lower uterine segment carcinoma to improve the detection sensitivity of probable Lynch syndrome

OBJECTIVE

The aim of this study was to investigate a magnetic resonance imaging-based definition of lower uterine segment carcinoma.

METHODS

We retrospectively reviewed 587 consecutive patients with endometrial cancer who underwent hysterectomy. Lower uterine segment carcinoma was determined through pathological examination and magnetic resonance imaging assessment. For imaging assessment, the location of the inner lining of the uterus was classified into four equal parts on a sagittal section image. A tumor was defined as lower uterine segment carcinoma when its thickest part was located in the second or the third part from the uterine fundus. Lower uterine segment carcinoma was further divided into lower uterine segment in a narrow sense, upon which diagnosis was exclusively based on pathological findings, and lower uterine segment in a broad sense that were the remaining lower uterine segment carcinomas except lower uterine segment carcinomas in a narrow sense. The relationship between lower uterine segment carcinoma and probable Lynch syndrome was investigated. Patients with loss of MSH2, MSH6, and PMS2 expression or those with tumors with loss of MLH1 and absence of MLH1 promoter methylation were diagnosed as probable Lynch syndrome.

RESULTS

Lower uterine segment carcinoma was identified in 59 (10.2%) patients. Twenty-eight (47.5%) patients were categorized as lower uterine segment in a narrow sense and 31 (52.5%) as lower uterine segment in a broad sense. Among them, probable Lynch syndrome was identified in 12 (20.3%) cases. There was no difference in clinical profiles, including the prevalence of probable Lynch syndrome between the two categories.

CONCLUSIONS

A magnetic resonance imaging-based expanded definition of lower uterine segment carcinoma is likely to secure characteristics equivalent to a conventional pathology-based definition of lower uterine segment carcinoma. The novel definition of lower uterine segment carcinoma might improve the detection of probable Lynch syndrome.

Prognostic factors for patients with early-stage uterine serous carcinoma without adjuvant therapy

Objective

Uterine serous carcinoma (USC) is an aggressive type 2 endometrial cancer. Data on prognostic factors for patients with early-stage USC without adjuvant therapy are limited. This study aims to assess the baseline recurrence risk of early-stage USC patients without adjuvant treatment and to identify prognostic factors and patients who need adjuvant therapy.

Methods

Sixty-eight patients with International Federation of Gynecology and Obstetrics (FIGO) stage I–II USC between 1997 and 2016 were included. All the cases did not undergo adjuvant treatment as institutional practice. Clinicopathological features, recurrence patterns, and survival outcomes were analyzed to determine prognostic factors.

Results

FIGO stages IA, IB, and II were observed in 42, 7, and 19 cases, respectively. Median follow-up time was 60 months. Five-year disease-free survival (DFS) and overall survival (OS) rates for all cases were 73.9% and 78.0%, respectively. On multivariate analysis, cervical stromal involvement and positive pelvic cytology were significant predictors of DFS and OS, and ≥1/2 myometrial invasion was also a significant predictor of OS. Of 68 patients, 38 patients had no cervical stromal invasion or positive pelvic cytology and showed 88.8% 5-year DFS and 93.6% 5-year OS.

Conclusion

Cervical stromal invasion and positive pelvic cytology are prognostic factors for stage I–II USC. Patients with stage IA or IB USC showing negative pelvic cytology may have an extremely favorable prognosis and need not receive any adjuvant therapies.

Is lower uterine segment involvement a prognostic factor in endometrial cancer?

BACKGROUND/AIM

The purpose of this study is to investigate the prognostic significance of lower uterine segment (LUS) involvement in endometrial cancer (EC).

MATERIALS AND METHODS

We reviewed the patients who were operated at our institution between July 2007 and March 2015 with the diagnosis of EC. Tumors localized in the corpus and involving the LUS or localized entirely in the LUS formed Group A, while tumors in the uterine corpus without LUS involvement formed Group B. Clinicopathological characteristics and survival of the patients were compared in both groups.

RESULTS

A total of 500 patients were included in the study. There were 139 patients who had tumors involving the LUS and formed Group A, while 361 patients with endometrial tumors in the uterine corpus without LUS involvement formed Group B. We did not detect a significant difference between survival of the patients in group A and group B (78 months vs. 87 months, respectively; P > 0.05).

