Difference between revisions of "Endometrial cancer"

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===Diagnosis===
 
===Diagnosis===
 
<gallery mode="packed" heights="200">
 
<gallery mode="packed" heights="200">
File:Pie chart of relative incidences of endometrial carcinoma.png|Relative incidences of endometrial carcinomas by histopathology, being endometrioid in a majority of cases.<ref>{{cite journal|last1=Mendivil|first1=Alberto|last2=Schuler|first2=Kevin M.|last3=Gehrig|first3=Paola A.|title=Non-Endometrioid Adenocarcinoma of the Uterine Corpus: A Review of Selected Histological Subtypes|journal=Cancer Control|volume=16|issue=1|year=2009|pages=46–52|issn=1073-2748|doi=10.1177/107327480901600107}}</ref> Endometrioid carcinoma has patterns reminiscent of normal endometrium, with many new glands formed from columnar epithelium with some abnormal nuclei:
+
File:Pie chart of relative incidences of endometrial carcinoma.png|Relative incidences of endometrial carcinomas by histopathology, being '''endometrioid''' in a majority of cases.<ref>{{cite journal|last1=Mendivil|first1=Alberto|last2=Schuler|first2=Kevin M.|last3=Gehrig|first3=Paola A.|title=Non-Endometrioid Adenocarcinoma of the Uterine Corpus: A Review of Selected Histological Subtypes|journal=Cancer Control|volume=16|issue=1|year=2009|pages=46–52|issn=1073-2748|doi=10.1177/107327480901600107}}</ref> Endometrioid carcinoma has patterns reminiscent of normal endometrium, with many new glands formed from columnar epithelium with some abnormal nuclei:
 
File:Histopathology of low-grade (FIGO grade 1) endometrial endometrioid adenocarcinoma.png|'''Endometrioid adenocarcinoma'''<ref>{{cite journal|last1=Stewart|first1=Colin J.R.|last2=Crum|first2=Christopher P.|last3=McCluggage|first3=W. Glenn|last4=Park|first4=Kay J.|last5=Rutgers|first5=Joanne K.|last6=Oliva|first6=Esther|last7=Malpica|first7=Anais|last8=Parkash|first8=Vinita|last9=Matias-Guiu|first9=Xavier|last10=Ronnett|first10=Brigitte M.|title=Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites|journal=International Journal of Gynecological Pathology|volume=38|year=2019|pages=S75–S92|issn=0277-1691|doi=10.1097/PGP.0000000000000553}}<br>- "Figures - available via license: Creative Commons Attribution 4.0 International"</ref>, with low-grade being distinguished from hyperplasia with atypia by the presence of glandular crowding with endometrial stromal exclusion, and significant cribriform, confluent glandular, labyrinthine, papillary/villoglandular, or non-squamous solid architecture.<ref name="RabbanGilks2019">{{cite journal|last1=Rabban|first1=Joseph T.|last2=Gilks|first2=C. Blake|last3=Malpica|first3=Anais|last4=Matias-Guiu|first4=Xavier|last5=Mittal|first5=Khush|last6=Mutter|first6=George L.|last7=Oliva|first7=Esther|last8=Parkash|first8=Vinita|last9=Ronnett|first9=Brigitte M.|last10=Staats|first10=Paul|last11=Stewart|first11=Colin J.R.|last12=McCluggage|first12=W. Glenn|title=Issues in the Differential Diagnosis of Uterine Low-grade Endometrioid Carcinoma, Including Mixed Endometrial Carcinomas|journal=International Journal of Gynecological Pathology|volume=38|year=2019|pages=S25–S39|issn=0277-1691|doi=10.1097/PGP.0000000000000512}}</ref>
 
