Assessment of endometrial sampling as a predictor of final surgical pathology in endometrial cancer

Abstract

Background: The histology and grade of endometrial cancer are important predictors of disease outcome and of the likelihood of nodal involvement. In most centres, however, surgical staging decisions are based on a preoperative biopsy. The objective of this study was to assess the concordance between the preoperative histology and that of the hysterectomy specimen in endometrial cancer.

Methods: Patients treated for endometrial cancer during a 10-year period at a tertiary cancer centre were identified from a prospectively collected pathological database. All pathology reports were reviewed to confirm centralised reporting of the original sampling or biopsy specimens; patients whose biopsies were not reviewed by a dedicated gynaecological pathologist at the treating centre were excluded. Surgical pathology data including histology, grade, depth of myometrial invasion, cervical stromal involvement and lymphovascular space invasion (LVSI) as well as preoperative histology and grade were collected. Preoperative and final tumour cell type and grade were compared and the distribution of other high-risk features was analysed.

Results: A total of 1329 consecutive patients were identified; 653 patients had a centrally reviewed epithelial endometrial cancer on their original biopsy, and are included in this study. Of 255 patients whose biopsies were read as grade 1 (G1) adenocarcinoma, 45 (18%) were upgraded to grade 2 (G2) on final pathology, 6 (2%) were upgraded to grade 3 (G3) and 5 (2%) were read as a non-endometrioid high-grade histology. Overall, of 255 tumours classified as G1 endometrioid cancers on biopsy, 74 (29%) were either found to be low-grade (G1-2) tumours with deep myometrial invasion, or were reclassified as high-grade cancers (G3 or non-endometrioid histologies) on final surgical pathology. Despite these shifts, we calculate that omitting surgical staging in preoperatively diagnosed G1 endometrioid cancers without deep myometrial invasion would result in missing nodal involvement in only 1% of cases.

Conclusions: Preoperative endometrial sampling is only a modest predictor of surgical pathology features in endometrial cancer and may underestimate the risk of disease spread and recurrence. In spite of frequent shifts in postoperative vs preoperative histological assessment, the predicted rate of missed nodal metastases with a selective staging policy remains low.

Figure 1

Endometrial biopsy: endometrioid adenocarcinoma FIGO grade 1, low (A) and high (B) power. Hysterectomy: subsequent resection reveals significant solid component that was not represented in the biopsy. The final grade was FIGO grade 3. Low (C) and high (D) power.

Figure 2

Endometrial biopsy: endometrioid adenocarcinoma FIGO grade 1, low (A) and high (B) power. Hysterectomy: subsequent resection reveals a serous carcinoma component that was not sampled in the biopsy. Overall, serous carcinoma accounted for 70% of the tumour and endometrioid for 30%. Low (C) and high (D) power.

Figure 3

Final surgical pathology histological features of preoperatively defined grade 1 endometrioid adenocarcinoma cases grade 1–2 low risk – with no high-risk features such as deep myometrial invasion, LVSI or cervical stromal invasion LVSI.