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  IN THIS Article
 ::  Abstract
 :: Introduction
 :: Materials and Method
 :: Results
 :: Discussion
 ::  References
 ::  Article Tables

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  Table of Contents     
ORIGINAL ARTICLE
Year : 2015  |  Volume : 61  |  Issue : 2  |  Page : 84-87

An audit of histopathology reports of carcinoma endometrium: Experience from a tertiary referral center


1 Department of Pathology, Biostatistics and Epidemiology, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Medical Records, Biostatistics and Epidemiology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Submission24-Feb-2014
Date of Decision22-Mar-2014
Date of Acceptance14-May-2015
Date of Web Publication13-Mar-2015

Correspondence Address:
K K Deodhar
Department of Pathology, Biostatistics and Epidemiology, Tata Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.150444

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 :: Abstract 

Background: The aim was to see, compliance to minimum data information in carcinoma endometrium reports, in a team of 13 pathologists, and also to analyze these parameters e.g. tumor size, type, grade, depth of myometrial invasion, lymph node yield, pTNM stage etc. Materials and Methods: During the period of 2008-2010, from the files of Pathology department of our hospital, reports of 114 cases of carcinoma endometrium, who were operated in house, were analyzed. Results: The median age was 58.04 years and median tumor size was 4 cm. Endometrioid adenocarcinoma was the most common type (82.5%), followed by malignant mixed Mullerian tumor (MMMT) (6.1%) and Serous carcinoma (3.5%). Grade 2 was the commonest tumor grade (42.1%). Less than half of myometrial invasion was seen in 50% of the cases and more than half of the myometrial invasion was seen in 46.5% of cases. (Information was not available in four cases). Parametrial involvement was seen in 5.3% cases. The pTNM stage was not mentioned in 71.9% reports. The median lymph node yield was 15. Conclusion: The compliance to adhere to and to provide minimum data information in carcinoma endometrium reports is generally good. Lymph node yield is reasonable. Mentioning of pTNM staging is to be done more meticulously. Use of proformas/checklists is recommended.


Keywords: Audit, endometrial carcinoma, histopathology report


How to cite this article:
Deodhar K K, Rekhi B, Menon S, Ganesh B. An audit of histopathology reports of carcinoma endometrium: Experience from a tertiary referral center . J Postgrad Med 2015;61:84-7

How to cite this URL:
Deodhar K K, Rekhi B, Menon S, Ganesh B. An audit of histopathology reports of carcinoma endometrium: Experience from a tertiary referral center . J Postgrad Med [serial online] 2015 [cited 2019 Nov 17];61:84-7. Available from: http://www.jpgmonline.com/text.asp?2015/61/2/84/150444



 :: Introduction Top


Histopathological reporting of surgically resected cancer specimens requires specific information or confirmation, to determine the extent (stage) of the tumor. This is important to decide the adjuvant therapy and also helps in the quality control of related departments such as radiology and surgery. The minimum datasets needed for reporting have been widely and freely available on websites of reputed international organizations for several years now. The present study was carried out with the objective of assessing compliance to reporting the minimum data sets for carcinoma endometrium histopathology reports as a marker of completeness of the pathology examination and an internal audit of the pathology department.


 :: Materials and Method Top


Data retrieval

Files from the Department of Pathology of our hospital (2008-10) were screened. These were seen by a team of 13 pathologists by rotation. Of these, a total of 574 surgical pathology reports were generated that pertained to endometrial pathology. These included 'in-house' operated cases, referrals post surgery (slides and/or blocks seen by a pathologist who was outside of the institution) as well as cases that were sent to us for consultation as we are a referral center. We included for the purpose of the study, only cases that were operated in house. Thus, a total of 114/574 cases of carcinoma endometrium were chosen. Exclusions were hysterectomies for fibroids, adenomyoma, and endometriosis.

Procedure followed in department of pathology

The specimens from the operation theatres are sent to our department in fresh state in plastic sealed bags. The specimens are opened and fixed overnight in copious amount of formaline and are then dissected in fixed state as per the standard protocol. [1],[2] Lymph nodes are also dissected after fixation. WHO classification for sub typing the endometrial carcinomas is used. [3] Parametrial connective tissue is blocked in its entirety. We do not practice any fat dissolving solution technique for lymph node harvest. A careful gross examination, palpation, dissection and selection of the bits is done.

Data collection and analysis

Following details were recorded- case number, pathology number, age, nature of surgery, tumor size (including maximum tumor size), tumor type (for example whether endometrioid adenocarcinoma, serous adenocarcinoma or Malignant Mixed Mullerian Tumor), tumor grade, presence and extent of myometrial invasion (less than half or equal to or more than half of myometrial invasion), distance to serosa (whether mentioned or not), lymphatic emboli (seen/not seen), perineural invasion (seen/not seen), isthmic involvement, comment on adjacent endometrium, squamous differentiation, cervical involvement, comment on ovaries and tubes, comment on parametrium, whether frozen section was carried out or not, right and left pelvic lymph nodes (total number; metastatic or not), paraaortic nodes (number and involvement) and any other comments. Descriptive statistics were used with quantitative data being expressed as median and range and qualitative data as percentages.


