Hysterectomy for Endometrial Cancer
The approach to hysterectomies performed for endometrial cancer parallels the approach to hysterectomies for benign disease. Additional steps include inking the paracervical and para-metrial soft tissue margins and evaluating the extent of the tumor.
Orient, weigh, and measure the uterus as described in the section on hysterectomies for benign disease, and ink the soft tissue resection margins around the cervical canal. Also, ink the parametrial tissue, which extends along the body of the uterus and into the broad ligament. Care-fully examine the serosal surfaces for evidence of tumor extension. Ink these areas a different color for orientation.
If the adnexa are present, remove them at their lateral insertions along the uterus. Make multiple transverse cuts through the ovary and fallopian tube, looking for evidence of either direct tumor extension or metastatic spread. Submit at least one section from each side to demonstrate the ovary and fallopian tube with adjacent soft tissue.
Bivalve the uterus by using a long, sharp knife guided by a probe placed through the cervical canal. Closely examine the endometrial cavity. Endometrial carcinomas can be shaggy, sessile tumors or polypoid masses arising from the surface of the endometrium. They may be either focal or diffuse. The sounding depth of the uterus from the external cervical os to the superior limit of the endometrial cavity may be measured, but it is no longer used in the staging of endometrial cancers.
While the tumor is fresh, remove a portion to freeze for future molecular diagnostic tests if desired. The bivalved uterus may now be photographed and pinned to a wax tablet for fixation.
The dissection begins with longitudinal sectioning of the cervix. Extend these incisions through the lower uterine segment to include both endometrial and endocervical mucosal surfaces. Note whether or not the tumor grossly involves the endocervical mucosa and/or stroma.
Submit a section of this region from the anterior and posterior halves to evaluate for tumor extension into the cervix, an important factor in determining the stage of the cancer. This step may
also be accomplished by taking transverse sections of the upper endocervix and lower uterine segment. Next, serially bread-loaf the uterine corpus and lower uterine segment with transverse sections. Record the size, location, and appearance of the tumor. Describe the pattern of invasion. Does the tumor have a broad pushing front, an infiltrating finger-like pattern, or is it discontinuous? Measure the greatest depth of tumor invasion into the myometrium starting from the normal junction of the endometrium and the myometrium. In addition, measure the total myometrial thickness at this point, and specify the uninvolved distance from the deep tumor/myometrial junction to the serosa. When selecting sections for histologic analysis, include the deepest point of tumor invasion as well as the interface with grossly uninvolved endometrium. The best sections are those that show the full thickness from the endometrium to the serosa. Sometimes, however, the myometrium may be too thick to fit in a standard-size tissue cassette. In these situations, divide the section into endometrial and serosal halves. Be sure to designate their relationship clearly in your summary of sections.
Lymph nodes from the pelvic and para-aortic regions may also be included as separate specimens. They can be handled in a routine manner for evaluation of metastatic disease.
What procedure was performed, and what structures/organs are present?
What is the size of the tumor?
What are the histologic type and grade of neoplasm present?
What is the maximum depth of tumor invasion (in millimeters)? (Measure from the normal endometrial/myometrial junction.)
What is the total myometrial thickness at the deepest point of invasion (in millimeters)?
What is the distance from the deepest tumor/myometrial junction to the serosa (in millimeters)?
Does the tumor extend through the serosa?
Does the tumor involve the endocervix? (Specify surface glandular and/or stromal involvement.)
Is capillary–lymphatic space invasion seen?
Does the tumor involve the adjacent adnexa?
Does the tumor involve any margins (cervical/vaginal, right paracervical/parametrial, left paracervical/parametrial)? Give the distance of the tumor from closest margin (in centimeters).
Does the tumor involve any lymph nodes? (Include the number of nodes involved and the number of nodes examined at each specified site.)