Endometrial biopsy - interpretation.pptx

Endometrial biopsy interpretation - covers the basics of endometrial dating, hyperplasia and carcinoma.

1. ENDOMETRIAL BIOPSY  INTERPRETATION DR.MEKALA NIRAIMATHI.M, FIRST  YEAR POST GRADUATE, MD PATHOLOGY.

2. INTRODUCTION                       Interpreting the biopsy material demands a  logical  approach that takes  into account  many factors  like  patient history  ,appreciation of   limitation,specific  request of clinician performing the biopsy.

3. ENDOMETRIUM-INDICATIONS OF SAMPLING BLEEDING                                               NON-BLEEDING 1.AUB                                                      1. Infertility - primary/secondary 2.Menorrhagia                                      2. Pre-op assessment before any  3. Post menopausal bleeding                   other indication for   hysterectomy                                                                                                                                           3.Serial biopsies-Evaluation of effect                                                                       of   hormone therapy                                                                                                                                                                                                     

4. Causes of abnormal uterine bleeding Pre menopausal bleeding Gestation,abortion,retained products of conception Anovulatory cycles – PCOS Malignancy and hyperplasia Perimenopausal bleeding Anovulatory cycles-withdrawal bleeding Cycling endometrium- fibroids,adenomyosis Endometritis,hyperplasia,carcinoma,cervical carcinoma Iatrogenic

5. In postmenopausal women, atrophy is the most common cause of abnormal bleeding. Polyps,coagulopathies can also cause abnormal uterine bleeding. Pregnancy related causes of bleeding include ectopic pregnancy,intrauterine pregnancy,gestational trophablastic disease.

6. Procedures for obtaining endometrial tissue 1. Office based biopsy:    Provides a representative sample.    May not contain sufficient tissue.    Accurate for diffuse lesions but focal lesions may be missed.    Cervical dilatation is not necessary.    Cost effective,convenient     Anaesthesia is not required.    Can be done in conjuunction with ultrasound/hysteroscopy.

7. Pipelle device

8. Endometrial pipelle   biopsy in postmenopausal woman where the specimen  consists entirely of superfificial strips of atrophic endometrial glands without accompanying endometrial stroma.

9. 2.Curettage A).Complete curettage B).Fractional curettage  Ideal method,cervical dilatation and endometrial curettage provides more tissue for evaluation. Rate of incfection,perforation and hemorrhage are more with curettage.

10. SELECTION OF PROPER TIME FOR CURETTAGE In Infertile patients – shortly before onset of menstruation In menorrhagia – 5 to 10 days after onset of menstruation due to irregular shedding. In metrorrhagia - done without delay when much of the endometrium is still available for examination.

11. PREPARATION OF ENDOMETRIAL SPECIMEN Fixation – 4% of neutral formaldehyde.Adequate fixation is important(minimum 6hrs to overnight fixation) Routine staining method:Hematoxylin and Eosin

12. What to know before interpreting a biopsy? Whether patient has been given hormonal medications to control bleeding prior to sampling,oral contraceptive pills,hormone replacement therapy,tamoxifen . Age,LMP,menstrual history,menopausal status,pregnancy status Reason for biopsy,ultrasound and CT scan findings if any.

13. Criteria for adequacy of endometrial sample Adequate sample – presence of more than 10 endometrial strips Suboptimal sample – less than 10 strips Insufficient for diagnosis – no endometrial tissue sampled Adequate sample is defined as one that is of sufficient size to determine gland to stromal ratio and to demonstrate endometrial morphological features. It should also contain surface epithelium.

14. LAYERS OF ENDOMETRIUM                                 Select a fragment with intact lining epithelium for interpretation as this represents the 'Stratum functionalis ' - the most hormone responsive layer.

15. Gross Evaluation Of Endometrial Tissue Appearance of tissue – received fresh or in fixative,weight,size or measurement. In case of biopsy,entire tissue should be submitted and stated. In endometrial polypectomy,sampling of non polypoid endometrium should also be performed. Large endometrial polyps  - representative sampling ( atleast one block per centimeter ) should be taken.