CONCLUSION

We found that LUS involvement was not an independent prognostic factor for poor survival, but it is associated with other poor prognostic factors such as deep myometrial invasion, uterine serosal involvement, lymphovascular space invasion, lymph node metastasis and higher FIGO grade.

Clear cell carcinoma of the lower uterine segment: A case report

Uterine carcinoma of the lower uterine segment (LUS) is a rare tumor that accounts for 3–3.5% of cases of uterine malignant cancer. The tumor arises from the lower region of the uterine body through the upper region of the cervix. The present study reported a case of clear cell carcinoma that originated from the LUS. A 50-year-old woman visited a local hospital due to irregular vaginal bleeding. She was suspected to have a uterine tumor and was referred to Tachikawa Hospital (Tokyo, Japan). Transvaginal ultrasound and magnetic resonance imaging revealed a uterine tumor from the lower region of the uterine body through the upper region of the cervix. Endocervical curettage revealed clear cell carcinoma. Based on a diagnosis of clear cell carcinoma of the LUS, radical hysterectomy was performed with bilateral salpingo-oophorectomy, paraaortic lymph node dissection and omentectomy. Macroscopically, the tumor was limited to the lower region of the uterine body through the upper region of the cervix in the resected uterus. Histopathological findings indicated no tumors in the uterine corpus and uterine cervix, but clear cell carcinoma was observed in the LUS epithelium. At the 1-year follow-up, the patient remained free of local recurrence and metastasis. To the best of our knowledge, clear cell carcinoma of the LUS has not previously been reported. More cases are required to clarify the pathology.

Survival outcome in endometrial cancer patients according to hereditary predisposition

OBJECTIVE

A familial history of ovarian cancer/breast cancer is considered a significant prognostic factor for ovarian cancer. We investigated hereditary factors by examining the incidence of synchronous malignancy in patients with endometrial cancer, and assessed the prognostic role of heredity in endometrial cancer.

METHODS

We retrospectively evaluated patients with endometrial cancer who underwent surgery from January 2001 to April 2011. A hereditary background in this study was defined as double primary cancer, that is, endometrial cancer accompanied by colon, ovarian, or breast cancer suggestive of Lynch syndrome, hereditary breast ovarian cancer syndrome, or Cowden syndrome, respectively.

RESULTS

Among 282 patients with endometrial cancer in the study population, 20 patients (7.1%) had a hereditary predisposition: 10 patients (3.5%) had ovarian cancer, six patients (2.1%) had breast cancer, and four patients (1.4%) had colon cancer. Age and lower uterine segment involvement were not statistically different between the hereditary and nonhereditary groups. The majority of the women in the hereditary group presented with Stage I cancer; however, there were no significant differences in Stage I cancer between the hereditary group and the sporadic endometrial cancer group (85% and 77%, respectively, p = 0.561). The median follow-up period was 60 months. A 5-year overall survival rate was not different between the two groups (95% and 95%, respectively, p = 0.659). Among a subgroup of patients with Stage I endometrial cancer, the 5-year overall survival rate was lower in the endometrial cancer with a hereditary predisposition group compared with the sporadic endometrial cancer group (94% and 98%, respectively, p = 0.027).

CONCLUSION

Seven percent of the women with endometrial cancer in our study had other malignancies such as ovarian, colon, or breast cancer synchronously. Among a subgroup of patients with Stage I cancer in the endometrial cancer with a hereditary predisposition group, the 5-year overall survival rate was significantly lower (94%). This finding should be confirmed in a larger population.

Immunohistochemical characterization of endometrial carcinomas: endometrioid, serous and clear cell adenocarcinomas in association with genetic analysis

Developments in immunohistochemistry, which are closely linked with the advances in the analyses of genetic abnormalities and their associated molecular disorders as early and late histogenetic events, have contributed greatly to the improvement of pathological diagnostic confirmation and validation. Immunohistochemistry has also generated great benefit to the innovation of therapeutic strategies for various kinds of cancers. In this article, the three representative histological types of corpus cancer, namely, endometrioid adenocarcinoma, serous adenocarcinoma and clear cell adenocarcinoma, will be histologically approached in association with their immunohistochemical profiles as well as genetic disorders. First, the focus will be on 'Conventional/prototypic features,' followed by 'Controversy over conventional histological subclassification,' and subsequently 'Tumorigenesis and re-subclassification'.

