Diagnostic problems on frozen section examination of myometrial invasion in patients with endometrial carcinoma with special emphasis on the pitfalls of deep adenomyosis with carcinomatous involvement

Frozen-section and paraffin section diagnoses were compared in 55 patients with Stage I endometrial adenocarcinoma. In 44 patients (80%), a corresponding depth of myometrial invasion and in 54 (98%) patients the same tumor grade were found. Regarding the depth of myometrial invasion and histologic grade, sensitivity, specificity, positive and negative predictive values were 70%, 86%, 73%, 83% and 92%, 100%, 100%, 94%, respectively. Concerning myometrial invasion 9% false-positivity and 10% false-negativity rates were noted. The histopathologic characteristics of false-positive and false-negative patients are emphasized because carcinomatous involvement of deeply situated adenomyosis and advanced grade tumors are the main diagnostic pitfalls. It is important for pathologists to be able to identify carcinomatous involvement of adenomyosis and adjacent foci of minimal myometrial invasion during frozen-section examination which can prevent aggressive surgery.

Endometrial carcinoma; Frozen section; Myometrial invasion

[1] Greenlee R.T., Murray T., Boldan S., Wingo P.A.: "Cancer statislies, 2000". CA Cancer J. Clin., 2000, 50, 7.

[2] Cancer facts and figures. Atlanta, GA: American Cancer Society, 1997.

[3] Atad J., Weill S., Ben-David Y., Hallak M., Klein O., Lurie M., Abramovici H.: "Intraoperative frozen section examination of myometrial invasion depth in patients with endometrial carcinoma". Int. J. Gynecol. Cancer, 1994, 4, 352.

[4] Hacker N.F.: "Uterine cancer". In: Berek J.S., Hacker N.F. (eds.), Practical Gynecologic Oncology (3rd ed.). Philadelphia: Lippincott Williams & Wilkins, 2000, 407.

[5] Creasman W.T., Monrow C.L., Bumdy L.: "Surgical pathological spread patterns of endometrial cancer". Cancer, 1967, 60, 2035.

[6] Larson D.M., Connor G.P., Broste S.K., MS, Kraw1sz B.R., Johnson K.K., PA: "Prognostic signifigance of gross myometrial invasion with endometrial cancer". Obstet. Gynecol., 1996, 88, 394.

[7] Artner A., Bosze P., Gonda G.:'The value of ultrasound m preoperative assesessment of the myometrial and cervical invasion in endonetrial carcinoma". Gynecol. Oncol., 1994, 54, 147.

[8] Dore R., Moro G., Andrea D.Z.F., La Fianza A., Franchi M., Bolis P.F.: "CT evaluation of myometrium invasion in endometrial carcinoma". J. Comput. Assist. Tomogr., 1987, 11, 282.

[9] Lien H.H., Blomlie Y., Trope C., Kaern J., Abeler Y.M.: "Cancer of the endometrium: value of MR imaging in determining depth of invasion into the myometrium". AJR Am. Roentgenol., 1991, 157, 1221.

[10] Lien H.H., Blomlie Y., Kjorstad K., Abel er Y., Kaalhus O.: "Clinical Stage Ⅰ carcinoma of the cervix: value of MR imaging in determining degree of invasiveness". AJR Am. J. Roentgenol., 1991, 156, 1191.

[11] Franchi M., Ghezzi F., Melpignano M., Cherchi P.L., Scrabelli C., Apolloni C., Zanaboni F.: "Clinical value of intraoperative gross examination in endometrial cancer". Gynecol. Oneal., 2000, 76, 357.

[12] Vorgias G., Hintipas E., Katsoulis M., Kalinoglou N., dertimas B., Akrivos T.: "Intraoperative gross examination of myometrial invasion and cervical infiltration in patients with endometrial cancer decision making accuracy". Gynecol. Oneal., 2002, 85, 483.

[13] Larson D.M., Johnson K.K.. Brostc S.K., Krawisz B.R., Kresl J.J.: "Comparison of D&C and office endometrial biopsy in predicting final histopathologic grade in endometrial cancer". Obstet. Gynecol., 1995, 86, 38.

[14] Kayikcioglu F., Boran N., Meydanli M.M., Tulunay G., Kose FM., Bulbul D.: "Is frozen-section diagnosis a reliable guide in surgical treatment of stage I endometrial carcinoma?". Acta Oneal., 2002, 41, 444.

[15] Shim J.U., Rose P.G., Reale FR., Soto H., Tak W.K., Hunter R.E.: "Accuracy of frozen-section diagnosis at surgery in clinical Stage I and II endometrial carcinoma". Am. J. Obst et. Gynecol., 1992, 166, 1335.