File:Histopathology of low-grade (FIGO grade 1) endometrial endometrioid adenocarcinoma.png|'''Endometrioid adenocarcinoma'''<ref>{{cite journal|last1=Stewart|first1=Colin J.R.|last2=Crum|first2=Christopher P.|last3=McCluggage|first3=W. Glenn|last4=Park|first4=Kay J.|last5=Rutgers|first5=Joanne K.|last6=Oliva|first6=Esther|last7=Malpica|first7=Anais|last8=Parkash|first8=Vinita|last9=Matias-Guiu|first9=Xavier|last10=Ronnett|first10=Brigitte M.|title=Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites|journal=International Journal of Gynecological Pathology|volume=38|year=2019|pages=S75–S92|issn=0277-1691|doi=10.1097/PGP.0000000000000553}}<br>- "Figures - available via license: Creative Commons Attribution 4.0 International"</ref>, with low-grade being distinguished from hyperplasia with atypia by the presence of glandular crowding with endometrial stromal exclusion, and significant cribriform, confluent glandular, labyrinthine, papillary/villoglandular, or non-squamous solid architecture.<ref name="RabbanGilks2019">{{cite journal|last1=Rabban|first1=Joseph T.|last2=Gilks|first2=C. Blake|last3=Malpica|first3=Anais|last4=Matias-Guiu|first4=Xavier|last5=Mittal|first5=Khush|last6=Mutter|first6=George L.|last7=Oliva|first7=Esther|last8=Parkash|first8=Vinita|last9=Ronnett|first9=Brigitte M.|last10=Staats|first10=Paul|last11=Stewart|first11=Colin J.R.|last12=McCluggage|first12=W. Glenn|title=Issues in the Differential Diagnosis of Uterine Low-grade Endometrioid Carcinoma, Including Mixed Endometrial Carcinomas|journal=International Journal of Gynecological Pathology|volume=38|year=2019|pages=S25–S39|issn=0277-1691|doi=10.1097/PGP.0000000000000512}}</ref>
 
File:Histopathology of complex hyperplasia with atypia.jpg|'''Complex hyperplasia with atypia''' for comparison: Sparse intervening stroma.<ref>{{cite journal|last1=Rao|first1=Shalinee|last2=Sundaram|first2=Sandhya|last3=Narasimhan|first3=Raghavan|title=Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India|journal=Indian Journal of Medical and Paediatric Oncology|volume=30|issue=4|year=2009|pages=131|issn=0971-5851|doi=10.4103/0971-5851.65335}}<br>- [https://www.researchgate.net/figure/Closely-packed-endometrial-glands-with-sparse-intervening-stroma-and-stratification-of_fig2_46256480 Figure- available via license: Creative Commons Attribution 2.0 Generic]</ref>
 
File:Histopathology of complex hyperplasia with atypia.jpg|'''Complex hyperplasia with atypia''' for comparison: Sparse intervening stroma.<ref>{{cite journal|last1=Rao|first1=Shalinee|last2=Sundaram|first2=Sandhya|last3=Narasimhan|first3=Raghavan|title=Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India|journal=Indian Journal of Medical and Paediatric Oncology|volume=30|issue=4|year=2009|pages=131|issn=0971-5851|doi=10.4103/0971-5851.65335}}<br>- [https://www.researchgate.net/figure/Closely-packed-endometrial-glands-with-sparse-intervening-stroma-and-stratification-of_fig2_46256480 Figure- available via license: Creative Commons Attribution 2.0 Generic]</ref>
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<gallery mode="packed" heights="200">
 
<gallery mode="packed" heights="200">
 
File:Histopathology of low-grade (FIGO grade 1) endometrial endometrioid adenocarcinoma.png|'''Grade 1'''<ref>{{cite journal|last1=Stewart|first1=Colin J.R.|last2=Crum|first2=Christopher P.|last3=McCluggage|first3=W. Glenn|last4=Park|first4=Kay J.|last5=Rutgers|first5=Joanne K.|last6=Oliva|first6=Esther|last7=Malpica|first7=Anais|last8=Parkash|first8=Vinita|last9=Matias-Guiu|first9=Xavier|last10=Ronnett|first10=Brigitte M.|title=Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites|journal=International Journal of Gynecological Pathology|volume=38|year=2019|pages=S75–S92|issn=0277-1691|doi=10.1097/PGP.0000000000000553}}<br>- "Figures - available via license: Creative Commons Attribution 4.0 International"</ref>
 
