Hysterectomy

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Author: Mikael Häggström [notes 1]

Fixation

Generally 10% neutral buffered formalin.

See also: General notes on fixation

Gross processing

Benign indications

Applicable in bleeding disorders, pain, leiomyoma and endometrial hyperplasia.[1]

Gross examination

For orientation:

  • The round ligament lies anterior to the tubes and ovaries.[1]
  • The peritoneum extends further down along the cervix posteriorly than anteriorly.[2] Its ends bluntly posteriorly and sharply anteriorly.[2]

Optionally, remove the adnexa.[1]

Steps:[1]

  • Perform a general inspection
  • Measure length, width, thickness
  • The uterus is usually opened at the front in the midline, optionally with an incision towards each corner.[notes 2] Open the cavity completely, along the existing incision. The cavity is sometimes be squeezed or rolled around a leiomyoma, and you'll you have to improvise and perhaps go around the leiomyoma to open the cavity properly. Cut through the front wall into both corners.
  • Inspect the mucosa. If any polyps: Further information: Endometrial polyp
  • Measure the thickness of the mucosa and myometrium
Smooth muscle tumor (in this case leiomyoma).

Gross report

Components:[1]

  • Shape of uterus and adnex
  • Measurements
  • Mucosa, such as smooth or irregular.
  • Any polyps. Further information: Endometrial polyp
  • Mucosal and endometrial thickness
  • Any smooth muscle tumor. Further information: Smooth muscle tumor

Slices for microscopy

Submit:[1]

  • Four cross-sectiosn from any accompanying ectocervix. In subtotal extirpation, a cross-section is taken from the lower resection border.
  • A transverse slice through the endocervix, possibly divided into two.
  • One slice from the front and one from the back wall of the corpus, and one piece from each corner, including myometrium.
  • Any mucosal parts with macroscopically abnormal appearance, including polyps.
  • In case of endometrial hyperplasia, most of the mucosa of the corpus and fundus.
  • Samples form all smooth muscle tumors >5 cm in diameter. Further information: Smooth muscle tumor

Microscopic evaluation

Look for signs of malignancy:

Cervix

Cervical intraepithelial neoplasia edit
Histology Grade Corresponding Cytology Description Image
CIN 1 (Grade I) Low-grade squamous intraepithelial lesion (LSIL)
  • Mild epithelial dysplasia
  • Confined to the basal 1/3 of the epithelium
LSIL (CIN 1), Cervical Biopsy (3776284166).jpg
CIN 2/3 High-grade squamous intraepithelial lesion (HSIL)[notes 3]
  • Represents a mix of low and high-grade lesions not easily differentiated by histology
CIN 2 (Grade II)[notes 4]
  • Moderate dysplasia confined to the basal 2/3 of the epithelium
CIN 3 (Grade III)[notes 5]
  • Severe dysplasia with undifferentiated neoplastic cells that span more than 2/3 of the epithelium
  • May involve the full thickness
  • May also be referred to as cervical carcinoma in situ
Histopathology of CIN 3.jpg
Endocervical gland invasion is associated with high-grade lesions.[3]


Uterine body

Main findings:

Microscopy report

Example in a normal case:

Microscopy of hysterectomy shows ecto and endocervix without atypia. The glands have columnar epithelium without atypia.

In the uterine cavity, there is endometrial mucosa with ordinary thickness and regularly arranged endometrial glands. (Optionally: Description of likely menstrual phase.) Sharp delimitation between endometrium and myometrium. The myometrium contains no focal changes. No evidence of malignancy.

This example is Public Domain, and can be copied without any need for author attribution.

Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
  2. The uterus can also be opened laterally, through the parameters.
  3. HSIL+ encompasses HSIL, AGC, and cancer
  4. CIN 2+ encompasses CIN 2, CIN 3, adenocarcinoma in situ (AIS), and cancer
  5. CIN 3+ encompasses CIN 3, AIS, and cancer

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Monica Dahlgren, Janne Malina, Anna Måsbäck, Otto Ljungberg. Stora utskärningen. KVAST (Swedish Society of Pathology). Retrieved on 2019-09-26.
  2. 2.0 2.1 . General Specimen Orientation Tips. The University of Michigan (2020-01-29).
  3. Nagi, Chandandeep S.; Schlosshauer, Peter W. (2006). "Endocervical glandular involvement is associated with high-grade SIL ". Gynecologic Oncology 102 (2): 240–243. doi:10.1016/j.ygyno.2005.12.029. ISSN 00908258.