Surgicopathologic Review of the Endomtrium.pptx

Histopathologic Endometrium

1. Surgico -pathologic Conference DEPARTMENT OF OBSTERTICS AND GYNECOLOGY PASAY CITY GENERAL HOSPITAL P. Burgos St. Pasay City Prayer: Dr. Cheska San Juan Opening Remarks: Dr. Jeanette Bautista Case Presenter: Dr. Arnie Gaile Flores Closing Remarks: Dr. Olivia Jane Chua-Fernandez Guest Reactors Horacio A. Saguil Jr. MD, FPDP, MMHoA , PhD John Alexander C. San Juan , MD, DPSP Bernadette C. Yap-Abela MD, FPOGS, DSGOP, FPSPCPC Moderator November 3, 2023, 10:00 AM

2. OPENING REMARKS DRA. JEANETTE BAUTISTA

3. B .L. 65 -year-old, single, G3P3(3003) Filipino Roman Catholic Married

4. Chief complaint Vaginal Bleeding

5. History of Present Illness

6. Obstetrical history Pregnancy Order Year/ Hospital Mode of Delivery AOG Sex Birth weight Pregnancy Outcome Complications/ Abnormalities G1 1981/ Ospital ng Maynila NSD FT F 2500g Alive None G2 1982/ Fabella Hospital NSD FT F 2700g Alive None G3 1990/ Fabella Hospital NSD FT F 3100g Alive None

7. Menstrual history She had her Menarche at the age of 14 -year-old. Subsequent menses at regular monthly intervals, 3-2 days duration, using 3-4 pads per day, moderately soaked, not associated dysmenorrhea. Menopause at age 52 years old

8. Sexual history She had her first coitus at 20-year-old and had 1 sexual partners No foul-smelling vaginal discharge No post coital bleeding No contraceptive method use.

9. Past Medical History Patient has hypertension for 15 years and on Losartan 50mg /Tab OD No diabetes mellitus, bronchial asthma, thyroid disease, lung disease or heart problem. She had no previous surgeries.

10. Family History (+) Hypertension- Maternal/ Paternal Patient had no other heredofamilial disease such as diabetes mellitus, bronchial asthma, thyroid disease, lung disease, heart problem, Cancer

11. Personal and Social History A high school undergraduate, housewife She is a non-smoker, non-alcohol beverage drinker and denies any illicit drug use. Presently, living in for 41 years to a 67 -year-old Taxi driver.

12. Review of systems

13. Physical Examination at the ER General Survey: Conscious, coherent, ambulatory, not in cardiopulmonary distress Vital Signs: BP: 120/80 mmHg CR: 86 bpm RR: 20 cpm Temp: 36.5C Height: 158 Weight: 86 kg BMI: 30.3 kg/m 2 Obesity class I

14. Physical Examination at the ER HEENT: Pink palpebral conjunctiva, anicteric sclera, no anterior neck mass nor cervical lymphadenopathy Chest and Lungs: Symmetrical chest expansion, no retraction, clear breath sounds Adynamic precordium, normal rate, regular rhythm, no murmur

15. Physical Examination at the ER Abdomen: Flabby, Soft, non tender Pelvic examination: External Genitalia: grossly normal, no lesion Speculum Exam: scanty whitish discharge non-foul smelling, cervix pinkish, smooth with no lesion Internal Examination: cervix closed E xtremities : no pitting edema

16. TRANSVAGINAL ULTRASOUND Normal sized anteverted uterus with thickened endometrium To consider endometrial pathology. Endometrial thickness of 1.58cm, hyperechoic, (+) intracavitary fluid Normal ovaries. Cervix measures 3.03 x 3.05 x 3.66 cm. Dilated Canal fluid-filled No fluid in the cul de sac

17. HISTOPATHOLOGIC DIAGNOSIS S/P Diagnostic hysteroscopy followed with endometrial curettage -Endometrioid adenocarcinoma, moderately differentiated, FIGO grade II