Relationship of lower uterine segment cancer with Lynch syndrome: a novel case with an hMLH1 germline mutation

Lynch syndrome is a genetic disease that often develops in patients with endometrial cancer and is caused by abnormal DNA mismatch repair (MMR) genes. In the United States, it was recently reported that the prevalence of Lynch syndrome with an hMSH2 mutation in patients with endometrial cancer in the lower uterine segment (LUS) is much greater than that in patients with endometrial cancer, although no such reports have been published in Asia. In this study, we examined the correlation between endometrial cancer in LUS and abnormalities in MMR genes. We examined 625 patients, who were diagnosed with endometrial cancer and underwent a hysterectomy. Nine patients (1.4%) had cancer based on pathological confirmation of a tumor in the lower part of the uterus and no cancer in the upper part. These cases were compared with 27 cases of sporadic endometrial (non-LUS) cancer. The age and BMI of the patients with LUS cancer were significantly lower than those of the patients with non-LUS cancer. No differences were observed in the pathological characteristics. The microsatellite instability (MSI)-positive rates were similar. Immunohistochemistry showed a decreased expression of hMLH1 and hMSH6 in patients with LUS cancer. In contrast with earlier reports from the United States, hMSH2 was expressed in all the cases. Of the 2 patients with LUS cancer who exhibited high MSI, 1 patient showed abnormal methylation of hMLH1, while the other patient was diagnosed with Lynch syndrome with a mutation in the hMLH1 gene. This is the second report on the relationship of LUS cancer and Lynch syndrome, and the first to describe an Asian patient with LUS cancer with Lynch syndrome induced by an hMLH1 mutation.

Carcinoma of the Lower Uterine Segment (LUS): Clinicopathological Characteristics and Association with Lynch Syndrome

Endometrial cancer arises from the uterine body and fundus in many cases, but can also originate from the lower region of the uterine body through the upper region of the cervix. Such tumors are referred to as carcinoma of the lower uterine segment (LUS) or isthmus, and account for 3-6.3% of all cases of endometrial cancer. This relatively low incidence has permitted performance of only small-scale studies, but the clinical and pathological characteristics of carcinoma of the LUS in all these reports have differed from those of other endometrial cancers. Generally, endometrial cancer is classified into estrogen-dependent endometrioid adenocarcinoma (designated as type I), and non-endometrioid types that are less associated with estrogen and include poorly differentiated adenocarcinoma (type II). In some reports, carcinoma of the LUS has been found to have type II characteristics. Carcinoma of the LUS has also been associated with Lynch syndrome, a hereditary disease with frequent development of colorectal, endometrial, and ovarian cancers. Lynch syndrome is thought to be induced by mismatch repair gene mutation. The frequency of Lynch syndrome in cases of general endometrial cancer is 1-2%. In contrast, the frequency in patients with carcinoma of the LUS is much higher, with up to 29% of cases diagnosable with Lynch syndrome and a high frequency of hMSH2 mutation found in one study. This suggests that further investigation of the clinical and pathological characteristics of carcinoma of the LUS and the association with Lynch syndrome is required through performance of a large-scale survey.

Carcinoma of the lower uterine segment: a newly described association with Lynch syndrome

PURPOSE

Endometrial carcinoma in the lower uterine segment (LUS) is a poorly described cancer that can be clinically confused with endocervical carcinoma. We performed a case-comparison study to document the clinicopathologic characteristics of LUS tumors and their association with risk factors for endometrial cancer.

PATIENTS AND METHODS

The clinical records and pathology reports from women who underwent hysterectomy at our institution for endometrial or endocervical adenocarcinoma over an 11-year interval were reviewed. The LUS group consisted of women with endometrial tumors that clearly originated between the lower uterine corpus and the upper endocervix. Immunohistochemistry and microsatellite instability and MLH1 methylation assays were performed.

RESULTS

Thirty-five (3.5%) of 1,009 women had endometrial carcinoma of the LUS. Compared with patients with corpus tumors, LUS patients were younger, had higher stage tumors, and had more invasive tumors. Preoperative diagnosis of the LUS tumors more frequently included the possibility of endocervical adenocarcinoma. Seventy-three percent of the LUS tumors had an immunohistochemical expression pattern typical of conventional endometrioid adenocarcinoma. Ten (29%) of 35 women with LUS tumors were confirmed to have Lynch syndrome or were strongly suspected to have Lynch syndrome on the basis of tissue-based molecular assays.