[16] Goff B.A., Rice L.W.: "Assessment of depth of myometrial invasion in endometrial adenocarcinoma". Gynecol. Oneal., 1990, 38, 46.

[17] Zorlu C.G., Kuscu E., Ergun Y., Aydogdu T., Cobanoglu O., Erdas O.: "lntraoperative evaluation of prognostic factors in Stage I endometrial cancer by frozen section: how reliable?". Acta Ohstet. Gynecol. Scand., 1993, 72, 382.

[18] Noumoff J.S., Menzin A., Mikuta J., Lusk E.J., Morgan M., LiYolsi VA.: "The ability to evaluate prognostic variables on frozen section in hysterectomies performed for endometrial carcinoma". Gynecol. Oncol., 1991, 42, 202.

[19] Fanning J., Tsukada Y., Piver M.S.: "Intraoperative frozen section diagnosis of depth of myometrial inaison of depth of myometrial in endometri invasion in endometrial adenocarcinoma". Gynecol. Oncol., 1990, 37, 47.

[20] Logacre T.A., Hendrickson: "Diffusely infiltrative endometrial adenocarcinoma: An adenoma malignum pattern of myoinvasion" Am. J. Surg. Pathol., 1999, 23, 69.

[21] Hall J.B., Young R.H., Nelson J.H.: "The prognostic significance of adenomyosis in endometrial carcinoma". Gynecol. Oncol., 1984, 17, 32.

[22] Mittal K.R., Barwick W.B.: "Endometrial adenocarcinoma involving adenomyosis without true myometrial invasion is characterized by frequent preceding estrogen therapy, low histologic grades and excellent prognosis". Gynecol. Oneal., 1993, 49, 197.

[23] Koshiyarna M., Suzuki A., Ozawa M., Fujita K., Sakakibara A., Kawamura M. et al.: "Adenocarcinomas arising from uterine adenornyosis: A report of four cases". Int. J. Gynecol. Pathol., 2002, 21, 239.

[24] Takai N., Akizuki S., Nasu K., Etoh Y., Miyakawa I.: "Endometnoid adenocarcinorna arising from adenomyosis". Gynecol. Ohstet. Invest., 1999, 48, 141.

[25] Ichiwara Y., Takano K., Higa S., Tanabe M., Wada A., Sugita M. et al.: "Endornetrial carcinoma coexisting with pregnancy, presurned derived from adenornyosis: a case report". Int. J. Gynecol. Cancer, 2001, 11. 488.

[26] Hernandez E., Woodruff J.D.: "Endometrial adenocarcrnoma arising in adenomyosis". Am. J. Ohstet. Gynecol., 1980, 138, 827.

[27] Sasaki T., Sugiyama T., Nanjo H., Hoshi N., Murakami M., Sugita A. et al.: "Endometrioid adenocarcinoma arising from adenomyosis: report and immunohistochemical analysis of an unusual case". Pathol. Int., 2001, 51, 308.

[28] Jacques S.M., Lawrence W.D.: "Endometrial adenocarcinoma with variable-level myometrial involvement limited to adenomyosis: a clinicopathologic study of 23 cases". Gynecol. Oneal., 1990, 37, 401.

[29] Nascimento A.F., Hirch M.S., Cviko A., Quade BJ., Nucci M.R.: "The role of CD l O staining in distinguishing invasive endometrial adenocarcinoma from adenocarcinoma involving adenomyosis". Mod. Pathol., 2003, 16, 22.

[30] Srodon M., Klein W.M., Kurman R.J.: "CD 10 immunostaining does not distinguish endometrial carcinoma invading myometrium from carcinoma involving adenomyosis". Am. J. Surg. Pathol., 2003, 27, 786.

[31] Figge D.C., Otto P.M., Tamimi H.K., Greer B.E.: "Treatment vanables in the management of endometrial cancer". Am. J. Obstet. Gynecol., 1983, 146, 495.

[32] Doering D.L., Barnhill D.R., Weiser E.B., Burke T.W., Woodward J.E., Park R.C.: "Intraopcrativc evaluation of depth of myometrial invasion in Stage I endometrial adenocarcinoma". Obstet. Gynecol., 1989, 74, 930.

[33] Malviya V.K., Deppe G., Malone L.M., Sundareson A.S., Lawrence W.D.: " Reliability of frozen section examination in identifying poor prognostic indicators in Stage I endometrial carcinoma". Gynecol. Oncol., 1989, 34, 299.

[34] Altintas A., Cosar E., Vardar M.A., Demir C., Tuncer I.: "Intraoperative assessment of depth of myometrial invasion in endometrial carcinoma". Eur. J. Gynaecol. Oneal., 1999, 20, 329.