The pattern of epithelial mucin secretion in normal, hyperplastic, and adenocarcinomatous endometrium

Glandular Crowdings in Endometrial Polyps: Clinical Follow-Up and Possible Worrisome Features

INTRODUCTION

Interpretation of changes and premalignant lesions in endometrial polyps can be challenging. We evaluated the clinical course of patients with focal gland crowdings in endometrial polyps via repeat biopsies and searched for possible morphological findings in the initial biopsy that may foresee a premalignant course.

METHODS

Specimens diagnosed as endometrial polyp and focal gland crowding in patients who had a repeat biopsy in a 1-year period were reexamined. Morphological findings in the initial biopsies were recorded. The group whose repeat biopsies were "premalignant or malignant" (Group 1), and the group with "benign" repeat biopsies (Group 2) were compared.

RESULTS

"Endometrial polyp and gland crowdings" was diagnosed in 115 specimens of which 38 patients had repeat biopsies. Among these 8 (21%) were diagnosed as "endometrial intraepithelial neoplasia (EIN)" (Group 1) and 30 (79%) as "benign" (Group 2). Morphological features in the initial biopsies were evaluated; PAX2 loss was 6 of 8 (75%) for Group 1 and 7 of 30 (23%) for Group 2 (P = .020), and altered epithelial cytological features were present in 5 of 8 (62%) versus 4 of 30 (13%) (P = .015), both significantly higher in Group 1. Dark intraluminal secretion, intraluminal histiocytes, intraglandular epithelial proliferation, and mean diameter of crowded gland areas were not statistically different between the 2 groups.

CONCLUSION

"Focal gland crowdings" in endometrial polyps do carry a risk of EIN in subsequent biopsies. We suggest that the loss/decrease of PAX2 and altered epithelial cytological features in these areas in the initial biopsy are indicative of a premalignant course.

Navigating through perplex morphologic changes after exogenous hormone usage

Clinical application of exogenous hormone as a method of contraception and/or treatment of various gynecologic disorders is exceedingly common. Unfortunately, the concurrent use of these agents also complicates the interpretation of pathology specimens. Various studies have shown that morphologic changes induced by hormonal therapies are present in both non-neoplastic and neoplastic tissues within the women's reproductive tract. It is important to understand the exogenous hormone induced morphologic changes, as it helps the pathologists make the accurate diagnosis, and in turn, guide clinicians to make optimal clinical decisions. In this review, we summarize the morphologic changes in both neoplastic and non-neoplastic endometrial, cervical, and myometrial surgical specimens after hormonal therapies, particularly after progestin treatment. In the endometrium, particularly in the scenario of progestin-treated atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia (AEH/EIN), there is notoriously poor interobserver agreement and difficulty in assessing for the residual disease. We summarize current literature and propose our recommended approach in assessing these challenging endometrial biopsies, including a diagnostic algorism, the use of PAX-2, PTEN, beta-catenin immunohistochemistry panel, as well as consistency in diagnostic wording of the report. In the cervix, progestin makes dysplastic lesions appear metaplastic, thus high-grade squamous dysplastic lesions may be easily missed. Within the myometrium, lesions such as adenomyosis may show various degree of decidualization, while smooth muscle neoplasms may show apoplectic changes, and stromal lesions including endometrial stromal sarcoma may show more eosinophilic cytoplasm. All such changes may pose more or less diagnostic challenges in our daily practice. However, most are readily recognizable when we understand particular hormone related scenarios.

Endometrial human chorionic gonadotropin (hCG) expression is a marker for adequate secretory transformation of the endometrium

PURPOSE

Successful embryo implantation into the endometrium depends on embryonic characteristics and proper endometrial development. Reproductive medicine often focuses on embryo quality, whereas reliable diagnostic tests for endometrial receptivity are still needed. We previously found that human chorionic gonadotropin (hCG), one of the earliest proteins secreted by the embryo, was also expressed by the luteal phase endometrium around the implantation window. Here, we tested our hypothesis of endometrial hCG as an implantation marker.

METHODS

Endometrial biopsies and serum samples were taken from patients undergoing routine infertility diagnostics. Correlations of immunohistochemically detected endometrial hCG expression with adequate endometrial secretory transformation, the infiltration of CD45-positive leukocytes, clinical diagnostic parameters, and endometrial thickness were analyzed.

