Key to Reports in the EIN Type Collection

Information about data and fields shown in the tissue Report Pages. Individual pages may be pulled through any of a number of retrieval strategies summarized on the Explore Type Collection Page.

Table showing interpretive cutoffs for various assays performed.  Discrepancies between results obtained using various analytical methods are noted, with explanations and resolutions when appropriate.

Analysis Precancer(EIN)  Result Uncertain Result Benign Result
Clonality Monoclonal Indeterminate Polyclonal
Pathologist Diagnosis Atypical Hyperplasia Non-Atypical Hyperplasia Other
Computer D-Score <0 0-1 >1
Computer VPS <55% . >55%

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Details

Report Number: The page number of the report.

Summary Diagnosis: Diagnosis in the Endometrial Intraepithelial Neoplasia (EIN) classification system. Generally, lesions were classified as precancers (EIN) or non-precancers (benign) when indicated by at least two of the three analytical methods used (Morphology by computer, Morphology by pathologist review; and Genetic analysis). Uncertain lesions, designated indeterminate, resulted when equivocal results in one analytical method were unable to resolve opposed conclusions in the others.

Area Number: A unique laboratory identifier for each tissue area studied. This number should be referenced in any correspondence regarding a particular tissue region.

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Morphology Analysis

Glass hematoxylin and eosin stained histological slides were prepared, and areas to be studied delimited by circling with an ink pen. These circled areas were subjected to computer morphometric analysis and reviewed blindly by four gynecologic pathologists. Circumscribing black lines ensured that all analyses were performed on the same regions, and can be seen in some of the photomicrographs as fuzzy shadows at the perimeter.

By Computer: Computerized morphometric analysis was performed by Dr. Jan P.A.Baak according to published Methods using a Leitz Q-Prodit v6.0 system.

D-Score: This calculated index incorporating Volume Percentage Stroma (VPS), Standard Deviation of the Shortest Nuclear Axis (SDSNA), and gland Outer Surface Density (OUTSD) in the outcome-predictive formula D= 0.6229 + (0.0439 x VPS) - (3.9934 x Ln(SDSNA)) - (0.1592 x OUTSD). Lesions were classified as probable precancers, unknown, or probable benign based upon the D-Score:

If D-Score <0, probable precancer.

If D-Score 0-1, uncertain

If D-Score >1, probable benign (non-precancer)

Volume Percentage Stroma (VPS): The total volume(100%) of each tissue specimen was subdivided into three subcomponents: Stroma, Epithelium, and Gland Lumen. The volume percentage stroma is easily measured manually with a microscope ocular grid, and contributes the greatest predictive power of all three parameters measured to calculate the D-score. Endometrial tissues with a VPS less than 55% are usually monoclonal precancers.

By 4 Expert Pathologists: Original glass slides were circulated amongst four subspecialty gynecologic pathologists (George L. Mutter, Brigham and Women's Hospital, Boston, MA; Christopher P. Crum, Brigham and Women's Hospital, Boston, MA; Ralph M. Richart, Columbia Presbyterian Medical Center, NY, NY, and Alex Ferenczy, The Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada) whose opinions are coded as Pathologists A-D, non-respectively.

Diagnosis: WHO criteria were applied to classify hyperplasias by architecture and cytology. Non-hyperplasias were clasified as cancer or other. In ascending order, diagnoses were assigned a whole number from 1-5, and these assignments used to calculate an average diagnostic value from the mean of 4 assessments.

Other (1): everything not fitting into the other categories.

SH (2): Simple Hyperplasia. Hyperplasia with no Atypia, simple architecture.

CH (3): Complex Hyperplasia. Hyperplasia with no atypia, complex architecture.

AH (4): Atypical Hyperplasia. Hyperplasia with cytologic atypia in either simple or complex glands.

CA (5): Carcinoma.

Follow-up: Each pathologist provided a whole number score from 0-3 corresponding to their clinical impression of the indicated area. Originally dubbed the "Anxiety Index", reviewers were pointedly asked their level of concern for cancer risk, if the lesion had been left in situ. "Imagine a clinician has asked for management recommendations based on your assessment of risk for progression to cancer, irrespective of the nomenclature you choose for diagnosis. This will range from no increased risk (Index=0), to high risk (Index=3)".

0: No increased risk. No follow-up needed.

1: Very low risk. Follow-up necessary only for new or persistent symptoms.

2: Moderate Risk. Worrisome findings require additional pathologic evaluation by repeat curettage or biopsy.

3: High risk. Complete ablation required based on current findings.

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Genetic Analysis

Clonality: Hypothetically, endometrial precancers are Monoclonal lesions, and Polyclonal tissues are non-precancers.

Monoclonal: Probable precancer

Polyclonal: Probable benign

Clonal Method: None of the analytical methods used to ascertain clonality is perfect, as all suffer from moderate sensitivity in detection of monoclonality. Thus, a fraction of all true precancers will appear to be polyclonal. The assay method applied depended on presence or absence of unstable microsatellites (microsatellite instability) in the accompanying endometrial cancer. Those patients with microsatellite unstable cancers were examined for the presence of clonally propagated altered microsatellites in non-malignant tissues (Microsatellites). Patients with microsatellite stable cancers could be studied by X inactivation analysis using a tetranucleotide repeat in the X chromosome linked androgen receptor gene (HUMARA) as an informative marker. Use of the HUMARA assay is invalid in patients with microsatellite instability, as this phenotype tends to alter the HUMARA repeat and create erroneous results. Thus, application of the two assays occurred in mutually exclusive sets of tissues. Interpretive criteria for diagnosis of monoclonality was:

X inactivation (HUMARA): Monoclonal if structurally altered allele (relative to reference myometrium) was clonally propagated.

Microsatellite (tetranucleotide): Monoclonal if inactive X chromosome allele was skewed in lesional tissue relative to companion myometrium.

K-ras: K-ras codon 12 genotypes were evaluated by Dr. Takayuki Enomoto and H. Wada of the Department of Obstetrics and Gynecology of Osaka University Medical School, Osaka, Japan, using a Single Stranded Conformational Polymorphism (SSCP) screen followed by direct sequencing. Only uteri with k-ras mutant cancers were examined for k-ras mutations in associated non-malignant tissues.

Not Done: The tissue was not examined for k-ras mutations

Mutant: A mutation in k-ras codon 12 was confirmed

Wild type: K-ras was examined but found to have a normal sequence.

Features Shared with Matched Cancer: The uteri of all patients examined contained endometrial adenocarcinoma, and those genetic features shared between the carcinoma and non-malignant areas are listed here as supportive evidence of continuity between precancers and cancers. Results of clonal testing, and mutation analysis are noted. In the case of patients with microsatellite unstable cancers, the molecular weight of novel alleles was carefully compared between cancer and non-cancerous tissues to determine the number of shared alleles, of the total number of novel alleles appearing throughout the carcinoma..

 

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