Difference between revisions of "Endometrioid endometrial carcinoma"

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#redirect [[Endometrial_carcinoma#Endometrioid_endometrial_carcinoma]]
{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Image      = Endometrioid endometrial adenocarcinoma high mag.jpg
| Width      =
| Caption    = Endometrioid endometrial adenocarcinoma. [[H&E stain]].
| Synonyms  = endometrioid endometrial adenocarcinoma
| Micro      =
| Subtypes  =
| LMDDx      = [[complex endometrial hyperplasia]], [[microglandular hyperplasia]] of the cervix, [[endocervical adenocarcinoma]], [[serous carcinoma of the endometrium]] - esp. for high-grade tumours, [[clear cell carcinoma of the endometrium]], [[simple endometrial hyperplasia]], [[endometrium with squamous morules]]
| Stains    =
| IHC        = ER +ve, PR +ve, vimentin +ve, p16 -ve, CEA -ve
| EM        =
| Molecular  =
| IF        =
| Gross      = endometrial thickening
| Grossing  = [[hysterectomy for endometrial cancer grossing]]
| Site      = [[endometrium]] - see ''[[endometrial carcinoma]]''
| Assdx      = [[obesity]]
| Syndromes  = [[Lynch syndrome]], [[Cowden syndrome]]
| Clinicalhx =
| Signs      = [[abnormal uterine bleeding]] (AUB)
| Symptoms  =
| Prevalence = common
| Bloodwork  =
| Rads      =
| Endoscopy  =
| Prognosis  = good - esp. low-grade
| Other      =
| ClinDDx    =
| Tx        = usu. total hysterectomy
}}
'''Endometrioid endometrial carcinoma''', abbreviated '''EEC''', is the most common type of [[endometrial carcinoma]].  It is strongly associated with [[obesity]].
 
It is also known as '''endometrioid endometrial adenocarcinoma'''.
 
==General==
*Good prognosis - usually.
*Women in 40s & 50s.
*Associated with estrogen excess (unopossed estrogen stimulation).
**Typical patient is [[obese]].
 
Associated syndromes:
*[[Lynch syndrome]].<ref name=pmid11873308>{{Cite journal  | last1 = Lax | first1 = SF. | title = [Dualistic model of molecular pathogenesis in endometrial carcinoma]. | journal = Zentralbl Gynakol | volume = 124 | issue = 1 | pages = 10-6 | month = Jan | year = 2002 | doi = 10.1055/s-2002-20303 | PMID = 11873308 }}</ref><ref name=pmid23426126>{{Cite journal  | last1 = Karamurzin | first1 = Y. | last2 = Soslow | first2 = RA. | last3 = Garg | first3 = K. | title = Histologic evaluation of prophylactic hysterectomy and oophorectomy in Lynch syndrome. | journal = Am J Surg Pathol | volume = 37 | issue = 4 | pages = 579-85 | month = Apr | year = 2013 | doi = 10.1097/PAS.0b013e3182796e27 | PMID = 23426126 }}</ref>
*[[Cowden syndrome]].
 
==Gross==
*Thickened endometrium.
 
==Microscopic==
Features:
*Atypical (ovoid) glands with - one of the following four:<ref name=Ref_GP239>{{Ref GP|239}}</ref><ref name=pmid7074572>{{Cite journal  | last1 = Kurman | first1 = RJ. | last2 = Norris | first2 = HJ. | title = Evaluation of criteria for distinguishing atypical endometrial hyperplasia from well-differentiated carcinoma. | journal = Cancer | volume = 49 | issue = 12 | pages = 2547-59 | month = Jun | year = 1982 | doi =  | PMID = 7074572 }}</ref><ref>URL: [http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Endometrium_11protocol.pdf http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Endometrium_11protocol.pdf]. Accessed on: 12 January 2012.</ref>
*#[[Desmoplastic stromal response]].
*#Confluent cribriform growth. †
*#Extensive papillary growth. †
*#Severe cytologic atypia. †
*Endometrioid features:
**+/-Low-grade nuclear features.
**Squamous metaplasia - very common.
***Look for ''squamous morules'':
****Ball of cells with an intensely eosinophilic cytoplasm - '''key feature'''.
****Central nucleus.
****Intercellular bridges - may be hard to find.
****+/-Dyskeratotic cells.
 