File:Histopathology of low-grade (FIGO grade 1) endometrial endometrioid adenocarcinoma.png|'''Grade 1'''<ref>{{cite journal|last1=Stewart|first1=Colin J.R.|last2=Crum|first2=Christopher P.|last3=McCluggage|first3=W. Glenn|last4=Park|first4=Kay J.|last5=Rutgers|first5=Joanne K.|last6=Oliva|first6=Esther|last7=Malpica|first7=Anais|last8=Parkash|first8=Vinita|last9=Matias-Guiu|first9=Xavier|last10=Ronnett|first10=Brigitte M.|title=Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites|journal=International Journal of Gynecological Pathology|volume=38|year=2019|pages=S75–S92|issn=0277-1691|doi=10.1097/PGP.0000000000000553}}<br>- "Figures - available via license: Creative Commons Attribution 4.0 International"</ref>
 +
File:Histopathology of endometrial adenocarcinoma, endometrioid type.jpg|'''Grade 2'''.
 
File:Histopathology of grade 2 endometrioid endometrial adenocarcinoma with mucinous differentiation, low magnification.jpg|'''Grade 2''' (with mucinous differentiation)<ref group=notes>Mucinous endometrioid adenocarcinoma is an altered differentiation / metaplasia with intracytoplasmic mucin (intraluminal mucin pooling does not qualify).<br>- {{cite web|url=http://www.pathologyoutlines.com/topic/uterusendometrioid.html|title=Uterus - Carcinoma - Endometrioid carcinoma|author=Aarti Sharma, M.D., Ricardo R. Lastra, M.D.|website=PathologyOutlines}} Topic Completed: 3 September 2020. Minor changes: 21 September 2020</ref>
 
File:Histopathology of grade 2 endometrioid endometrial adenocarcinoma with mucinous differentiation, low magnification.jpg|'''Grade 2''' (with mucinous differentiation)<ref group=notes>Mucinous endometrioid adenocarcinoma is an altered differentiation / metaplasia with intracytoplasmic mucin (intraluminal mucin pooling does not qualify).<br>- {{cite web|url=http://www.pathologyoutlines.com/topic/uterusendometrioid.html|title=Uterus - Carcinoma - Endometrioid carcinoma|author=Aarti Sharma, M.D., Ricardo R. Lastra, M.D.|website=PathologyOutlines}} Topic Completed: 3 September 2020. Minor changes: 21 September 2020</ref>
 
File:Histopathology of FIGO grade 3 endometrioid carcinoma of the endometrium with glandular architecture.png|'''Grade 3''', with glandular architecture.<ref name=Murali2019/>
 
File:Histopathology of FIGO grade 3 endometrioid carcinoma of the endometrium with glandular architecture.png|'''Grade 3''', with glandular architecture.<ref name=Murali2019/>
 
File:Histopathology of solid FIGO grade 3 endometrioid carcinoma of the endometrium.png|3 endometrioid carcinoma|'''Grade 3''', with solid architecture.<ref name=Murali2019>{{cite journal| author=Rajmohan Murali, M.B.B.S., M.D., F.R.C.P.A., Ben Davidson, M.D., Ph.D., Oluwole Fadare, M.D., Joseph A. Carlson, M.D., Ph.D., Christopher P. Crum, M.D., C. Blake Gilks, M.D., Julie A. Irving, M.D., F.R.C.P.C., Anais Malpica, M.D., Xavier Matias-Guiu, M.D., Ph.D., W. Glenn McCluggage, F.R.C.Path., Khush Mittal, M.D., Esther Oliva, M.D., Vinita Parkash, M.D., Joanne K. L. Rutgers, M.D., Paul N. Staats, M.D., Colin J. R. Stewart, M.D., Carmen Tornos, M.D., and Robert A. Soslow, M.D. | title=High-grade Endometrial Carcinomas: Morphologic and Immunohistochemical Features, Diagnostic Challenges and Recommendations. | journal=Int J Gynecol Pathol | year= 2019 | volume= 38 Suppl 1 | issue=  | pages= S40-S63 | pmid=30550483 | doi=10.1097/PGP.0000000000000491 | pmc=6296248 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30550483  }}<br>- "This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited."</ref> Carcinomas with identifiable endometrial component, and with over 50% solid architecture should be classified as grade 3 endometrioid carcinoma.<ref name=Murali2019/>
 
