Results of a questionnaire regarding criteria for adequacy of endometrial biopsies

The effects of Saline Infusion Sonography on the histological quality of endometrial sampling in women with postmenopausal bleeding

BACKGROUND

The aim of this study is to analyze the histopathological features of endometrial samples obtained by aspiration when performed before or after the saline contrast sonohysterography in women with postmenopausal bleeding and a thickened endometrium. Hypothetically, the saline infusion could disrupt the tissue and therefore affect the quality of the sample. Furthermore, we want to determine which histological features have impact on the quality of the endometrial sample.

METHODS

We performed a randomized controlled trial (ESPRESSO trial) in which we analyzed the aspiration samples in two groups. Women were allocated either to saline contrast sonohysterography and subsequent endometrial sampling (SCSH-Sampling group) or to the opposite order (Sampling-SCSH group). Dedicated gyneco-pathologists retrospectively assessed the specimens and recorded the type (blood, mucus, epithelium, intact glands, stroma and tissue context) and quantity (on a scale of 0-3) of material that was found in the specimens.

RESULTS

This analysis consisted of 197 samples, with 101 women in the SCSH-Sampling group and 96 women in the Sampling-SCSH group. No significant differences were found in the histological features between the two groups. All significant histological features differed significantly in the sufficient samples compared to the insufficient samples: higher amounts of blood, more endometrial epithelium, presence of intact endometrial glands, better stroma and tissue context. Oppositely, a significantly higher amount of mucus was found in the insufficient samples.

CONCLUSION

This study shows that the histological features of the endometrial sample were not affected by the saline contrast sonohysterography, when performed prior to the tissue sampling. Trial registration ESPRESSO TRIAL, NTR5690, registered 16 February 2016, https://trialsearch.who.int/Trial2.aspx?TrialID=NTR5690 .

Vibrational Biospectroscopy: An Alternative Approach to Endometrial Cancer Diagnosis and Screening

Endometrial cancer (EC) is the sixth most common cancer and the fourth leading cause of death among women worldwide. Early detection and treatment are associated with a favourable prognosis and reduction in mortality. Unlike other common cancers, however, screening strategies lack the required sensitivity, specificity and accuracy to be successfully implemented in clinical practice and current diagnostic approaches are invasive, costly and time consuming. Such limitations highlight the unmet need to develop diagnostic and screening alternatives for EC, which should be accurate, rapid, minimally invasive and cost-effective. Vibrational spectroscopic techniques, Mid-Infrared Absorption Spectroscopy and Raman, exploit the atomic vibrational absorption induced by interaction of light and a biological sample, to generate a unique spectral response: a “biochemical fingerprint”. These are non-destructive techniques and, combined with multivariate statistical analysis, have been shown over the last decade to provide discrimination between cancerous and healthy samples, demonstrating a promising role in both cancer screening and diagnosis. The aim of this review is to collate available evidence, in order to provide insight into the present status of the application of vibrational biospectroscopy in endometrial cancer diagnosis and screening, and to assess future prospects.

Endometrial sampling at an academic hospital in South Africa: Histological findings, lessons learnt and interesting surprises

Background

Outpatient sampling is used to investigate endometrial pathology. Little is known about practice habits and local failure rates at Chris Hani Baragwanath Academic Hospital in Johannesburg, South Africa.

Objective

This study assessed the frequency of samples that showed no or limited histological representation of endometrium, and described demographic and pathological features.

Methods

All endometrial sample histology reports from the National Health Laboratory Services at the hospital from 01 July 2013 to 31 May 2017 were retrieved by searching the laboratory’s information system. Clinical variables (age, menopausal state, indication for biopsy, endometrial thickness on ultrasound) and pathological findings (macroscopic amount of tissue, histological diagnosis, microscopic presence of endometrial tissue) were extracted and statistically analysed.