Notes:
* † There is a size cut-off for criteria 2, 3 and 4: > 2.1 mm.<ref name=pmid7074572/>
*Dyskeratosis = abnormal keratinization;<ref>URL: [http://dictionary.reference.com/browse/dyskeratosis http://dictionary.reference.com/browse/dyskeratosis]. Accessed on: 5 September 2011.</ref> classically have intensely eosinophilic cytoplasm +/- nuclear fragmentation ([http://dictionary.reference.com/browse/karyolysis?db=medical&q=karyolysis karyorrhexis]) - see: [http://www.drmihm.com/pictures/Figure%203.jpg several dyskeratotic cells].
*[[Squamous metaplasia]] != neoplastic -- it may occur due to hormones.<ref name=pmid7748076>{{Cite journal  | last1 = Miranda | first1 = MC. | last2 = Mazur | first2 = MT. | title = Endometrial squamous metaplasia. An unusual response to progestin therapy of hyperplasia. | journal = Arch Pathol Lab Med | volume = 119 | issue = 5 | pages = 458-60 | month = May | year = 1995 | doi =  | PMID = 7748076 }}</ref>
*Squamous morules in endometrioid endometrial carcinoma - not associated with [[HPV]] infection.<ref name=pmid15333650>{{Cite journal  | last1 = Chinen | first1 = K. | last2 = Kamiyama | first2 = K. | last3 = Kinjo | first3 = T. | last4 = Arasaki | first4 = A. | last5 = Ihama | first5 = Y. | last6 = Hamada | first6 = T. | last7 = Iwamasa | first7 = T. | title = Morules in endometrial carcinoma and benign endometrial lesions differ from squamous differentiation tissue and are not infected with human papillomavirus. | journal = J Clin Pathol | volume = 57 | issue = 9 | pages = 918-26 | month = Sep | year = 2004 | doi = 10.1136/jcp.2004.017996 | PMID = 15333650 }}</ref>
 
DDx:
*[[Complex endometrial hyperplasia with atypia]].
*[[Complex endometrial hyperplasia]].
*[[Microglandular hyperplasia]] of the cervix.
*[[Endocervical adenocarcinoma]].
*[[Serous carcinoma of the endometrium]] - esp. if high-grade nuclear features are present diffusely.
*[[Clear cell carcinoma of the endometrium]] - esp. when clear cells present.
 
===Grading===
*FIGO system most commonly used.
*Based on gland formation & adjusted by nuclear pleomorphism.
 
Preliminary grade based on gland formation:<ref>{{Ref PBoD|1087-8}}</ref><ref>URL: [http://www.pathologyoutlines.com/uterus.html#endometrialcarc http://www.pathologyoutlines.com/uterus.html#endometrialcarc].</ref><ref>URL: [http://www.emedicine.com/med/topic2832.htm http://www.emedicine.com/med/topic2832.htm].</ref><ref name=pmid12496701>{{cite journal |author=Ayhan A, Taskiran C, Yuce K, Kucukali T |title=The prognostic value of nuclear grading and the revised FIGO grading of endometrial adenocarcinoma |journal=Int. J. Gynecol. Pathol. |volume=22 |issue=1 |pages=71–4 |year=2003 |month=January |pmid=12496701 |doi= |url=}}</ref>
*Grade 1: <5% solid component.
*Grade 2: 5-50% solid component.
*Grade 3: >50% solid component.
 
Modifiers/adjustment:
*High grade nuclei upgrades cancer by one.
**Tadrous says: high grade nuclei = increased size, irregular large nucleoli, irregular chromatin pattern (clumped, coarse).<ref>{{Ref DCHH|240}}</ref>
**Winham ''et al''. describe it as: [[nuclear pleomorphism]] identifiable with the 10× objective or enlarged nuclei (1.5-2× normal) with [[prominent nucleoli]], irregular nuclear contours, and dispersed chromatin.<ref name=pmid24487465>{{Cite journal  | last1 = Winham | first1 = WM. | last2 = Lin | first2 = D. | last3 = Stone | first3 = PJ. | last4 = Nucci | first4 = MR. | last5 = Quick | first5 = CM. | title = Architectural versus nuclear atypia-defined FIGO grade 2 endometrial endometrioid adenocarcinoma (EEC): a clinicopathologic comparison of 154 cases with clinical follow-up. | journal = Int J Gynecol Pathol | volume = 33 | issue = 2 | pages = 120-6 | month = Mar | year = 2014 | doi = 10.1097/PGP.0b013e31828bb4ed | PMID = 24487465 }}</ref>
 
===Images===
<gallery>
Image:Endometrioid endometrial adenocarcinoma low mag.jpg | EEA - low mag. (WC)
Image:Endometrioid endometrial adenocarcinoma intermed mag.jpg | EEA - intermed. mag. (WC)
Image:Endometrioid endometrial adenocarcinoma high mag.jpg | EEA - high mag. (WC)
Image: Endometrioid endometrial adenocarcinoma very high mag.jpg | EEA - very high mag. (WC)
</gallery>
www:
*[http://www.diagnosticpathology.org/content/2/1/40/figure/F1?highres=y Squamous morule with dyskeratotic cell (diagnosticpathology.org)].
 