 :: Results Top


Demographics - The median age was 58 years (range 34-82) The median tumor size was 4 cm (range 0.4-13 cm) [Table 1].
Table 1: Age and tumor size


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Audit findings: Endometrioid adenocarcinoma was the most common type of carcinoma (n =94; 82.5%), followed by MMMT (n = 7; 6.1%), followed by serous carcinoma n =4; 3.5%) [Table 2]. Grade 2 was the most common tumor grade [Table 3]. Myometrial invasion was less than half in ( n =57) 50% of the cases, whereas it was equal to or more than half the thickness in 46.5 % of cases [Table 4]. Distance in millimeters to serosa was mentioned in 54.88% cases. Involvement of the cervix, parametria, lymphatic embolization, perineural invasion, mentioning pTNM stage is given in [Table 5]. [Table 6] shows actual pTNM staging (inferred from the report). Most (111) were laproscopic surgeries, only 3 were open surgeries. 'Tumorfree distance to serosa' is the distance of the deepest portion of tumor cells in myometrium to the serosa. This measurement has been identified as an independent prognostic factor in endometrial adenocarcinoma. [1],[2] Comment on the tubes and ovaries were made in all cases. Squamous differentiation in the tumor was mentioned in 17/109 (15.6%) cases. Information about omental tissue, peritoneal tissue biopsy was not uniformly available in all the reports. Out of 15 non-endometrioid type carcinoma reports, omentum was involved by the tumor in 2 cases and negative for tumor in 5 cases. It was not removed in seven cases; in one case peritoneal nodule was removed which was free of tumor. Comment on the vagina was given (free of tumor) in two cases only. In lymph nodes the mean overall lymph node yield was 15.67 with a median of 15 [Table 7]. (Right pelvic nodes: mean=8; median=8; left pelvic nodes: mean=6.97; median=7) (information was not available in 6 cases). In 28 cases (31.92%), paraaortic nodes were removed and frozen section was carried out in 43/114 cases (37.7%).
Table 2: Tumor type


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Table 3: Grade of the tumor


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Table 4: Depth of myometrial invasion


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Table 5: Other parameters


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Table 6: TNM stage


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Table 7: Lymph node retrieval


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 :: Discussion Top


Minimum data sets (macroscopic and microscopic findings) for all cancers are available. [1],[2] Sections taken at the grossing table depend on the information that is required in the cancer data set. A meticulous report is important as it determines the treatment and prognosis. It also facilitates regular audits and review of all aspects of services. The utility of audits in pathology is well known. Audits can bring out the inadequacies in the histopathology reports. [4],[5] It is well recognized that standardization in cancer reporting improves the completeness and quality of the reports. [6],[7],[8] With respect to similar audits from our country, we came across an audit of rectal carcinoma reports by Nambiar et al. from India. [9]

Comment about the lymphovascular emboli, perineural invasion, involvement of the cervix was mentioned in 100% of the cases. Tumor type was given in all cases. The grade of the tumor was mentioned in 95.5% of the cases. Myometrial invasion was not mentioned in four (3.5%) cases; and tumor size was missing from the reports in seven (6%) cases. Of note is that pTNM stage was not mentioned in 71.9% cases.

The 2009 FIGO staging for endometrial cancer no longer requires the pathologist to distinguish between those carcinomas confined to the endometrium and those showing invasion of the inner half of the myometrium. The tumor is FIGO Stage IA if myometrial invasion is absent or confined to less than the inner half (<50% myoinvasion). The tumor is staged as IB if it involves the outer half of the uterine wall (>50% myoinvasion).

It is a controversial issue as to what is the number of lymph nodes that must be removed for proper staging. Lutman et al. found that pelvic lymph node count ≥12 is an independent prognostic factor for both overall survival (OS) and progressionfree survival (PFS) in patients with FIGO stage I and II with high grade histology. [10] Cragun et al. reported that patients with grade 3 endometrial cancers having more than 11 pelvic nodes removed had improved OS and PFS compared with patients with 11 or fewer nodes removed. [11] Chan et al. showed correlation between increase in the number of lymph nodes removed and number of nodal metastasis. They concluded that the removal of 21 to 25 nodes was considered to significantly increase the probability of detecting at least one lymph node metastasis. [12] Our mean and median lymph node yield is reasonable, but increase in its number is desirable.

Euscher et al found median pelvic LN yield to be 11 and paraaortic LN yield to be 6. [13] After a careful dissection of the lymph nodes from the fat, they submitted the residual fatty tissue in 64% of the cases, to see whether such a practice would result in significant increase in the number of nodes or result in findings that can impact the clinical management. They concluded that standard processing of lymphadenectomy specimens adequately reflects the actual number of lymph nodes obtained in a case of endometrial carcinoma.