File:Histopathology of solid FIGO grade 3 endometrioid carcinoma of the endometrium.png|3 endometrioid carcinoma|'''Grade 3''', with solid architecture.<ref name=Murali2019>{{cite journal| author=Rajmohan Murali, M.B.B.S., M.D., F.R.C.P.A., Ben Davidson, M.D., Ph.D., Oluwole Fadare, M.D., Joseph A. Carlson, M.D., Ph.D., Christopher P. Crum, M.D., C. Blake Gilks, M.D., Julie A. Irving, M.D., F.R.C.P.C., Anais Malpica, M.D., Xavier Matias-Guiu, M.D., Ph.D., W. Glenn McCluggage, F.R.C.Path., Khush Mittal, M.D., Esther Oliva, M.D., Vinita Parkash, M.D., Joanne K. L. Rutgers, M.D., Paul N. Staats, M.D., Colin J. R. Stewart, M.D., Carmen Tornos, M.D., and Robert A. Soslow, M.D. | title=High-grade Endometrial Carcinomas: Morphologic and Immunohistochemical Features, Diagnostic Challenges and Recommendations. | journal=Int J Gynecol Pathol | year= 2019 | volume= 38 Suppl 1 | issue=  | pages= S40-S63 | pmid=30550483 | doi=10.1097/PGP.0000000000000491 | pmc=6296248 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30550483  }}<br>- "This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited."</ref> Carcinomas with identifiable endometrial component, and with over 50% solid architecture should be classified as grade 3 endometrioid carcinoma.<ref name=Murali2019/>
 
</gallery>
 
</gallery>
 +
 +
:{{Comprehensive-begin}}Also perform '''nuclear grading:'''{{Comprehensive-end}}
 +
<gallery mode="packed" heights="200">
 +
File:Histopathology of endometrioid cancer, grade 1, nuclear grade 1.jpg|'''Nuclear grade 1''': Oval, mildly enlarged nucleus with evenly distributed chromatin.{{MH}}<ref name="pmid22496699">{{cite journal| author=Nofech-Mozes S, Ismiil N, Dubé V, Saad RS, Ghorab Z, Grin A | display-authors=etal| title=Interobserver agreement for endometrial cancer characteristics evaluated on biopsy material. | journal=Obstet Gynecol Int | year= 2012 | volume= 2012 | issue=  | pages= 414086 | pmid=22496699 | doi=10.1155/2012/414086 | pmc=3306930 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22496699  }} </ref>
 +
File:Histopathology of endometrioid cancer, grade 1, nuclear grade 2.jpg|'''Nuclear grade 2''': Intermediate features.{{MH}}<ref name="pmid22496699"/>
 +
</gallery>
 +
*'''Nuclear grade 3''': Markedly enlarged and pleomorphic nuclei, with coarse chromatin and distinct nucleoli.<ref name="pmid22496699"/>
  
 
===Staging===
 
===Staging===
 
If possible, perform '''staging''' by the FIGO system:<ref>{{cite web |title=Stage Information for Endometrial Cancer |url=http://www.cancer.gov/cancertopics/pdq/treatment/endometrial/HealthProfessional/page3 |publisher=National Cancer Institute |access-date=23 April 2014 |url-status=live |archive-url=https://web.archive.org/web/20140406044240/http://www.cancer.gov/cancertopics/pdq/treatment/endometrial/HealthProfessional/page3 |archive-date=6 April 2014  |date=January 1980 }}</ref><ref>{{cite web|url=https://www.ncbi.nlm.nih.gov/books/NBK525981/|title=Endometrial Cancer|author=Murray J. Casey; Garth K. Summers; David Crotzer.|website=StatPearls, National Center for Biotechnology Information}} Last Update: July 13, 2020</ref>
 