Results

A total of 1926 samples were included, 91% of which were submitted for abnormal or postmenopausal bleeding. No endometrium was observed in 25% of samples and 13% showed limited endometrium. Benign diagnoses (86%) were most common, with proliferative or secretory changes, endometrial polyps and endometritis accounting for most of these. Associations between the amount of sample received and the presence of endometrial tissue (p ≤ 0.001) and benign versus malignant diagnoses (p ≤ 0.001) were noted. The greater the endometrial thickness, the greater the likelihood of obtaining more sample (bulky vs scant p < 0.001) and making a malignant versus benign diagnosis (p = 0.005).

Conclusion

These findings are in keeping with literature outside Africa. Histology reports should be explicit when terms such as ‘inadequate’ or ‘insufficient’ are used, in order to facilitate clinical decision-making.

Insufficient and Scant Endometrial Samples: Determining Clinicopathologic Outcomes and Consistency in Reporting

There are no widely accepted pathologic criteria for reporting endometrial samples with limited tissue and no consensus on the clinical follow-up of patients with these samples. Our study compares clinicopathologic outcomes and determines reporting consistency for these samples. This was done in 3 parts: (1) retrospective chart review of all patients with reported insufficient or scant endometrial samples from 2010 to 2013 at our center to determine repeat sampling and final pathologic diagnosis; (2) survey of gynecologists about their practice for managing patients with these samples; (3) blind review of 99 cases of previously reported scant or insufficient samples in which 4 reviewers separately reassigned cases as scant, insufficient, or diagnostic. Agreement was determined across reviewers. For part (1): 1149 patients had insufficient (49%) or scant (51%) samples with no significant difference in repeat biopsy rate (33% vs. 31%; P=0.33). Final diagnosis of uterine malignancy was higher in patients with a previous insufficient sample than with scant (19% and 9%, respectively), but this was not statistically significant. For part (2): among gynecologists surveyed, 4 of 5 reported managing patients with insufficient or scant samples similarly. For part (3): complete consensus across raters occurred in 57% of cases (Fleiss κ, 0.4891). Similar repeat biopsy rates between scant and insufficient samples suggest that our clinicians choose similar management for both terminologies. As such, distinction between insufficient and scant samples may not be necessary in pathologic reporting. Given the malignancy outcomes, both groups merit repeat sampling in the appropriate context.

Diagnostic accuracy of endometrial biopsy in relation to the amount of tissue

AIMS

For the diagnostic workup of postmenopausal bleeding, histological examination of the endometrium is frequently performed. Failure of endometrial sampling due to insufficient material is often reported but objective criteria for quality assessment of endometrial biopsies are lacking. The aim of the present study is to evaluate the association between the amount of tissue obtained by endometrial sampling and the diagnostic accuracy, and to establish a cut-off level for a minimal amount of tissue required for a conclusive diagnosis.

METHODS

For this retrospective cohort study, clinicopathological data and Pipelle endometrial sampling slides of 139 patients who were treated with hysterectomy were collected. The surface of evaluable endometrial tissue was measured by means of structured digital assessment. The correlation between the predictive values in relation to the endometrial tissue surface was calculated for different cut-off values.

RESULTS

The median endometrial tissue surface was 4.7 mm² (range 0.4-156.4) for benign endometrium, 27.8 mm² (range 0.0-208.4) for premalignant endometrium and 43.8 mm² (range 0.0-223.6) for malignant endometrium. There was a significant association between the endometrial tissue surface and the correctness of diagnosis. A minimal endometrial tissue surface of 35 mm² could be defined, for positive and negative predictive values of 92.6% and 85.7%, respectively.

CONCLUSIONS

The diagnostic accuracy of Pipelle endometrial sampling is associated with the amount of endometrial tissue surface, with a minimal cut-off value of 35 mm² required to classify an endometrial sample as conclusive. Quantification of endometrial tissue can contribute to standardisation of quality assessment of endometrial samplings.