18. NORMAL HISTOLOGY OF THE UTERUS

19. HISTOLOGY OF A MENSTRUAL CYCLE EARLY SECRETORY

20. ENDOMETRIAL HYPERPLASIA HYPERPLASIA WITHOUT ATYPIA HYPERPLASIA WITHOUT ATYPIA

21. ENDOMETRIOD ADENOCARCINOMA FIGO GRADE

22. SPECIMEN SLIDE

23. HISTOPATHOLOGIC DIAGNOSIS S/P Diagnostic hysteroscopy followed with endometrial curettage -Endometrioid adenocarcinoma, moderately differentiated, FIGO grade II

24. PRE OPERATIVE DIAGNOSIS G3P3(3003) AUB-M (Endometroid adenocarcinoma, moderately differentiated, FIGO grade II) Menopause for 13 years Hypertension stage II S/P Diagnostics hysteroscopy followed with endometrial curettage (July 1, 2022, PCGH)

25. PLAN For Exploratory laparotomy with peritoneal fluid cytology followed with Extrafascial Hysterectomy with Bilateral salpingo -oophorectomy followed with bilateral lymph node dissection +/- Paraaortic lymph node dissection under spinal under spinal epidural anesthesia

26. INTRAOPERATIVE FINDINGS No ascitic fluid was noted. On palpation, the cecum, right pelvic gutter, ascending colon, peritoneum overlying the right kidney, liver edge, gallbladder, subdiaphragm , small intestine, transverse colon, spleen, peritoneum overlying the left kidney, descending colon and left pelvic gutter were all smooth. Retroperitoneal and paraaortic lymph nodes were all smooth. The uterus was not enlarged with pinkish smooth serosa

27. OPERATIVE FINDINGS

28. GROSS SPECIMEN

29. GROSS SPECIMEN

30. GROSS SPECIMEN

31. POST OPERATIVE

32. PROCEDURE Exploratory laparotomy with peritoneal fluid cytology followed with Extrafascial Hysterectomy with Bilateral salpingo -oophorectomy followed with bilateral lymph node dissection under spinal under spinal epidural anesthesia

33. FINAL DIAGNOSIS G3P3(3003) Endometroid adenocarcinoma FIGO grade II Menopause for 13 years Hypertension stage II S/P Diagnostics hysteroscopy followed with endometrial curettage (July 1, 2022, PCGH) S/P Exploratory laparotomy with peritoneal fluid cytology followed with Extrafascial Hysterectomy with Bilateral salpingoophorectomy followed with bilateral lymph node dissection under spinal under spinal epidural anesthesia

34. FINAL HISTOPATHOLOGIC DIAGNOSIS - Endometriod adenocarcinoma, FIGO histologic grade II -Tumor invasion is more than fifty percent (>50%) of the myometrium -Tumor size: 2.5 cm in widest dimension - lymphovascular space invasion is not observed -Negative for tumor involvement: -bilateral ovaries -bilateral fallopian tubes -Cervix -Parametrium - All four (4) isolated lymph nodes, Specimen labeled “ Right Lymph nodes” - All five (5) isolated lymph nodes, specimen labeled “ Left Lymph nodes” -AJCC pathologic staging: pT1bN0Mx

35. FINAL HISTOPATHOLOGIC DIAGNOSIS -Other findings: -Chronic cervicitis with squamous metaplasia and Nabothian cysts -Corpus Albicans, Bilateral ovaries -Unremarkable Fallopian tubes, bilateral -Peritoneal fluid cytology -The international system of reporting serous fluid cytology: Negative for malignancy

36. SPECIMEN: UTERUS LOW POWER FIELD SCANNER VIEW

37. SPECIMEN: CERVIX

38. CANCER OF THE ENDOMETRIUM: 2018 FIGO STAGING

39. MANAGEMENT Stage I: Confined to the Corpus Surgery: EHBSO, PFC, Lymph Node Dissection Surgico -Pathologic Staging Adjuvant Treatment IA G1, G2 No Adjuvant Treatment (Level IA) G3 Vaginal Brachytherapy (Level IIB) IB G1, G2 Vaginal Brachytherapy (Level IA) G3 Pelvic EBRT (Level IA) +/- Chemotherapy (Level IB)

40. FOLLOW UP For referral to Gynecologic Oncologist Follow up every 6 months for 2 years then annually thereafter Physical Exam including through speculum, Pelvic and Rectovaginal exam every visit Elicit new symptoms associated with possible recurrence Whole Abdominal CT scan if there is a suspicion of recurrent disease