16. INTERPRETATION OF BIOPSY  GLANDS Are the glands evenly spaced out Gland : stromal ratio Shape – round/dilated Any dilatation or branching Any secretory activity- vacuolation/luminal secretion Lining epithelium-Pseudostratified vs low columnar or cuboidal Mitoses-present or not STROMA Compact,cellular Loose edematous Stromal cells-spindly/ ovoid imparting a blue colour or plump and with mod cytoplasm imparting eosinophilic appearance- Pseudodecidual change Presence of spiral arterioles Hemorrhage,granulocytes,collapse stromal balls

17. ARTEFACTS 1.Telescoping artefact 2.Glandular molding

18. 3.Pseudopapillary endometrium 4. Pseudolipomatosis

19. CONTAMINANTS & OTHER ELEMENTS Superficial myometrium – vigorous curettage,postmenopausal atrophic lining Cervical tissue and mucus – with neutrophils,histiocytes,giant cells

20. Aggregate of  histiocytes in an endometrial biopsy composed of cells  with a coffee-bean nucleus and abundant eosinophilic  cytoplasm Nodular histiocytic hyperplasia

21. Histiocytes – occasional mitotic figures,intracytoplasmic inclusions Foamy histiocytes with abundant cytoplasm -  endometrial hyperplasia, carcinoma, pyometra,xanthogranulomatous endometritis EXTRAUTERINE TISSUES: Adipose tissue – m/ c, uterine lipoleiomyoma , lipoma, hamartomatous lesion,metaplastic adipose tissue within the endometrial stroma, uterine perforation Adipose tissue is accompanied by fibrinous material and mesothelial cells - underlying mesothelial proliferation Intestinal mucosa – secondary to perforation

22. NORMAL CYCLICAL ENDOMETRIUM Proliferative phase – begins 3rd/4th day of cycle until ovulation Secretory phase – 16th to 28th day  Menstrual phase – begins menstruation

23. PROLIFERATIVE ENDOMETRIUM Glands – evenly spaced,simple tubular,mitotic figures seen. Stroma – Compact and cellular, scanty thin walled stromal blood vessels,lymphoid aggregates present. Lining – Pseudostratified columnar cells with moderate basophilic cytoplasm,oval /round nuclei.

24. Endometrial thickness upto 4-5mm Stromal,glandular and vascular growth until ovulation Proliferative activity is maximum between 8th and 10th day of cycle In late proliferative phase - glands become more convoluted,tortuous,variable in size & shape but they remain tubular in architecture

25. Interval endometrium ( day 15-16) Features of both proliferative and secretory endometrium. Subnuclear vacuoles present. Mitosis persists , disappear later in secretory phase. Glands have proliferative architecture.

26. SECRETORY ENDOMETRIUM Characterized by glandular secretion,stromal matutration and vascular differentiation. Under the influence of progesterone secreted by corpus luteum. Endometrial thickness increase  upto 7 – 8 mm. Three stages: 1.Early secretory phase - 16th to 18th day                             2.Mid secretory phase - 19th to 23rd day                             3.Late secretory phase - 24th to 28th day Interval of 36-48hrs between ovulation & recognizable early secretory activity.

27. Day 17 – subnuclear vacuoles(piano key appearance) Rare mitosis,secretory vacuoles present. Epithelium no longer psedostratified,appears as single layer. Vacuoles move towards the gland  lumen,secretion into glands. Day 18 - vacuoles both above and below gland nuclei. Day 19 – Vacuoles above gland nuclei. Day 20 – peak secretion. Rest of secretory phase occurs in stroma,as glands are exhausted take saw tooth appearance. Day 21 - beginning of stromal edema. Day 22 - peak stromal edema. Day 23 - glands show saw tooth infoldings,spiral arterioles in stroma. Dayb 24 - more secretory exhaustion,spiral arterioles in  predecidual cuffing

28. EARLY SECRETORY ENDOMETRIUM Day 16,17 - Early  secretory phase- Irregular basal/subnuclear vacuoles(Piano key app), pseudostratified nuclei,  Numerous mitoses present  . Day 18 - Supranuclear (luminal) vacuoles  Pseudostratified nuclei . Mitoses rare.

29. MID SECRETORY ENMDOMETRIUM(D 19 –23) Mid-secretory endometrium. The glands contain  supranuclear vacuoles with secretions within the glandular lumina. There is marked stromal  edema with “ naked ” stromal cells

30. LATE SECRETORY PHASE(D 24 – 28) Closely packed glands superficially resembling a hyperplastic endometrium  Predecidual  change surrounding the spiral arteries and focally beneath the epithelium

31. MENSTRUAL PHASE(D 1 – 4) The stromal cells aggregate into “blue balls Apoptotic bodies are present within the endometrial glands and stroma

32. Lower Uterine Segment 1. Isthmic endometrium 2.Poorly responsive to steroid hormones 3.lower uterine segment endometrium is not  useful for dating the menstrual cycle.

