Necrosis in Biopsy Specimen Heralds Poor Prognosis for Type I Endometrial Carcinoma Patients

Caroline Helwick

November 03, 2009

November 3, 2009 (Chicago, Illinois) — Type I endometrial cancer patients, who normally have a good prognosis, occasionally succumb to their disease within 2 to 3 years. Investigators from the University of Illinois School of Medicine, in Chicago, found that the presence of necrosis in the biopsy specimen might predict this outcome.

"Although staging and treatment decisions in type I endometrial cancer patients are made on the basis of surgical staging, the presence of necrosis in biopsy specimens may indicate the potential for more aggressive behavior than we usually expect," said Marsha A. Apushkin, MD, at the American Society for Clinical Pathology (ASCP) 2009 Annual Meeting.

She said the impetus for the study came from senior author Carey Z. August, MD, who observed this curious disease course in a friend who was expected to make a full recovery but whose tumor behaved more like type II tumors (such as papillary serous carcinoma), which have a poor prognosis.

"These patients usually don't die so soon," Dr. Apushkin said. "In this study, we looked for features that might predict a more aggressive course among the type I adenocarcinomas."

Dr. Apushkin and colleagues searched the records of the Advocate Illinois Masonic Medical Center Tumor Registry for cases of type I endometrioid endometrial adenocarcinoma diagnosed between 1998 and 2008. Five cases were identified in which distant metastases developed (1 was lost to follow-up). The comparison group consisted of 6 cases of type I endometrial cancer in which metastases were not observed.

Hemoxylin- and eosin-stained slides of the biopsy or surgical specimen were evaluated for the following: architectural grade of glandular component; nuclear grades of glandular and squamous components; and presence of undifferentiated tumor, myoinvasion, necrosis, and other forms of differentiation. Immunostains for p16, synaptophysin, estrogen receptor, and Ki67 were examined, and the glandular, squamous, and undifferentiated components were compared.

"Because of the small sample size, we anticipated that our findings would not achieve statistical significance but would be of interest in a descriptive study," she noted.

All cases that resulted in distant metastases showed stage III or IV disease at hysterectomy. Only 1 of the 5 was treated with chemotherapy, reflecting the approach to treating patients believed to have good prognosis; 3 of 5 were treated with radiotherapy.

Of the 4 cases with follow-up, all patients were dead of disease at follow-up. Survival after treatment was 7, 10, 14, and 32 months. One patient was lost to follow-up at 17 months.

The only difference in histologic parameters between the biopsies of these cases and the control cases was the presence of necrosis in the former, Dr. Apushkin reported. There were no consistent differences in level of expression of any of the immunohistochemical markers.

Julietta Fiscella, MD, from the University of Rochester's Strong Memorial Hospital, in Minnesota, said she found the findings very concerning. She suggested that micrometastases might be missed with current techniques.

"I do a lot of gynecologic pathology. Maybe I should go back and examine the clinical course of my type I patients," she said. "It would be absolutely interesting to follow them. I also think it is important to confirm these findings in a larger study."

Dr. Apushkin said the findings could lead to changes in preoperative and intraoperative staging procedures, and in treatment for type I disease.

Dr. Apushkin has disclosed no relevant financial relationships.

American Society for Clinical Pathology (ASCP) 2009 Annual Meeting: Abstract 37. Presented October 29, 2009.


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