CONCLUSION

The prevalence of Lynch syndrome in patients with LUS endometrial carcinoma (29%) is much greater than that of the general endometrial cancer patient population (1.8%) or in endometrial cancer patients younger than age 50 years (8% to 9%). On the basis of our results, the possibility of Lynch syndrome should be considered in women with LUS tumors.

Sonographic evaluation of the endometrium in patients with a history or an appearance of polycystic ovarian syndrome

OBJECTIVE

The purpose of this study was to assess the incidence and significance of a thick, cystic-appearing endometrium in association with a history or an ovarian appearance of polycystic ovarian syndrome.

METHODS

An Institutional Review Board-approved, retrospective medical record review of sonographic studies from January 1, 1998, to December 31, 2005, found 245 patients with clinical features, a characteristic sonographic appearance of the ovaries, hormonal abnormalities, or a history of polycystic ovarian syndrome. The sonographic thickness and appearance of the endometrium (homogeneous or heterogeneous) and histologic findings on biopsy were obtained.

RESULTS

Two hundred twenty-seven patients had a homogeneous endometrium in the range of 1 to 17 mm (mean +/- SD, 6.4 +/- 3.1 mm); 18 patients had a heterogeneous endometrium in the range of 4 to 23 mm (mean, 13.2 +/- 5.6 mm). Of the 18 patients with a heterogeneous endometrium, 9 also had a sonographic finding of tiny cystic foci within the endometrium. Of these, 5 had endometrial biopsy, resulting in 2 cases of a proliferative endometrium and 1 case each of simple hyperplasia, hyperplasia with atypia, and scant tissue. No cases of hyperplasia were present in the patients with a homogeneous endometrium.

CONCLUSIONS

A heterogeneous cystic endometrium is associated with the prolonged proliferative phase from chronic anovulation as well as endometrial hyperplasia.

Endometrioid carcinoma of the uterine corpus: a review of its pathology with emphasis on recent advances and problematic aspects

This review considers the pathologic features of endometrioid carcinoma of the uterine corpus, which accounts for approximately 80% of endometrial adenocarcinomas, with an emphasis on its histologic features, recent advances, and problematic aspects. In addition to typical endometrioid carcinoma, the variants of endometrioid carcinoma covered include secretory carcinoma, villoglandular endometrioid carcinoma, endometrioid carcinoma with small nonvillous papillae, endometrioid carcinomas with microglandular and sertoliform patterns, and endometrioid carcinomas with metaplastic changes. These changes include a variety of different appearances of squamous epithelia (ranging from mature and keratinizing to immature with only subtle evidence of a squamous nature), clear cells, surface changes resembling syncytial metaplasia or microglandular hyperplasia, ciliated cells, oxyphilic cells, and spindled epithelial cells (sarcomatoid carcinoma). The last is one of several variants that may cause a biphasic appearance, all of which should be distinguished from the malignant müllerian mixed tumor. Rare findings in endometrioid carcinomas include hyalinization, psammoma bodies, and foci of stromal metaplasia such as osteoid. Unusual growth patterns of endometrioid carcinomas include involvement of adenomyosis, the "diffusely" infiltrating pattern of myoinvasion, and a previously unemphasized pattern of myoinvasion with "pinched off" glands that may be cystic or have a pseudovascular appearance, often with a myxoid stromal reaction. Other aspects of endometrioid carcinoma discussed are its immunoprofile, grading, cervical involvement (including a hitherto undescribed "burrowing" pattern of extension within the cervix that can result in underdiagnosis of stage IIB disease), carcinoma arising in the lower uterine segment, carcinoma arising in polyps and adenomyomas, carcinoma in young women, tamoxifen-related carcinoma, associated ovarian endometrioid carcinoma, and peritoneal keratin granulomas. Finally, the differential diagnosis of endometrioid carcinoma is briefly considered with a section on benign mimics, including curettage-related changes, menstrual changes, adenomyosis-related problems, metaplastic changes, atypical polypoid adenomyoma, radiation atypia, and papillary proliferations, and a section on metastatic colonic carcinoma.