Endometrial Samples From Postmenopausal Women: A Proposal for Adequacy Criteria

Approximately 75% of endometrial cancer occurs in women older than 55 yr of age. Postmenopausal bleeding is often considered endometrial cancer until proven otherwise. One diagnostic challenge is that endometrial biopsy or curettage generally yields limited samples from elderly patients. There are no well-defined and unified diagnostic criteria for adequacy of endometrial samples. Pathologists who consider any sample including those lacking endometrial tissue as "adequate" run the risk of rendering false-negative reports; on the contrary, pathologists requiring ample endometrial glands along with stroma tend to designate a greater number of samples as "inadequate," leading to unnecessary follow-up. We undertook a quantitative study of 1768 endometrial samples from women aged 60 yr and older aiming to propose validated adequacy criteria for diagnosing or excluding malignancy. Using repeat-procedure outcomes as reference, we found that samples exceeding 10 endometrial strips demonstrated high negative predictive value close to 100%. Such samples can be scant, yet appear to be sufficient in excluding malignant conditions. When tissue diminished to <10 strips, negative predictive value dropped significantly to 81%. The risk of undersampled malignancy rose to 19%. Among 274 malignant cases, only 4 cases yielded limited tissue yet >10 strips. In conclusion, we propose 10 endometrial strips as the minimum for adequate samples from postmenopausal women. Applying such validated adequacy criteria will greatly reduce false-negative errors and avoid unnecessary procedures while ultimately improving diagnostic accuracy. Our criteria may serve as a reference point in unifying the pathology community on this important and challenging topic.

Genetic analysis of uterine aspirates improves the diagnostic value and captures the intra-tumor heterogeneity of endometrial cancers

Endometrial cancer is the most common cancer of the female genital tract in developed countries. Although the majority of endometrial cancers are diagnosed at early stages and the 5-year overall survival is around 80%, early detection of these tumors is crucial to improve the survival of patients given that the advanced tumors are associated with a poor outcome. Furthermore, correct assessment of the pre-clinical diagnosis is decisive to guide the surgical treatment and management of the patient. In this sense, the potential of targeted genetic sequencing of uterine aspirates has been assessed as a pre-operative tool to obtain reliable information regarding the mutational profile of a given tumor, even in samples that are not histologically classifiable. A total of 83 paired samples were sequenced (uterine aspirates and hysterectomy specimens), including 62 endometrioid and non-endometrioid tumors, 10 cases of atypical hyperplasia and 11 non-cancerous endometrial disorders. Even though diagnosing endometrial cancer based exclusively on genetic alterations is currently unfeasible, mutations were mainly found in uterine aspirates from malignant disorders, suggesting its potential in the near future for supporting the standard histologic diagnosis. Moreover, this approach provides the first evidence of the high intra-tumor genetic heterogeneity associated with endometrial cancer, evident when multiple regions of tumors are analyzed from an individual hysterectomy. Notably, the genetic analysis of uterine aspirates captures this heterogeneity, solving the potential problem of incomplete genetic characterization when a single tumor biopsy is analyzed.

A Structured Assessment to Decrease the Amount of Inconclusive Endometrial Biopsies in Women with Postmenopausal Bleeding

Objective. To determine whether structured assessment of outpatient endometrial biopsies decreases the number of inconclusive samples. Design. Retrospective cohort study. Setting. Single hospital pathology laboratory. Population. Endometrial biopsy samples of 66 women with postmenopausal bleeding, collected during the usual diagnostic work-up and assessed as insufficient for a reliable histological diagnosis. Methods. Endometrial biopsy samples were requested from the pathology laboratories. The retrieved samples were systematically reassessed by a single pathologist specialized in gynecology. Main Outcome Measure. Disagreement between initial assessment and conclusion after structured reassessment. Results. We retrieved 36 of 66 endometrial biopsy samples from six different pathology laboratories. Structured reassessment of the retrieved samples by a single pathologist specialized in gynecology did not change the conclusion in 35 of the 36 samples. The remaining sample contained a large amount of endometrial tissue and the diagnosis at reassessment was endometrial hyperplasia without atypia. All other samples contained insufficient material for a reliable diagnosis. Conclusion. A structured reassessment of endometrial biopsies samples, which were classified as inconclusive due to insufficient material, did not change the conclusion. Although it might be helpful for pathologists to have diagnostic criteria for adequacy and/or inadequacy of an endometrial biopsy sample, the gain in efficiency is likely to be small.