==IHC==
*Vimentin +ve.
*ER +ve.
*PR +ve.
 
Others:
*p16 -ve -- positive in [[serous endometrial carcinoma]]<ref name=pmid17581420>{{Cite journal  | last1 = Chiesa-Vottero | first1 = AG. | last2 = Malpica | first2 = A. | last3 = Deavers | first3 = MT. | last4 = Broaddus | first4 = R. | last5 = Nuovo | first5 = GJ. | last6 = Silva | first6 = EG. | title = Immunohistochemical overexpression of p16 and p53 in uterine serous carcinoma and ovarian high-grade serous carcinoma. | journal = Int J Gynecol Pathol | volume = 26 | issue = 3 | pages = 328-33 | month = Jul | year = 2007 | doi = 10.1097/01.pgp.0000235065.31301.3e | PMID = 17581420 }}</ref> and [[endocervical adenocarcinoma]].
*CEA -ve.
 
==Sign out==
===Biopsy===
<pre>
Endometrium, Curettage:
- ENDOMETRIOID ENDOMETRIAL ADENOCARCINOMA, preliminary FIGO grade I.
</pre>
 
<pre>
Endometrium, Curettage:
- ENDOMETRIOID ENDOMETRIAL ADENOCARCINOMA, preliminary FIGO grade II.
 
Comment:
The architecture is in keeping with FIGO I; however, nuclear atypia is
present and therefore it is FIGO II.
</pre>
 
 
====Block letters====
<pre>
ENDOMETRIUM, BIOPSY:
- ENDOMETRIOID ENDOMETRIAL ADENOCARCINOMA, FIGO GRADE I/III.
</pre>
 
===Hysterectomy===
<pre>
UTERUS WITH CERVIX AND FALLOPIAN TUBES, TOTAL HYSTERECTOMY AND BILATERAL SALPINGECTOMY:
- ENDOMETRIOID ENDOMETRIAL ADENOCARCINOMA, FIGO GRADE I/III, pT2, pNx.
-- SURGICAL MARGINS NEGATIVE.
-- PLEASE SEE TUMOUR SUMMARY.
- LEIOMYOMAS WITH HYALINIZATION.
- FALLOPIAN TUBES WITHOUT SIGNIFICANT PATHOLOGY.
</pre>
 
===Micro===
The sections show endometrium with complex, fused and cribriform glands with scant intervening stroma over a region measuring greater than 2.1 millimetres. Focally, a desmoplastic stroma is also identified. No nuclear atypia is appreciated.
 
A subtle pattern of myoinvasion in low grade endometrial endometrioid carcinomas, microcystic, elongated and fragmented (MELF) should be searched for in the absence of frank invasion. At low power, microcystic tumor glands lie separated by muscle from non-invasive carcinoma in edematous stroma. At higher power lie microcystic glands with neutrophils, as well as elongated glands lined by flattened tumor cells. Eosinophilic tumor cells or squamous cells can often be seen within the lumens.  <ref name=pmid14501811>{{cite journal |author= Murray SK, Young RH, Scully RE |title= Unusual epithelial and stromal changes in myoinvasive endometrioid adenocarcinoma: a study of their frequency, associated diagnostic problems, and prognostic significance |journal= Int J Gynecol Pathol |volume=22 |issue= |pages=324-333 |year=2003 | pmid=14501811  |doi=10.1097/01.pgp.0000092161.33490.a9 }}</ref>
 
====Endocervical versus endometrial - biopsy====
The foamy histiocytes in the stroma and lack of desmoplasia slightly favour an endometrial origin; however, the lesion would be best classified with an excisional specimen and in conjunction with the clinical impression.
 
==See also==
*[[Endometrial carcinoma]].
*[[Endometrial hyperplasia]].
*[[Ductal adenocarcinoma of the prostate gland]].
*[[Microcystic elongated and fragmented glands in endometrioid endometrial carcinoma]] (MELF).
 