RESULTS

A highly significant correlation between the endometrial score, as a measurement for regular secretory transformation, and the intensity of hCG staining was found. The invasion of CD45-positive leukocytes increased with progressing endometrial secretory transformation and rising endometrial hCG expression. In addition, serum progesterone concentrations correlated with hCG expression by the endometrial glands.

CONCLUSIONS

Our results suggest endometrial hCG as a possible diagnostic parameter characterizing the endometrial secretory transformation and, thus, possibly also its implantation capability.

Uterine Glandular Carcinoma

This study correlated the histologic and immunohistochemical features of cervical and endometrial glandular carcinomas (adenosquamous carcinoma [ADENSQ] and ade nocarcinoma [AC] ) with clinical outcome. A series of 87 uterine glandular carcinomas (53 cervical, 33 endometrial, and 1 arising in both cervix and endometrium) were histologically classified into mullerian subtypes: 28 ADENSQ, 19 serous AC, 19 mu cinous AC, 15 endometrioid AC, and 6 clear cell AC. Utilizing both nuclear and archi tectural features, 66 glandular carcinomas were high histologic grade (3) and 21 were low histologic grade (1 or 2). Immunohistochemical studies performed on 83 of the cases showed: 33 + for monoclonal carcinoembryonic antigen (CEA-M); 38 + for polyclonal CEA (CEA-P); 26 + for placental alkaline phosphatase; 18 + for CA 125; 29 + for CA 19-9; 24 + for vimentin; 60 + for cytokeratin CAM 5.2; and 81 + for cytokeratin AE 1 : 3. The following significant correlations were identified. ADENSQ histology was associated with CEA-M staining (P < .025), and mucinous histology was associated with CA 19-9 staining (P < .025). Cervical primary site was associated with ADENSQ histology (P < .001) and staining with CEA-M (P < .025) and CEA-P (P < .05). Endometrial primary site was associated with endometrioid histology (P < .001). Forty-five patients had recurrent disease, 30 patients were disease-free for more than 1 year, and 12 patients had insufficient follow-up evaluation. Recurrent disease was associated with stage III or IV tumors (P < .001), grade 3 histology (P < .001), serous differentiation (P < .001), invasion to at least the middle third of the myometrium (P < .001) and large size of residual tumor at hysterectomy (mean 3.9 cm versus 1.3 cm, P < .005). Disease-free survival was associated with endometrioid differentiation (P < .05), strong CEA-M staining (P < .001), CEA-P staining (P < .025), and CA 19-9 staining (P < .05). Considering only stage 1 and 2 patients, grade 3 histology ( P < .025), deep myometrial invasion (P < .01), and size (P < .05) were still associated with recurrence and strong CEA-M staining (P < .025) was still associ ated with disease-free survival. However, strong CEA-M staining, deep myometrial invasion, and size of tumor after hysterectomy were all associated with histologic grade. Considering just histologic grade 3 carcinomas in stage 1 and 2 patients, absence of strong CEA-M staining, deep myometrial invasion, and size of tumor was no longer associated with recurrent disease. Histologic grade was the only independent predictor of prognosis in stage I and II patients. Int J Surg Pathol 1 (1): 13-24, 1993

Ultrastructural analysis of the pathogenesis of Neisseria gonorrhoeae endometrial infection

We have studied gonococcal infection in human endometrium organ culture and in human primary endometrial epithelial cells using various microscopic techniques including scanning electron microscopy, transmission electron microscopy, bright field light microscopy and laser scanning confocal microscopy. Here we describe the interactions between Neisseria gonorrhoeae and human endometrial luminal epithelial cells at the ultrastructural levels. N. gonorrhoeae attached to cilia but were not observed associated with the plasma membrane of ciliated epithelial cells or internalized into ciliated epithelial cells. N. gonorrhoeae could be found in intracellular vacuoles in secretory epithelial cells. N. gonorrhoeae have diverse interactions with endometrial epithelium. These include intimate association and colocalization with asialoglycoprotein receptor (ASGP-R) and CEACAM, lamellipodia and ruffle formation and colocalization with CR3, and microvillus engagement. These studies indicate that N. gonorrhoeae utilize multiple mechanisms to associate with endometrial epithelial cells and can associate with both ciliated and secretory cells. This diversity is consistent with a role of the endometrium as a transition zone between frequently asymptomatic cervical gonorrhoea and symptomatic pelvic inflammatory disease.