Clinical outcomes of patients with insufficient sample from endometrial biopsy or curettage

Endometrial biopsy and curettage are widely used uterine sampling procedures. Occasionally, the amount of tissue obtained is so minimal that diagnosis cannot be reached. In published studies, insufficient samples comprise 2% to 60% of endometrial samples and are influenced by multiple contributory factors. To date, specific quantitative criteria for an adequate endometrial sample have not been established in the pathology community. The decision to classify a sample as nondiagnostic is subject to great interobserver variability, especially where elderly patients are concerned. Meanwhile, whether or not to repeat the procedure is the dilemma for clinical management. Herein we studied the clinicopathologic features of 1120 endometrial samples designated as insufficient for diagnosis. Such samples were more commonly encountered in elderly patients than younger ones (14.6% vs. 5.8%). Our pathologists generally required one intact tissue fragment containing both glands and stroma for premenopausal patients and 5 to 10 strips of atrophic endometrial epithelium for postmenopausal patients. By the 12-mo follow-up, 38% of patients with nondiagnostic samples had second sampling procedures and 7% underwent hysterectomy. The second sample was adequate in 75% of patients, 10% of which showed malignant tumor. If any worrisome histologic findings were present in the initial nondiagnostic sample, a high percentage of these patients were found to have uterine malignancy on second procedures (43%). Aims of this study are to bring awareness to this commonly overlooked topic, to validate our diagnostic criteria, and to outline important clinical implications.

Endometrial biopsy in women with abnormal uterine bleeding: inadequate and unassessable categorisation is not clinically relevant

AIMS

Inadequate endometrial biopsy comprises a dilemma for gynaecologists and histopathologists alike. This study was conducted to assess the clinical merit of classifying scant endometrial biopsy into inadequate and unassessable using McCluggage criteria.

METHODS

We retrospectively classified 268 endometrial biopsies, initially reported as inadequate, into inadequate (n=74) and unassessable (n=174) using McCluggage criteria after excluding 20 cases; all taken from patients aged ≥50 years with abnormal uterine bleeding attending Sandwell and West Birmingham Hospitals, UK from 1 January 2007 until 30 September 2012. The electronic clinical records were reviewed to find out the consequent clinical decisions and final outcomes. The follow-up period was 15 months after including the last patient.

RESULTS

The median age was 57 years (range: 50-97), and the median number of visits to hospital till the diagnosis was achieved was 2 (range: 1-4). The final diagnosis of endometrial hyperplasia or cancer was reported in 9 cases; 5 (7.1%) with an initial finding of inadequate and 4 with unassessable (2.4%); the difference was statistically insignificant (p=0.13). More patients in the inadequate category (82.4%) underwent further investigations when compared with the unassessable category (68.4%); the difference was statistically significant (p=0.029). There was no statistically significant difference in the inadequate to unassessable ratio when the endometrial thickness was ≥5 mm or <5 mm within the Pipelle group (p=0.46) or the curettage group (p=0.34).

CONCLUSIONS

Our findings suggest that categorising scant endometrial specimens into inadequate or unassessable has no clinical implications. The gynaecologist should interpret the histopathology report in the light of clinical scenario.

Predicting the Coexistence of an Endometrial Adenocarcinoma in the Presence of Atypical Complex Hyperplasia: Immunohistochemical Analysis of Endometrial Samples

Objective

This study aimed to determine whether immunohistochemical markers in complex atypical endometrial hyperplasia could predict the presence of a concurrent endometrial carcinoma.

Methods

Endometrial biopsies of 39 patients with complex atypical hyperplasia were selected retrospectively between 1999 and 2006. Only patients who underwent a hysterectomy were included. A coexisting endometrial carcinoma was present in 25 patients (64%). Immunohistochemical analysis was performed on formalin-fixed paraffin-embedded sections of the endometrial biopsies, using antibodies for MIB-1, β-catenin, E-cadherin, p53, PTEN, CD44, HER2-neu, survivin, COX-2, tenascin, and bcl-2. To evaluate the potential utility of these markers, a prediction model was constructed.