==References==
{{Reflist|2}}


[[Category:Diagnosis]]
[[Category:Diagnosis]]
[[Category:Endometrial carcinoma]]

Latest revision as of 21:40, 22 February 2023

Endometrioid endometrial carcinoma
Diagnosis in short

Endometrioid endometrial adenocarcinoma. H&E stain.
Synonyms endometrioid endometrial adenocarcinoma
LM DDx complex endometrial hyperplasia, microglandular hyperplasia of the cervix, endocervical adenocarcinoma, serous carcinoma of the endometrium - esp. for high-grade tumours, clear cell carcinoma of the endometrium, simple endometrial hyperplasia, endometrium with squamous morules
IHC ER +ve, PR +ve, vimentin +ve, p16 -ve, CEA -ve
Gross endometrial thickening
Grossing notes hysterectomy for endometrial cancer grossing
Site endometrium - see endometrial carcinoma
Associated Dx obesity
Syndromes Lynch syndrome, Cowden syndrome
Signs abnormal uterine bleeding (AUB)
Prevalence common
Prognosis good - esp. low-grade
Treatment usu. total hysterectomy

Endometrioid endometrial carcinoma, abbreviated EEC, is the most common type of endometrial carcinoma. It is strongly associated with obesity.

It is also known as endometrioid endometrial adenocarcinoma.

General

  • Good prognosis - usually.
  • Women in 40s & 50s.
  • Associated with estrogen excess (unopossed estrogen stimulation).
    • Typical patient is obese.

Associated syndromes:

Gross

  • Thickened endometrium.

Microscopic

Features:

  • Atypical (ovoid) glands with - one of the following four:[3][4][5]
    1. Desmoplastic stromal response.
    2. Confluent cribriform growth. †
    3. Extensive papillary growth. †
    4. Severe cytologic atypia. †
  • Endometrioid features:
    • +/-Low-grade nuclear features.
    • Squamous metaplasia - very common.
      • Look for squamous morules:
        • Ball of cells with an intensely eosinophilic cytoplasm - key feature.
        • Central nucleus.
        • Intercellular bridges - may be hard to find.
        • +/-Dyskeratotic cells.

Notes:

  • † There is a size cut-off for criteria 2, 3 and 4: > 2.1 mm.[4]
  • Dyskeratosis = abnormal keratinization;[6] classically have intensely eosinophilic cytoplasm +/- nuclear fragmentation (karyorrhexis) - see: several dyskeratotic cells.
  • Squamous metaplasia != neoplastic -- it may occur due to hormones.[7]
  • Squamous morules in endometrioid endometrial carcinoma - not associated with HPV infection.[8]

DDx:

Grading

  • FIGO system most commonly used.
  • Based on gland formation & adjusted by nuclear pleomorphism.

Preliminary grade based on gland formation:[9][10][11][12]

  • Grade 1: <5% solid component.
  • Grade 2: 5-50% solid component.
  • Grade 3: >50% solid component.

Modifiers/adjustment:

  • High grade nuclei upgrades cancer by one.
    • Tadrous says: high grade nuclei = increased size, irregular large nucleoli, irregular chromatin pattern (clumped, coarse).[13]
    • Winham et al. describe it as: nuclear pleomorphism identifiable with the 10× objective or enlarged nuclei (1.5-2× normal) with prominent nucleoli, irregular nuclear contours, and dispersed chromatin.[14]

Images

  • EEA - low mag. (WC)

  • EEA - intermed. mag. (WC)

  • EEA - high mag. (WC)

  • EEA - very high mag. (WC)

www:

IHC

  • Vimentin +ve.
  • ER +ve.
  • PR +ve.

Others:

Sign out

Biopsy

Endometrium, Curettage: 
- ENDOMETRIOID ENDOMETRIAL ADENOCARCINOMA, preliminary FIGO grade I.

Endometrium, Curettage:
- ENDOMETRIOID ENDOMETRIAL ADENOCARCINOMA, preliminary FIGO grade II.

Comment:
The architecture is in keeping with FIGO I; however, nuclear atypia is
present and therefore it is FIGO II.


Block letters

ENDOMETRIUM, BIOPSY: 
- ENDOMETRIOID ENDOMETRIAL ADENOCARCINOMA, FIGO GRADE I/III.

Hysterectomy

UTERUS WITH CERVIX AND FALLOPIAN TUBES, TOTAL HYSTERECTOMY AND BILATERAL SALPINGECTOMY:
- ENDOMETRIOID ENDOMETRIAL ADENOCARCINOMA, FIGO GRADE I/III, pT2, pNx.
-- SURGICAL MARGINS NEGATIVE.
-- PLEASE SEE TUMOUR SUMMARY.
- LEIOMYOMAS WITH HYALINIZATION.
- FALLOPIAN TUBES WITHOUT SIGNIFICANT PATHOLOGY.

