Hysterectomy

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Author: Mikael Häggström [notes 1]

Fixation

Generally 10% neutral buffered formalin.

See also: General notes on fixation

Comprehensiveness

On this resource, the following formatting is used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))
Other legend

<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]

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]

Steps:[1]

  • (Remove the adnexa.[1] Weigh the uterus without the adnexa.)
  • Perform a general inspection
  • Measure the 3 dimensions, including the cervix. (Also measure the length of the cervix, the maximum diameter of the cervix, and the width of the cervical os.)
  • Open the uterus by transmural radial cuts on both sides of the uterine cavity.[notes 2] 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.
  • 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.
  • (Even the absence of) any polyps. Further information: Endometrial polyp
  • Mucosal and endometrial thickness
  • (Even the absence of) any smooth muscle tumor. Further information: Smooth muscle tumor
Example
(A. Labeled - __. The specimen is received in formalin and consists of a resected) uterus with cervix [and bilateral fallopian tubes and ovaries]. The uterus and cervix measure [ ] cm and weighs [ ] grams. The serosa is [tan-pink and smooth]. The cervix measures [ ] cm in diameter and [ ] cm in length. The ectocervical mucosa is [tan-pink and smooth] and the cervical os[ is patent] and measures [ ] cm in diameter. The specimen is bisected in the coronal plane. The endocervical canal is [patent and displays a tan-pink smooth mucosa]. The endometrial cavity is [triangular] and is lined by[ smooth] endometrium measuring [0.1] cm in average thickness. The myometrium measures up to [ ] cm in thickness.[

- It displays __ intramural leiomyomata measuring up to __ cm in greatest diameter.

] The right ovary measures [ ] cm and has a [tan-pink and smooth] capsule. Cut sections show [no gross lesions]. The right fallopian tube measures [ ] cm in length and [ ] cm in average diameter. The serosa [is tan-pink and smooth]. Cut sections reveal a small patent lumen and no gross lesions. The left ovary measures [ ] cm and has a [tan-pink and smooth] capsule. Cut sections show [no gross lesions].The left fallopian tube measures [ ] cm in length and [ ] cm in average diameter. The serosa [is tan-pink and smooth]. Cut sections reveal a small patent lumen and no gross lesions. Representative sections are submitted for microscopic examination in [ ] cassettes.

Slices for microscopy

Submit:[1]

  • One, (two - at 6 and 12 o'clock), ((or four)) cross-sections 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.))
  • Endometrium and myometrium, by one slice from the front and one from the back wall of the corpus.
  • {{Any mucosal parts with macroscopically abnormal appearance, including polyps.}}
  • {{In case of endometrial hyperplasia, most of the mucosa of the corpus and fundus.}}
  • {{Samples from all smooth muscle tumors >5 cm in diameter.}} Further information: Smooth muscle tumor

See also:

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.

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.
    • In the US, the cut goes from side to side, through the cervix and uterine cavity, keeping the anterior and posterior halves attached by a relatively thin connection left at the fundus. It is done by cutting with scissors with the blunt end in the cervix and then uterine cavity, or by a blade guided on each side by the shanks of a pair of forceps inserted through the cervix.
    • In Sweden, the uterus is usually opened at the front in the midline, optionally with an incision towards each corner.
    It can be done by scissors, or by inserting a probe or forceps to guide a long blade.
  2. HSIL+ encompasses HSIL, AGC, and cancer
  3. CIN 2+ encompasses CIN 2, CIN 3, adenocarcinoma in situ (AIS), and cancer
  4. CIN 3+ encompasses CIN 3, AIS, and cancer

Main page

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.