An Audit on Complex hyperplasia reporting at Derriford Hospital Dr R Khan (SpR) Dr A Oriolowo (Consultant Histopathologist)

Aim To compare the endometrial biopsies reported as complex hyperplasia and the final diagnosis in hysterectomy specimens.

Reporting of small biopsy specimens Tissue Handling: A sieve may be useful to ensure that all the material is retrieved. All the submitted tissue should be processed. Interpretation: Unequivocal distinction between atypical hyperplasia and grade 1 endometrioid carcinoma can be difficult on small biopsies. Outcome: Patients with atypical endometrial hyperplasia may benefit from discussion at the gynaecological oncology MDT and management should be based on clinical, pathological and imaging findings.

Method We looked at reports of endometrial biopsies reported as complex hyperplasia and reviewed their hysterectomy results, over a 5 year period - from 2011 to 2016. We reviewed the slides of endometrial biopsies that were reported as complex hyperplasia without atypia and had hysterectomy diagnosis of endometrioid carcinoma.

Results Total number of endometrial biopsies reported over 5 years (from 2011 to 2016) 10347 Total number of cases of endometrial hyperplasia 438 Total number reported as complex hyperplasia 66 Total number with complex hyperplasia that underwent hysterectomy 65 Total number with complex hyperplasia that did not undergo hysterectomy 1

Biopsy results of cases that underwent hysterectomy Complex hyperplasia without atypia 15 Complex hyperplasia with atypia 50 Total 65

Final Hysterectomy Results Of the 15 reported as complex hyperplasia without atypia underwent hysterectomy for various other reasons. On hysterectomy showed: Complex hyperplasia without atypia 2 Complex hyperplasia with atypia 3 Atrophic/ inactive endometrium 6 Proliferative endometrium Grade 1 Endometrioid carcinoma Total 15

2 cases of grade 1 Endometrioid carcinoma We reviewed the biopsy slides of these two cases and looked if we missed diagnosing atypia. We agreed that there was no atypia

Of the 50 cases reported as complex hyperplasia with atypia On hysterectomy showed: Complex hyperplasia without atypia 2 Complex hyperplasia with atypia 13 Endometrioid carcinoma grade 1 25 Endometrioid carcinoma grade 2 1 Endometrioid carcinoma grade 3 4 Polyp with cystic hyperplasia No hyperplasia/ atrophy/ benign Total 50 Of the above 50 cases, in 8 cases the suspicion of endometrioid ca was raised and 7/8 were grade 1 and 1/8 was grade 3.

Analysis The PPV for endometrial biopsy in this audit is 86%. False positive result of the audit is 8%. False negative result of this audit is 13%.

Discussion case One case (62yr,F): Endometrial curetting showed complex hyperplasia without atypia. Two months later inguinal lymph node sampling showed metastatic endometrioid adenocarcinoma. Died soon after.

We reviewed the biopsy slide of this case We agreed there was no atypia

Conclusion The positive predictive value of endometrial biopsy for carcinoma is affected by the type of biopsy. The diagnosis of cytological atypia is difficult and subjective.

Recommendation 1. Re-audit in an year 2. Look at the different type of biopsy pipelle vs. curettage, and look how it affects the PPV. 3. Consider second opinion in cases of cytological atypia.

References Dataset for histological reporting of endometrial cancer February 2014 by RCPATH