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3. Diagnosis

3.1 WHO/ISGP Classification of Endometrial Carcinoma

  • Endometrioid
    • Typical
    • Variants
      • Villoglandular (papillary)
      • With squamous differentiation
      • Secretory
      • Ciliated
  • High grade serous (HGS) adenocarcinoma (also known as serous carcinoma or uterine papillary serous carcinoma)
  • Clear cell adenocarcinoma
  • Mucinous adenocarcinoma
  • Squamous cell carcinoma
  • Undifferentiated carcinoma
  • Mixed carcinoma
    • (two of above histological types in which minor component accounts for 10% or more of the tumour)

Mixed Epithelial-Mesenchymal Tumors

  1. Adenofibroma
  2. Adenomyoma including atypical polypoid adenomyoma
  3. Adenosarcoma, homologous and heterologous
  4. Carcinofibroma
  5. Carcinosarcoma (also known as malignant mullerian mixed tumor - MMMT), homologous and heterologous. This is now recognized as representing high grade, metaplastic adenocarcinoma and treated as such.

3.2 Diagnosis/Surgical Management

An endocervical curettage is no longer recommended as part of clinical staging as it is not accurate for assessing cervical stromal invasion, and the presence of endocervical glandular involvement only is no longer part of the FIGO staging system. All patients with potential clinical involvement of the cervix should be referred for assessment regarding possible surgical staging.  Patients who are deemed to have inoperable disease by the gynecologic oncology team will be referred for preoperative chemotherapy plus or minus radiotherapy. These patients are at a higher risk of both locoregional and distant recurrence and require multidisciplinary care, which may include chemotherapy, radiotherapy and surgery.

In 1988 FIGO adopted a surgical staging system for cancer of the uterine corpus (Endometrium), which was revised in 2009. Careful intraoperative exploration, including nodal assessment, is the responsibility of the operating surgeon. Only those skilled and experienced in lymph node dissection should carry out such procedures (see Surgery Table 1).

We recommend all patients referred to BC Cancer have a pathology review.

Lymph node dissection is not routinely performed for grade 1 endometrioid tumors because the risk of nodal involvement is outweighed by the potential perioperative risks associated with this procedure, and therefore these cases may have surgery performed by a general gynecologist. Although full lymphadenectomy is not routinely performed for grade 2 and 3 endometrioid tumors, these cases have a higher risk of lymph node involvement and may require nodal sampling. Therefore, it is recommended that these patients have their surgery performed by a gynecologic oncologist. Lymph node dissection is routinely performed on all cases with non-endometrioid histology (Type 2 cancers such as high grade serous or clear cell carcinoma), as they may have lymph node involvement in the absence of high-risk uterine factors such as deep myometrial invasion.

At the time of the staging procedure careful evaluation of pelvic and para-aortic nodal areas should be carried out and any large lymph nodes should be biopsied/removed. In the setting of enlarged nodes, debulking of these nodes rather than complete node dissection is preferred, as these patients will receive postoperative XRT, and single modality treatment diminishes the rate of morbidity, particularly if there are enlarged para-aortic nodes and extended field radiotherapy is required. The patient should be referred as soon as a diagnosis is made for planning of chemotherapy and radiotherapy.

Proper handling of a hysterectomy specimen by the pathologist is essential for evaluating tumour factors that may affect postoperative adjuvant treatment in patients with endometrial adenocarcinoma. If the specimen is not going to be fixed promptly (e.g., surgery on Friday afternoon, or before a holiday), the gynecologist should open the uterus at the 3 and 9 o'clock positions on the cervix, extend these incisions from the external os laterally along the sides of the uterus up to the fundus, and promptly place the specimen in formalin for overnight fixation. Lack of prompt fixation may result in severely autolyzed hysterectomy specimens that will preclude accurate histologic grading and assessment of depth of invasion, which are essential for prognosis and treatment planning.

SOURCE: 3. Diagnosis ( )
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