In our records, a total of nine cases showed lymph node metastasis (7.9%). This compares to the quoted lymph node positivity in the literature which is 5-11%. [11],[14] In 28 cases (31.92%), paraaortic nodes were removed. Removal of paraaortic nodes has not been a consistent practice at the start of the 2008 and the practice increased towards 2010; and majority of the paraaortic lymph node removals are from 2010 (6 in 2008, 6 in 2009, and 16 in 2010). The mean paraaortic lymph node yield is 2.71 (median-2, range 0-9).

In summary, the above findings show that compliance with adhering to minimum data information in a team of 13 pathologists is generally good but improvements could be made in several areas. Endometrioid adenocarcinoma is the most common type of endometrial carcinoma. Lymph node yield, in our hands, is reasonable, and constant diligence is required. pTNM staging is one area that needs to be mentioned more meticulously.

 
 :: References Top

1.
The Royal college of pathologists. Datasets and tissue pathways. Available from: www.rcpath.org/publications-media/publications/datasets/endometrial.htm. [Last accessed on 2014 May 8].  Back to cited text no. 1
    
2.
College of American Pathologists. Reference Resources and Publications. Cancer Protocols. www.cap.org/apps/docs/committees/cancer/cancer_protocols/2013/Endometrium_13protocol_3201.pdf. [Last accessed on 2014 May 8].  Back to cited text no. 2
    
3.
Silverberg SG, Kurman RJ, Nogales F, Mutter GL, Kubik-Huch RA, Tavassoli FA. Epithelial tumours and related lesions. In: Tavassoli FA, Devilee P, editors. World Health Organization Classification of Tumours. Pathology and Genetics. Tumours of the Breast and Female Genital Organs. Lyon: IARC Press; 2003. p. 221-9.   Back to cited text no. 3
    
4.
Eon Y, Le Douy JY, Lamer B, Battini J, Bretagne JF. Quality and completeness of histopathology reports of rectal cancer resections. Results of an audit in Brittany. Gastroenterol Clin Biol 2006;30:235-40.  Back to cited text no. 4
    
5.
Verleye L, Ottevanger PB, Kristensen GB, Ehlen T, Johnson N, van der Burg ME, et al. Quality of pathology reports for advanced ovarian cancer: Are we missing essential information? An audit of 479 pathology reports from the EORTC-GCG 55971/NCIC-CTG OV13 neoadjuvant trial. Eur J Cancer 2011;47:57-64.  Back to cited text no. 5
    
6.
Srigley JR, McGowan T, Maclean A, Raby M, Ross J, Kramer S, et al. Standardized synoptic cancer pathology reporting: A population-based approach. J Surg Oncol 2009;99:517-24.  Back to cited text no. 6
    
7.
Austin R, Thompson B, Coory M, Walpole E, Francis G, Fritschi L. Histopathology reporting of breast cancer in Queensland: The impact on the quality of reporting as a result of the introduction of recommendations. Pathology 2009;41:361-5.  Back to cited text no. 7
    
8.
Haugland HK, Casati B, Dørum LM, Bjugn R. Template reporting matters - a nationwide study on histopathology reporting on colorectal carcinoma resections. Hum Pathol 2011;42:36-40.  Back to cited text no. 8
    
9.
Nambiar A, Vivek N, Bindu MR, Sudheer OV, Bai L. Completeness of low anterior resection pathology report: A hospital-based audit with recommendations on improving reporting. Indian J Cancer 2010;47:156-9.   Back to cited text no. 9
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10.
Lutman CV, Havrilesky LJ, Cragun JM, Secord AA, Calingaert B, Berchuck A, et al. Pelvic lymph node count is an important prognostic variable for FIGO stage I and II endometrial carcinoma with high-risk histology. Gynecol Oncol 2006;102:92-7.  Back to cited text no. 10
    
11.
Cragun JM, Havrilesky LJ, Calingaert B, Synan I, Secord AA, Soper JT et al. Retrospective analysis of selective lymphadenectomy in apparent early-stage endometrial cancer. J Clin Oncol 2005;23:3668-75.  Back to cited text no. 11
    
12.
Chan JK, Urban R, Cheung MK, Shin JY, Husain A, Teng NN, et al. Lymphadenectomy in endometrioid uterine cancer staging: How many lymph nodes are enough? A study of 11,443 patients. Cancer 2007;109:2454-60.  Back to cited text no. 12
    
13.
Euscher ED, Bassett R, Malpica A. Lymph node counts in endometrial cancer: Expectations versus reality. Am J Surg Pathol 2011;35:913-8.  Back to cited text no. 13
    
14.
Huang M, Chadha M, Musa F, Friedmann P, Kolev V, Holcomb K. Lymph nodes: Is total number or station number a better predictor of lymph node metastasis in endometrial cancer? Gynecol Oncol 2010;119:295-8.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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