A simple method for the prevention of endometrial autolysis in hysterectomy specimens

Practical Updates and Diagnostic Challenges in Endometrial Carcinoma

CONTEXT.—

Clinical management of endometrial carcinoma largely depends on the morphologic parameters ascertained based on the pathologic evaluation of surgical resection specimens. However, there are numerous controversial and nonstandardized aspects of both the macroscopic and microscopic assessment of surgical specimens, including grossing, adequate sampling, diagnosis, staging, reporting, and ancillary testing.

OBJECTIVE.—

To provide a comprehensive practical review of standardized grossing, key morphologic findings for reporting and staging, and diagnostic and prognostic use of ancillary testing in endometrial carcinomas.

DATA SOURCES.—

The existing literature, recommendations of the International Society of Gynecological Pathologists, and specialty consensus guidelines.

CONCLUSIONS.—

This review article summarizes important aspects of the grossing and sampling of surgical resection specimens for microscopic examination, key morphologic parameters that are required for reporting and staging, and morphologic features and immunoprofiles helpful in the differential diagnosis of low-grade and high-grade endometrial carcinomas, as well as the current status of the molecular classification of endometrial carcinoma and human epidermal growth factor receptor 2 testing in serous carcinoma. The information presented herein can be helpful in overcoming diagnostic challenges and issues related to the pathology reporting of endometrial carcinoma to practicing anatomic pathologists.

Endocervical Adenocarcinoma, Gross Examination, and Processing, Including Intraoperative Evaluation: Recommendations From the International Society of Gynecological Pathologists

The International Society of Gynecological Pathologists (ISGyP) Endocervical Adenocarcinoma Project aims to provide evidence-based guidance for the pathologic evaluation, classification, and reporting of endocervical adenocarcinoma. This review presents the recommendations pertaining to gross evaluation and intraoperative consultation of specimens obtained from patients in the setting of cervical cancer. The recommendations are the product of review of published peer-reviewed evidence, international guidelines and institutional grossing manuals, as well as deliberation within this working group. The discussion presented herein details the approach to the different specimen types encountered in practice: loop electrosurgical excision procedure, cone, trachelectomy, radical hysterectomy, pelvic exenteration, and lymphadenectomy specimens. Guidelines for intraoperative evaluation of trachelectomy and sentinel lymph node specimens are also addressed. Correlation with ISGyP recommendations on cancer staging, which appear as a separate review in this issue, is also included when appropriate. While conceived in the framework of endocervical adenocarcinoma, most of the discussion and recommendations can also be applied to other cervical malignancies.

The effects of delayed formalin fixation on endometrial pathology in hysterectomy specimens

Opening hysterectomy specimens for pathological assessment can be performed before or after formalin fixation. The former method, preferred by most pathologists, limits the autolytic changes of the endometrium, but it may result in a distortion of the uterine wall as a result of the contraction of the myometrium. This may interfere with the assessment of the degree of tumor extension to the uterine wall. The latter method, which is less common, preserves the uterine wall but may limit the assessment of the endometrial glands due to autolytic changes, and the effect of nuclear features is unknown. In this study, we assessed 78 hysterectomy specimens opened by the second method for these changes. The autolytic changes were present in all cases, but they didn't limit the pathologist's assessment to reach the final diagnosis in both the benign and malignant cases. Although, it was difficult to determine which of the nuclear changes was caused by delayed fixation, we found nuclear rounding and prominence of the nucleoli were not features of autolytic changes. Conditions with nuclear features that may mimic mild nuclear atypia were common in these specimens, but not severe atypia. We concluded that a delayed opening of the uterus is an acceptable procedure in dealing with these specimens.

Endometrial Carcinoma, Grossing and Processing Issues: Recommendations of the International Society of Gynecologic Pathologists

Endometrial cancer is the most common gynecologic neoplasm in developed countries; however, updated universal guidelines are currently not available to handle specimens obtained during the surgical treatment of patients affected by this disease. This article presents recommendations on how to gross and submit sections for microscopic examination of hysterectomy specimens and other tissues removed during the surgical management of endometrial cancer such as salpingo-oophorectomy, omentectomy, and lymph node dissection—including sentinel lymph nodes. In addition, the intraoperative assessment of some of these specimens is addressed. These recommendations are based on a review of the literature, grossing manuals from various institutions, and a collaborative effort by a subgroup of the Endometrial Cancer Task Force of the International Society of Gynecological Pathologists. The aim of these recommendations is to standardize the processing of endometrial cancer specimens which is vital for adequate pathological reporting and will ultimately improve our understanding of this disease.