Micro

The sections show endometrium with complex, fused and cribriform glands with scant intervening stroma over a region measuring greater than 2.1 millimetres. Focally, a desmoplastic stroma is also identified. No nuclear atypia is appreciated.

A subtle pattern of myoinvasion in low grade endometrial endometrioid carcinomas, microcystic, elongated and fragmented (MELF) should be searched for in the absence of frank invasion. At low power, microcystic tumor glands lie separated by muscle from non-invasive carcinoma in edematous stroma. At higher power lie microcystic glands with neutrophils, as well as elongated glands lined by flattened tumor cells. Eosinophilic tumor cells or squamous cells can often be seen within the lumens. [16]

Endocervical versus endometrial - biopsy

The foamy histiocytes in the stroma and lack of desmoplasia slightly favour an endometrial origin; however, the lesion would be best classified with an excisional specimen and in conjunction with the clinical impression.

See also

References

  1. ↑ Lax, SF. (Jan 2002). "[Dualistic model of molecular pathogenesis in endometrial carcinoma].". Zentralbl Gynakol 124 (1): 10-6. doi:10.1055/s-2002-20303. PMID 11873308.
  2. ↑ Karamurzin, Y.; Soslow, RA.; Garg, K. (Apr 2013). "Histologic evaluation of prophylactic hysterectomy and oophorectomy in Lynch syndrome.". Am J Surg Pathol 37 (4): 579-85. doi:10.1097/PAS.0b013e3182796e27. PMID 23426126.
  3. ↑ Nucci, Marisa R.; Oliva, Esther (2009). Gynecologic Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 239. ISBN 978-0443069208.
  4. ↑ 4.0 4.1 Kurman, RJ.; Norris, HJ. (Jun 1982). "Evaluation of criteria for distinguishing atypical endometrial hyperplasia from well-differentiated carcinoma.". Cancer 49 (12): 2547-59. PMID 7074572.
  5. ↑ URL: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Endometrium_11protocol.pdf. Accessed on: 12 January 2012.
  6. ↑ URL: http://dictionary.reference.com/browse/dyskeratosis. Accessed on: 5 September 2011.
  7. ↑ Miranda, MC.; Mazur, MT. (May 1995). "Endometrial squamous metaplasia. An unusual response to progestin therapy of hyperplasia.". Arch Pathol Lab Med 119 (5): 458-60. PMID 7748076.
  8. ↑ Chinen, K.; Kamiyama, K.; Kinjo, T.; Arasaki, A.; Ihama, Y.; Hamada, T.; Iwamasa, T. (Sep 2004). "Morules in endometrial carcinoma and benign endometrial lesions differ from squamous differentiation tissue and are not infected with human papillomavirus.". J Clin Pathol 57 (9): 918-26. doi:10.1136/jcp.2004.017996. PMID 15333650.
  9. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1087-8. ISBN 0-7216-0187-1.
  10. ↑ URL: http://www.pathologyoutlines.com/uterus.html#endometrialcarc.
  11. ↑ URL: http://www.emedicine.com/med/topic2832.htm.
  12. ↑ Ayhan A, Taskiran C, Yuce K, Kucukali T (January 2003). "The prognostic value of nuclear grading and the revised FIGO grading of endometrial adenocarcinoma". Int. J. Gynecol. Pathol. 22 (1): 71–4. PMID 12496701.
  13. ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 240. ISBN 978-0470519035.
  14. ↑ Winham, WM.; Lin, D.; Stone, PJ.; Nucci, MR.; Quick, CM. (Mar 2014). "Architectural versus nuclear atypia-defined FIGO grade 2 endometrial endometrioid adenocarcinoma (EEC): a clinicopathologic comparison of 154 cases with clinical follow-up.". Int J Gynecol Pathol 33 (2): 120-6. doi:10.1097/PGP.0b013e31828bb4ed. PMID 24487465.
  15. ↑ Chiesa-Vottero, AG.; Malpica, A.; Deavers, MT.; Broaddus, R.; Nuovo, GJ.; Silva, EG. (Jul 2007). "Immunohistochemical overexpression of p16 and p53 in uterine serous carcinoma and ovarian high-grade serous carcinoma.". Int J Gynecol Pathol 26 (3): 328-33. doi:10.1097/01.pgp.0000235065.31301.3e. PMID 17581420.
  16. ↑ Murray SK, Young RH, Scully RE (2003). "Unusual epithelial and stromal changes in myoinvasive endometrioid adenocarcinoma: a study of their frequency, associated diagnostic problems, and prognostic significance". Int J Gynecol Pathol 22: 324-333. doi:10.1097/01.pgp.0000092161.33490.a9. PMID 14501811.
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