Results

In the univariate analysis, expressions of both PTEN and HER2-neu were significantly different between the groups with and without a coexisting endometrial carcinoma (P < 0.05). Loss of PTEN staining was found in 13 (54%) and 1 (7%) of the patients with and without a coexistent carcinoma, respectively (odds ratio, 16.55; 95% confidence interval [CI], 1.87–146.65). HER2-neu expression was found in only 2 (8.6%) and 6 (43%) patients with and without a coexistent carcinoma, respectively, and was excluded from further analysis because of its low expression. A prediction model containing PTEN expression only showed an area under the curve of 73.4% (95% CI, 57.3%–89.6%). After adding MIB-1 and p53, discriminative power improved to 87.2% (95% CI, 75.1%–99.3%).

Conclusions

This study showed that PTEN expression in complex endometrial hyperplasia is a promising factor for the prediction of the presence of a coexisting endometrial carcinoma, and prediction may even better when MIB-1 and p53 expressions are considered simultaneously.

Factors affecting adequacy of Pipelle and Tao Brush endometrial sampling

OBJECTIVE

To compare factors influencing adequacy of endometrial samples obtained using two outpatient sampling devices--Pipelle and Tao Brush.

DESIGN

Pragmatic unblinded trial with investigation schedule randomised separately within two groups according to endometrial cancer risk.

SETTING

Gynaecology outpatient clinic of a large city hospital in Edinburgh, Scotland.

POPULATION

All women referred to a gynaecology outpatient clinic during a 28-month period complaining of abnormal vaginal bleeding.

METHODS

Women were assigned to two 'risk groups' for endometrial cancer ('high risk' for postmenopausal women and 'moderate risk' for premenopausal women aged over 40 years or with other risk factors). Women in each risk group had both types of biopsy and were randomised to two outpatient visualisations: hysteroscopy and/or transvaginal ultrasound scan.

MAIN OUTCOME MEASURES

Completion of the investigation, adequacy of sample and acceptability of investigation to women.

RESULTS

In 200 high-risk women, adequate samples were significantly more likely to be obtained by Tao Brush than Pipelle (P < 0.001). Nulliparity was strongly associated with failed insertion for both devices (P < 0.001). Inadequate samples were strongly associated with postmenopausal status only for Pipelle (P < 0.001), and among premenopausal women, for both samplers, with nulliparity (P < 0.001). A significantly greater proportion of women preferred the Tao Brush to the Pipelle endometrial sampler (P < 0.001).

CONCLUSIONS

In postmenopausal women, Tao Brush sampling offers advantages over use of Pipelle, and the former should be considered as an alternative or additional sampling device in this group of women.

My approach to the interpretation of endometrial biopsies and curettings

A major proportion of the workload in many histopathology laboratories is accounted for by endometrial biopsies, either curettage specimens or outpatient biopsy specimens. The increasing use of pipelle and other methods of biopsy not necessitating general anaesthesia has resulted in greater numbers of specimens with scant tissue, resulting in problems in assessing adequacy and in interpreting artefactual changes, some of which appear more common with outpatient biopsies. In this review, the criteria for adequacy and common artefacts in endometrial biopsies, as well as the interpretation of endometrial biopsies in general, are discussed, concentrating on areas that cause problems for pathologists. An adequate clinical history, including knowledge of the age, menstrual history and menopausal status, and information on the use of exogenous hormones and tamoxifen, is necessary for the pathologist to critically evaluate endometrial biopsies. Topics such as endometritis, endometrial polyps, changes that are induced by hormones and tamoxifen within the endometrium, endometrial metaplasias and hyperplasias, atypical polypoid adenomyoma, adenofibroma, adenosarcoma, histological types of endometrial carcinoma and grading of endometrial carcinomas are discussed with regard to endometrial biopsy specimens rather than hysterectomy specimens. The value of ancillary techniques, especially immunohistochemistry, is discussed where appropriate.