Quantification of nucleolar channel systems: uniform presence throughout the upper endometrial cavity

OBJECTIVE

To determine the prevalence of nucleolar channel systems (NCSs) by uterine region, applying continuous quantification.

DESIGN

Prospective clinical study.

SETTING

Tertiary care academic medical center.

PATIENT(S)

Forty-two naturally cycling women who underwent hysterectomy for benign indications.

INTERVENTION(S)

NCS presence was quantified by a novel method in six uterine regions-fundus, left cornu, right cornu, anterior body, posterior body, and lower uterine segment (LUS)-with the use of indirect immunofluorescence.

MAIN OUTCOME MEASURE(S)

Percentage of endometrial epithelial cells (EECs) with NCSs per uterine region.

RESULT(S)

NCS quantification was observer independent (intraclass correlation coefficient 0.96) and its intrasample variability low (coefficient of variation 0.06). Eleven of 42 hysterectomy specimens were midluteal, ten of which were analyzable with nine containing >5% EECs with NCSs in at least one region. The percentage of EECs with NCSs varied significantly between the LUS (6.1%; interquartile range [IQR] 3.0-9.9) and the upper five regions (16.9%; IQR 12.7-23.4), with fewer NCSs in the basal layer of the endometrium (17 ± 6%) versus the middle (46 ± 9%) and luminal layers (38 ± 9%) of all six regions.

CONCLUSION(S)

NCS quantification during the midluteal phase demonstrates uniform presence throughout the endometrial cavity, excluding the LUS, with a preference for the functional luminal layers. Our quantitative NCS evaluation provides a benchmark for future studies and further supports NCS presence as a potential marker for the window of implantation.

Antigen-epitope retrieval to facilitate proteomic analysis of formalin-fixed archival brain tissue

Formalin is a routine fixative facilitating tissue preservation and histopathology. Proteomic techniques require freshly frozen specimens, which are often difficult to procure, and methods facilitating proteomic analysis of archival formalin-fixed brain tissue are lacking. We employed antigen-epitope-retrieval principles to facilitate proteomic analysis of brain tissue that had been fixed and stored in formalin for 3-7 years. Twenty-micrometer-thick cryopreserved OCT-embedded sections from inferior temporal cortex of human (7 years in formalin) or mouse brain specimens (3 years in formalin) were hematoxylin-/eosin-stained. Approximately 16-64-mm2 areas of the tissue sections were manually scraped off slides, or approximately 2 mm2 of human brain cortex was captured off membrane-coated slides using laser microdissection. Tissue was treated using various pH and temperature conditions prior to trypsin digestion and nano-LC-MS/MS. The largest number of proteins were retrieved by solubilization at pH 9 at 95 degrees C for 1 h; treatments at pH 4 or 6 at 25 or 65 degrees C were generally ineffective. Three-year formalin-fixed murine tissue did not yield more proteins compared to human tissue. Use of formalin-fixed tissue for proteomics is an invaluable tool for medical research. The combination of proteomics and microdissection enables selective enrichment and identification of novel, unique, or abundant proteins that may be important in pathogenesis.

The effect of prior fixation on the distortion of uterine specimens opened after receipt in the pathology laboratory

AIM

To establish whether a period of fixation in formalin before incision reduced distortion of intact uterine specimens.

METHODS

A record was kept of the period between placing the intact specimen in formalin and incising the uterine corpus for 98 hysterectomy specimens. After fixation and at the time of cut up, the size of any gap that developed in the anterior uterine wall during the fixation period was measured. This was correlated with the period of fixation.

RESULTS

There was a negative association between the period of prior fixation and size of gap (p=0.0009). The delay in opening the specimen was not associated with any compromise in histological assessment of the tumour but facilitated the assessment of prognostic dimensions.

CONCLUSION

These findings indicate that the specimen should be placed in fixative as soon as possible after excision and before opening to ensure minimum distortion of the specimen.