If possible, perform '''staging''' by the FIGO system:<ref>{{cite web |title=Stage Information for Endometrial Cancer |url=http://www.cancer.gov/cancertopics/pdq/treatment/endometrial/HealthProfessional/page3 |publisher=National Cancer Institute |access-date=23 April 2014 |url-status=live |archive-url=https://web.archive.org/web/20140406044240/http://www.cancer.gov/cancertopics/pdq/treatment/endometrial/HealthProfessional/page3 |archive-date=6 April 2014  |date=January 1980 }}</ref><ref>{{cite web|url=https://www.ncbi.nlm.nih.gov/books/NBK525981/|title=Endometrial Cancer|author=Murray J. Casey; Garth K. Summers; David Crotzer.|website=StatPearls, National Center for Biotechnology Information}} Last Update: July 13, 2020</ref>
  
[[File:Histopathology of grade 2 endometrioid endometrial cancer with myometrial invasion.jpg|thumb|For biopsies, at least look for myometrial invasion (pictured).]]
+
[[File:Histopathology of grade 2 endometrioid endometrial cancer with myometrial invasion.jpg|thumb|230px|For biopsies, at least look for myometrial invasion (pictured).]]
 
+
[[File:Histopathology of endometrial cancer with lymphovascular invasion.jpg|thumb|230px|Generally look for '''lymphovascular invasion''' (pictured) as well.]]
 
{| class="wikitable"
 
{| class="wikitable"
 
!Stage
 
!Stage
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|Distant metastases including abdominal metastases and/or inguinal lymph nodes
 
|Distant metastases including abdominal metastases and/or inguinal lymph nodes
 
|}
 
|}
 +
 +
===Further workup===
 +
Generally perform the following molecular testing on endometrial carcinomas:<ref>{{DH}}</ref>
 +
*'''ER/PR and p53''' for all high grade carcinomas regardless of stage.
 +
*'''HER2''' on all high grade carcinomas, or only on serous carcinomas, or those that are stage III or IV or recurrent.
 +
*'''MMR''' on all cancer types and grades with further testing for MLH1 promotor methylation if MLH1 is lost.
  
 
===Microscopy report===
 
===Microscopy report===
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</gallery>
 
</gallery>
 
|}
 
|}
 +
{{CAP}}
 
{{Bottom}}
 
{{Bottom}}
 
<references />
 
<references />

Latest revision as of 16:25, 22 April 2022

Author: Mikael Häggström [note 1]

Presentations

Gross processing

Gross pathology of extensive endometrial adenocarcinoma (endometrioid type).

A regular hysterectomy grossing is performed, but with the following sampling and additions:[1]

