Resections Specimens

The uterus is usually removed together with the cervix as part of a hysterectomy. Occasionally the cervix is left in situ and a subtotal hysterectomy is performed. Myomectomies may also be performed, especially for uterine fibroids.

Initial procedure and description

• the specimen is measured in three dimensions (cm), i.e., superior to inferior, medial to lateral, anterior to posterior.

• the specimen is orientated. The peritoneal reflection extends lower on the posterior aspect of the uterus than anteriorly.

• ovaries and tubes, if present, are inspected and dealt with as described previously.

• the presence of any external abnormality is noted, e.g., tumour infiltration, serosal adhesions.

• the os of the cervix and the uterine cavity are entered using a probe.

• cutting along the probe, the uterus is opened longitudinally either along the lateral axis or along the anteroposterior axis from the external os to the cornu.

• the nature of the endometrium is commented on. The thickness can be measured and the presence of tumour, polyp or any focal lesion described and measured (cm).

• the presence or absence of uterine fibroids is noted. These are counted and the dimensions of the largest stated. Usually, uterine fibroids have a typical white whorled appearance and bulge above the surrounding myometrium. The presence of any grossly abnormal areas such as haemorrhage, necrosis, calcification or cystic degeneration is recorded.

• any cervical abnormalities are noted as described in Chapter 24.

• if a tumour is present the dimensions are measured. If this comprises an endometrial carcinoma (usually known from a previous biopsy specimen) then the depth of myometrial invasion is ascertained (inner or outer half) as is the presence or absence of gross cervical involvement. Assessment of myometrial invasion can be difficult as these uteri are often atrophic with a thin, compressed myometrium. Look for pale tumour tissue disrupting the intramyometrial line of vessels. Any obvious spread to the ovaries or fallopian tubes is documented.

• the presence of tumour infiltrating to the serosal surface of the uterus is also noted and in those tumours which do not extend to the serosal surface the minimum thickness of unin-volved myometrium is measured (mm).

• the presence of grossly visible foci of adenomyosis is recorded.

• the uterus is then sliced either transversely or longitudinally (depending on personal preference) at 3-5 mm intervals. During this procedure the presence of previously unidentified leiomyomas and the depth of invasion of endometrial carcinomas into the myometrium can be better assessed.

• photography may be undertaken.

• myomectomy specimens are enumerated, weighed, measured and described.

Blocks for histology

• when the hysterectomy was performed for benign disease, two representative sections showing the endometrial-myometrial junction and if possible the full wall thickness are examined. Two blocks of cervix showing the transformation zone (one from the anterior and one from the posterior lip) are also taken (Figure 23.3).

• when grossly visible adenomyosis is present this is sampled.

• if leiomyomas are present and these are grossly typical, one or two represenative sections suffice. If there are multiple leiomyomas, not all need to be examined microscopically.

• if there are areas of haemorrhage or necrosis within a leiomyoma or if any unusual gross findings are present, then extensive sampling should be undertaken, especially from the periphery of the lesion.

• with endometrial carcinomas, multiple sections are examined (Figure 23.4). They are taken to show the deepest point of myometrial infiltration, and also from uninvolved endometrium to assess the presence of coexistent hyperplasia.

• sections are taken from the cervix from any gross areas of cervical involvement. When this is not seen take three or four representative sections of the lower uterine segment and cervix.

• any grossly visible endometrial polyps are sampled.

• when there is a history of endometrial hyperplasia the endometrium should be examined in its entirety to assess the worst degree of hyperplasia and to evaluate the presence of a coexistent adenocarcinoma.

• ovaries and tubes, when grossly normal, are examined as per a benign protocol.

• any lymph nodes are examined in their entirety.

Histopathology report

• site of tumour within the uterus - fundus, body, lower uterine segment.

• size of tumour - measure in three dimensions (cm).

• gross appearance of tumour - polypoid or infiltrative. Colour and consistency. Presence or absence of haemorrhage and necrosis.

• tumour type - a variety of different adenocarcinomas arise in the endometrium. It is not acceptable to simply render a diagnosis of adenocarcinoma. The type of the adenocarcinoma should be stated.

• tumour differentiation - endometrial carcinomas of endometrioid and mucinous types are graded as Grade I-III (FIGO grading system). This depends on architectural and cytological features. Some of the special morphological subtypes such as uterine serous carcinoma and clear cell carcinoma are not graded since these are automatically high-grade tumours.

Corpus CarcinomHysterectomy Specimen
Figure 23.3. Blocking a routine hysterectomy specimen.

Tumour

Tumour

Paracervical Block

Endometrium Myometrium

Transverse section of endocervix, tumour and parametria!/ paracervical tissues

Endometrium Myometrium

Transverse section of endocervix, tumour and parametria!/ paracervical tissues

Longitudinal blocks of endocervix, tumour and transformation zone

1. Process adnexae

2. Probe and hemisect laterally

3. Amputate cervix and block

4. Transverse section corpus and isthmus

D = distance of deepest extent of tumour to nearest part of the serosa (mm)

Figure 23.4. Blocking a hysterectomy for uterine carcinoma.

• myometrial invasion - presence or absence of myometrial invasion. If present - confined to inner half or involves outer half.

• lymphovascular invasion - present/not present.

• lymph nodes - mention sites, number identified and presence or absence of tumour involvement.

• cervical involvement - presence or absence of involvement of the endocervical glands and stroma.

• serosal involvement - present/not present.

• measure minimum distance (mm) from the deepest point of myometrial infiltration by tumour to the serosa.

• surrounding endometrium - presence or absence and type of hyperplasia.

• other pathology - the presence of coexistent pathology should be mentioned.

• peritoneal washings - presence or absence of tumour cells.

• ovary and fallopian tube - presence or absence of tumour metastasis. Note that, especially with endometrioid tumours, synchronous neoplasms may be present within both the ovary and endometrium.

FIGO/TNM Staging pTis carcinoma in situ.

pT1 tumour confined to the corpus:

a. limited to the endometrium, b. invades less than half of the myometrium, c. invades more than half of the myometrium. pT2 tumour invades corpus and cervix:

a. endocervical glands only, b. cervical stroma.

pT3 outside the uterus but not outside the true pelvis:

a. serosa and/or adnexae, and/or malignant cells in ascites/peritoneal washings, b. vaginal disease (direct extension or metastasis).

pT4 extends outside the true pelvis or has obviously involved the mucosa of the bladder or rectum.

Regional nodes: pelvic (obturator and internal iliac), common and external iliac, parametrial, sacral and para-aortic.

pN0 no regional lymph nodes involved. pN1 metastasis in regional lymph node(s).

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