33. Gestational Endometrium The stroma is  expanded and composed of decidualized cells with abundant eosinophilic cytoplasm (1)glandular ferning with epithelial and intraluminal secretions (2) stromal edema and vascular congestion (3) decidual  reaction of the stromal cells.

34. Arias-Stella reaction 1.Almost always associated with pregnancy, either intrauterine or ectopic or with trophoblastic disease. 2.Cellular stratifification , vacuolated cytoplasm and enlargement  of the epithelial cell nuclei.

35. Endometrial glands in pregnancy may contain cells with optically clear nuclei.

36. Postmenopausal Endometrium Atrophic endometrium. There are widely spaced small atrophic tubules within a fibrotic background Cystic atrophy - Cystically dilated glands are  present within a fibrous stroma

37. Atrophic endometrium Lack of hormonal stimulation leads to endometrial atrophy. Non secretory glands. Flattened epithelium devoid of mitotic activity. Glands become cystic. Flattened non proliferating(distinguishes cystic atrophy from simple hyperplasia.

38. Anovulatory Cycle Estrogen effect       1.Focal gland dilatation and crowding       2.Disorder proliferation       3.Thin walled ectatic vessels

39. Disordered proliferative endometrium Irregularly shaped cystic dilated glands(>2 normal size). Stromal hemorrhage,breakdown common. Tubal metaplasia common. Lack of cytological atypia. Abnormal endometrial findings with some features of simple endometrial hyperplasia due to unopposed estrogen stimulation.

40. ENDOMETRITIS Stromal cells show spindle cell appearance Acute Endometritis – Neutophils with microabscess

41. Foamy histiocytes in  Xanthogranulomatous endometritis. Chronic endometritis Plasma cells with or without lymphoid follicles,Spindled stromal cells

42. SPECIFIC FORMS OF ENDOMETRITIS Chlamydia Trachomatis- lymphoid follicles and large numbers of blasts,stromal necrosis and reactive atypia ,inclusion bodies Cytomegalovirus-Typical intranuclear and cytoplasmic CMV inclusions   Herpes simplex virus inclusions are present within the glandular epithelium and there are multinucleated cells with molded ground-glass nuclei,patchy  necrosis of the endometrial glands and stroma Ureaplasma   urealyticum -subacute focal endometritis Actinomyces-actinomycotic granules (AMGs)-sulfur granules Malakoplakia-abnormal immune response to bacteria, most commonly Escherichia  coli,sheets of foamy histiocytes (von Hansemann’s histiocytes) containing Michaelis–Gutmann bodies.

43. Actinomycotic granules composed of thin basophilic radiating filaments with a more dense eosinophilic granular core. Actinomyces

44. Pseudoactinomycotic radiate granules. Pseudo actinomycotic radiate granules with thick, irregular, club like peripheral projections without a central dense core

45. Lymphoma-Like Lesion - dense aggregates of lymphoid cells, often with  large numbers of blasts and a starry-sky appearance, forming a superfificial  band-like infifiltrate Endometrial Granulomas- tuberculosis,schistosomiasis , Enterobius   vermicularis,Toxoplasma gondii,sarcoidosis,secondary to endometrial   ablation,idiopathic

46. Granulomatous endometritis Ligneous(pseudomembranous) endometritis.Band of amorphous eosinophilic material represents fibrin deposition 

47. Dysfunctional uterine bleeding Endometrial breakdown. With breakdown, the  stromal cells aggregate into stromal “blue balls”  Endometrial glands become disrupted and crowded  because of stromal collapse

48. Chronic endometrial breakdown. With chronic  breakdown, hemosiderin pigment may accumulate within histiocytes within the endometrial stroma Endometrial breakdown. With breakdown,fibrin   thrombi are typically seen

49. Estrogen related DUB Disordered proliferative endometrium. Occasional cystically dilated glands with  abnormal glandular shapes are present within an otherwise typical proliferative  endometrium

50. Progesterone-Related DUB: Luteal  Phase Defects Absolute insuffificiency of progesterone secretion by the corpus luteum Hypothalamic or pituitary dysfunction a lag in the histological date of the endometrium of at least 2 days compared to the actual postovulatory date. diagnosis can be made by a combination of repeated biopsies over several cycles and serial hormone measurements