  • 2 longitudinal sections through ecto/endocervix (1 anterior and 1 posterior).
  • 2 longitudinal sections through upper endocervix/lower uterine segment (1 anterior and 1 posterior), contiguous with sections taken from cervix.
  • Tumor:
  • Measure greatest dimension of tumor.
  • If tumor is smaller than 3 cm, submit entirely.
  • If tumor is larger than 3 cm, submit 1 per cm.
  • Measure tumor thickness (cavity to border of invasion) and entire thickness of the wall (cavity to serosa), at the location of greatest percentage of tumor relative to wall thickness.
  • Include 2 full-thickness sections (1 anterior and 1 posterior), including location with greatest percentage. It may need multiply contiguous sections.
  • Remaining sections can be superficial to include tumor and inner myometrium, such as from lower uterine segment to fundus to maintain orientation.
  • If possible, include 1 section with interface between tumor and normal.
  • Sections of any additional pathology, such as leiomyomas, polyps in their entirety.
  • 1 section of uninvolved endometrium if present.
  • Inspect serosa for implants and submit sections if grossly detected.
  • For serous carcinomas, submit the entire ovary and fallopian tube:
  • Ovary, serially sectioned perpendicular to long axis.
  • SEE-FIM protocol for fallopian tubes:
  • Remove the distal 2 cm (fimbriae) and section it parallel to the long axis.
Section the remainder of the tube transversely at 2-3 mm intervals.
  • For all other cancer types, submit adnexa as follows:
  • Ovaries: 2 representative sections of each.
  • Fallopian tubes: Entire fimbriae (longitudinally sectioned) and 2 representative cross-sections on each side.
  • Size smaller than 2 mm: submit intact.
  • Size larger than 2 mm: serially section perpendicular to the long axis in 2 mm intervals.
  • If no gross tumor, submit entirely.
  • If grossly positive, submit 1-2 representative sections showing the greatest tumor dimension and extranodal fat.

Microscopic evaluation

Diagnosis

Endometrioid adenocarcinoma

For endometrioid adenocarcinoma, perform grading:[7]

  • Grade 1: ≤5% solid non-glandular, non-squamous growth
  • Grade 2: >5% and ≤50% solid non-glandular, non-squamous growth
  • Grade 3: >50% solid non-glandular, non-squamous growth
((Also perform nuclear grading:))
  • Nuclear grade 3: Markedly enlarged and pleomorphic nuclei, with coarse chromatin and distinct nucleoli.[9]

Staging

If possible, perform staging by the FIGO system:[10][11]

For biopsies, at least look for myometrial invasion (pictured).
Generally look for lymphovascular invasion (pictured) as well.
Stage Description
IA Tumor is confined to the uterus with less than half myometrial invasion
IB Tumor is confined to the uterus with more than half myometrial invasion
II Tumor involves the uterus and the cervical stroma
IIIA Tumor invades serosa or adnexa
IIIB Vaginal and/or parametrial involvement
IIIC1 Pelvic lymph node involvement
IIIC2 Para-aortic lymph node involvement, with or without pelvic node involvement
IVA Tumor invades bladder mucosa and/or bowel mucosa
IVB Distant metastases including abdominal metastases and/or inguinal lymph nodes

Further workup

Generally perform the following molecular testing on endometrial carcinomas:[12]

  • ER/PR and p53 for all high grade carcinomas regardless of stage.
  • HER2 on all high grade carcinomas, or only on serous carcinomas, or those that are stage III or IV or recurrent.
  • MMR on all cancer types and grades with further testing for MLH1 promotor methylation if MLH1 is lost.

Microscopy report

Example:

(Endometrium, polypectomy:)
Endometrial adenocarcinoma, endometrioid type, FIGO grade 2, with mucinous differentiation. Carcinoma focally invades myometrial smooth muscle.

For cancers, generally include a synoptic report, such as per College of American Pathologists (CAP) protocols at cap.org/protocols-and-guidelines.

Notes

  1. Mucinous endometrioid adenocarcinoma is an altered differentiation / metaplasia with intracytoplasmic mucin (intraluminal mucin pooling does not qualify).
    - Aarti Sharma, M.D., Ricardo R. Lastra, M.D.. Uterus - Carcinoma - Endometrioid carcinoma. PathologyOutlines. Topic Completed: 3 September 2020. Minor changes: 21 September 2020
  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.

Main page

References

  1. Nicole Cipriani (2020-06-22). Gross Pathology Manual - Uterus, Endometrial Cancer. The University of Chicago Department of Pathology.
  2. Mendivil, Alberto; Schuler, Kevin M.; Gehrig, Paola A. (2009). "Non-Endometrioid Adenocarcinoma of the Uterine Corpus: A Review of Selected Histological Subtypes ". Cancer Control 16 (1): 46–52. doi:10.1177/107327480901600107. ISSN 1073-2748. 
  3. Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites ". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691. 
    - "Figures - available via license: Creative Commons Attribution 4.0 International"
  4. Rabban, Joseph T.; Gilks, C. Blake; Malpica, Anais; Matias-Guiu, Xavier; Mittal, Khush; Mutter, George L.; Oliva, Esther; Parkash, Vinita; et al. (2019). "Issues in the Differential Diagnosis of Uterine Low-grade Endometrioid Carcinoma, Including Mixed Endometrial Carcinomas ". International Journal of Gynecological Pathology 38: S25–S39. doi:10.1097/PGP.0000000000000512. ISSN 0277-1691. 
  5. Rao, Shalinee; Sundaram, Sandhya; Narasimhan, Raghavan (2009). "Biological behavior of preneoplastic conditions of the endometrium: A retrospective 16-year study in south India ". Indian Journal of Medical and Paediatric Oncology 30 (4): 131. doi:10.4103/0971-5851.65335. ISSN 0971-5851. 
    - Figure- available via license: Creative Commons Attribution 2.0 Generic
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 Rajmohan Murali, M.B.B.S., M.D., F.R.C.P.A., Ben Davidson, M.D., Ph.D., Oluwole Fadare, M.D., Joseph A. Carlson, M.D., Ph.D., Christopher P. Crum, M.D., C. Blake Gilks, M.D., Julie A. Irving, M.D., F.R.C.P.C., Anais Malpica, M.D., Xavier Matias-Guiu, M.D., Ph.D., W. Glenn McCluggage, F.R.C.Path., Khush Mittal, M.D., Esther Oliva, M.D., Vinita Parkash, M.D., Joanne K. L. Rutgers, M.D., Paul N. Staats, M.D., Colin J. R. Stewart, M.D., Carmen Tornos, M.D., and Robert A. Soslow, M.D. (2019). "High-grade Endometrial Carcinomas: Morphologic and Immunohistochemical Features, Diagnostic Challenges and Recommendations. ". Int J Gynecol Pathol 38 Suppl 1: S40-S63. doi:10.1097/PGP.0000000000000491. PMID 30550483. PMC: 6296248. Archived from the original. . 
    - "This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited."
  7. Soslow, Robert A.; Tornos, Carmen; Park, Kay J.; Malpica, Anais; Matias-Guiu, Xavier; Oliva, Esther; Parkash, Vinita; Carlson, Joseph; et al. (2019). "Endometrial Carcinoma Diagnosis ". International Journal of Gynecological Pathology 38: S64–S74. doi:10.1097/PGP.0000000000000518. ISSN 0277-1691. 
  8. Stewart, Colin J.R.; Crum, Christopher P.; McCluggage, W. Glenn; Park, Kay J.; Rutgers, Joanne K.; Oliva, Esther; Malpica, Anais; Parkash, Vinita; et al. (2019). "Guidelines to Aid in the Distinction of Endometrial and Endocervical Carcinomas, and the Distinction of Independent Primary Carcinomas of the Endometrium and Adnexa From Metastatic Spread Between These and Other Sites ". International Journal of Gynecological Pathology 38: S75–S92. doi:10.1097/PGP.0000000000000553. ISSN 0277-1691. 
    - "Figures - available via license: Creative Commons Attribution 4.0 International"
  9. 9.0 9.1 9.2 Nofech-Mozes S, Ismiil N, Dubé V, Saad RS, Ghorab Z, Grin A (2012). "Interobserver agreement for endometrial cancer characteristics evaluated on biopsy material. ". Obstet Gynecol Int 2012: 414086. doi:10.1155/2012/414086. PMID 22496699. PMC: 3306930. Archived from the original. . 
  10. . Stage Information for Endometrial Cancer. National Cancer Institute (January 1980).
  11. Murray J. Casey; Garth K. Summers; David Crotzer.. Endometrial Cancer. StatPearls, National Center for Biotechnology Information. Last Update: July 13, 2020
  12. Template:DH

Image sources