51. Endometrial Hyperplasia Proliferation of glands of irregular size and shape with an associated increase in the gland/stroma ratio compared with proliferative endometrium.  Classification is based on architectural pattern and cytological atypia. Architectural pattern – based on degree of glandular crowding(simple/complex) WHO classification Simple hyperplasia  Complex hyperplasia Simple atypical hyperplasia Complex atypical hyperplasia

52. WHO 2014 CLASSIFICATION Hyperplasia without atypia  Hyperplasia with atypia (atypical hyperplasia). Endometrioid intraepithelial neoplasia (EIN) Simple hyperplasia has risk of Ca endometrium <2% Simple atypical hyperplasia 8% Complex atypical hyperplasia 29% Hence cytological atypia increases the risk of progression to carcinoma more than architectural changes.

53.   Glands are minimally crowded but are dilated and have  outpouchings,abundant stroma. Glands are mildly crowded and some are cystically dilated Simple Hyperplasia without atypia

54. Closely packed glands Lack of abundant stroma Crowding & branching of glands Abundant mitotic stroma Oval basally located nuclei Complex hyperplasia without atypia

55. Hyperplasia without atypia Elongated nuclei perpendicular to basement membrane Evenly hyperchromatic

56. Atypical Hyperplasia Stratified cells Loss of Polarity Increased nuclear : cytoplasmic ratio Enlarged round nuclei,coarse chromatin,irregular nuclear membrane,prominent nucleoli Evaluation of atypia is most important feature in the evaluation oh endometrial hyperplasia.

57.  Branching and tubular glands   little intervening stroma Nuclei are rounded, have vesicular chromatin,  display stratification and loss of  polarity Atypical hyperplasia

58. Atypical hyperplasia. Nuclei vary from ovoid to rounded, have even chromatin with evident nucleoli and mitotic figures, and display some stratifification and loss of polarity

59. Differential Diagnosis of Endometrial Hyperplasia Disordered proliferative phase Endometrial polyps  Ciliated cell change (tubal metaplasia)  Cystic atrophy Endometrial glandular and stromal breakdown Atypical polypoid adenomyoma  Well-differentiated adenocarcinoma

60. Endometrial Polyps Present as AUB <5% associated with neoplasia                                                                                                               1.Lined by surface epithelium(may be atrophic or proliferative) 2.Glands - cystically dilatedv and tubular 3.Stroma - Fibrous stroma rich in collagen, edema 4.Vessels - thick walled blood vessels                                           

61. Atypical hyperplasia vs Well differentiated adenocarcinoma Criteria for carcinoma 1.Desmoplastic stroma 2.Confluent glandular pattern,Cribriform pattern 3.Extensive papillary pattern

62. 1.Confluent glandular pattern 2.Desmoplastic stroma Cribriform pattern

63. Endometrial Carcinoma Most common gynaecological malignancy in developed countries. According to Bokhman type I and type II Type I - due to excess estrogen stimulation against the background odf hyperplasia,low grade endometroid carcinoma. Type II - independent of estrogen stimulation,Serous carcinoma,BRCA mutation

64. Histopathological types 1.Endometroid carcinoma – most common type 90% Grade 1 – Back to back glands,nuclear rounding with loss of polarity,5% or less solid growth pattern Grade 2 – 6 to 50% solid growth pattern

65. Grade 3 – more than 50% solid growth pattern

66. 2.Adenocarcinoma with squamous differentiation: Adenoacanthoma – adenocarcinoma grade 1 and benign squamous component,Good prognosis. Adenosquamous carcinoma - composed of grade 2 and 3 and malignant squamous component. 3.Primary squamous cell carcinoma:extremely rare

67. Serous carcinoma             Clear cell carcinoma Elderly,papillary pattern                              1.Elderly  Cytological atypia                                         2.Distinct cellular margins      Psammoma bodies                                       3.Large amount of glycogen Aggressive                                                      4.hobnail configuration Lymphovascular invasion                             5.very poor prognosis Deep myometrial invasion                             

68. Mucinous carcinoma           Squamous carcinoma Minimal atypia                                                  1.Rare Neutrophilic infiltrates in epithelium            2.Squamous element derived from One half composed of cells with                     metaplasia of tumor. intracytoplasmic mucin.                                      3.Poor prognosis  Good prognosis                                                                             

69. Take home message Interact with clinician as history is important for interpretation. Separate blood clots from endometrial tissue for processing. Endometrium with surface epithelium is best for interpretation. Do not report hyperplasia on secretory endometrium. All endometrial cancers should be typed and if appropriate graded.

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