Characterising the use of surgical pathology rush requests: a descriptive analysis and survey.

This study aimed to characterise priority or 'rush' surgical pathology requests and identify potentially targetable factors. We performed a retrospective descriptive analysis of rush requests at our institution from 2016 to 2019 and conducted a survey asking pathologists about their perspectives on rush cases. There were 3677 rush cases, with case characteristics generally stable over the study period. Two categories of requests were identified based on hospital status; outpatient requests more frequently provided a specific date for diagnosis, while inpatient rush requests generally required a diagnosis as soon as possible. Most pathologists found rush cases to be somewhat more stressful compared with routine cases (65.2%) and found it very or extremely useful to know when a result is needed (86.9%). The use of hospitalisation status, and identifying if results are required by a certain date, may help in more effective triaging of rush surgical pathology cases.

BCOR Internal Tandem Duplication Associated Uterine Sarcoma: Expanding the Clinicopathologic Spectrum.

The diagnosis of high-grade endometrial stromal sarcoma has become more refined following molecular characterization of these tumors. Recently BCOR internal tandem duplications (ITD) have been identified in a small number of high-grade endometrial stromal sarcoma. Here we present an additional case of this rare entity in a young woman in her late teens. She presented with menorrhagia and underwent resection of 2 uterine lesions. The tumor was a spindle cell neoplasm composed of long fascicles with low to moderate cellularity, mild to moderate cytologic atypia, and up to 2 mitotic figures per 10 high power fields. Necrosis was not identified. Immunohistochemical stains showed the tumor to be positive for cyclin D1 in >50% of tumor cells, focally positive for CD10, and negative for SMA, desmin, h-caldesmon, and ALK1. BCOR ITD was confirmed by polymerase chain reaction with subsequent Sanger sequencing. Clues to the diagnosis of BCOR ITD uterine sarcoma include young patient age, uniform nuclear features, and diffuse positivity for cyclin D1. These features should prompt further molecular interrogation for definitive diagnosis, which is important for prognostication.

Direct Genetics Referral Pathway for High-Grade Serous Ovarian Cancer Patients: The "Opt-Out" Process.

PURPOSE: In order to meet a clinical need for better pathways to access genetic testing for ovarian cancer patients, we implemented and reviewed an opt-out referral process for genetic consultation whereby a referral is automatically sent to genetics following a pathological diagnosis of HGSC. METHODS: Following implementation of the opt-out referral process, each month a list of new cases of HGSC was generated from the synoptic pathology report and forwarded directly to the Cancer Genetics clinic. Using an advanced directive, patients were automatically referred for genetic counselling two months after surgery. If the patient declined genetic counselling (opted-out) after discussion with their surgeon within the two months after surgery, the Genetic Counsellor was informed and the patient was removed from the referral process. RESULTS: Between January 1, 2015, and December 31, 2017, 168 women were diagnosed with HGSC, of whom 167 received a referral for genetic consultation. In only one case the referral was cancelled by the surgeon, resulting in a referral rate of 99.4%. By the end of the study period, 133 women attended a genetics consultation appointment and 125 (94%) agreed to proceed with genetic testing. Among those who completed genetic testing, 15% tested positive for a BRCA1 or BRCA2 gene mutation. Of the women who tested positive for a BRCA1/2 mutation, 56% had no family history of breast or ovarian cancer. CONCLUSIONS: The opt-out referral process described in this study is s a feasible, effective, and patient-centred approach to increase access to BRCA1/2 testing for patients with ovarian cancer.

Insufficient and Scant Endometrial Samples: Determining Clinicopathologic Outcomes and Consistency in Reporting.

There are no widely accepted pathologic criteria for reporting endometrial samples with limited tissue and no consensus on the clinical follow-up of patients with these samples. Our study compares clinicopathologic outcomes and determines reporting consistency for these samples. This was done in 3 parts: (1) retrospective chart review of all patients with reported insufficient or scant endometrial samples from 2010 to 2013 at our center to determine repeat sampling and final pathologic diagnosis; (2) survey of gynecologists about their practice for managing patients with these samples; (3) blind review of 99 cases of previously reported scant or insufficient samples in which 4 reviewers separately reassigned cases as scant, insufficient, or diagnostic. Agreement was determined across reviewers. For part (1): 1149 patients had insufficient (49%) or scant (51%) samples with no significant difference in repeat biopsy rate (33% vs. 31%; P=0.33). Final diagnosis of uterine malignancy was higher in patients with a previous insufficient sample than with scant (19% and 9%, respectively), but this was not statistically significant. For part (2): among gynecologists surveyed, 4 of 5 reported managing patients with insufficient or scant samples similarly. For part (3): complete consensus across raters occurred in 57% of cases (Fleiss κ, 0.4891). Similar repeat biopsy rates between scant and insufficient samples suggest that our clinicians choose similar management for both terminologies. As such, distinction between insufficient and scant samples may not be necessary in pathologic reporting. Given the malignancy outcomes, both groups merit repeat sampling in the appropriate context.

Uterine Tumors Resembling Ovarian Sex Cord Tumors Identified at Resectoscopic Endometrial Ablation: Report of 2 Cases.

STUDY OBJECTIVES: To report 2 cases of uterine tumors resembling ovarian sex cord tumors (UTROSCTs) and examine the clinical significance of these tumors found during hysteroscopic endometrial ablation despite benign preoperative endometrial biopsy analysis and imaging suggestive of leiomyoma. DESIGN: Case report (Canadian Task Force classification III). SETTING: Tertiary care hospital. PATIENTS: Two patients with abnormal uterine bleeding. INTERVENTIONS: Hysteroscopic endometrial ablation/resection. MEASUREMENTS AND MAIN RESULTS: Pathological analysis of intrauterine tissue/lesions obtained by curettage or resection identified 2 unexpected UTROSCTs masquerading as leiomyomas. Following hysterectomy, no residual UTROSCT was identified in the specimens, and both women are well, one at 1 year postsurgery and the other at 3 years postsurgery. CONCLUSION: Obtaining additional tissue by routine curettage before endometrial ablation and/or endomyometrial resection, in conjunction with removal of any intrauterine lesions, can identify rare unexpected endometrial lesions not sampled by endometrial biopsy, not detected with ultrasound, and masquerading as leiomyomas during endometrial ablation.

Late Relapse of Ovarian Germ Cell Tumour.

BACKGROUND: Malignant ovarian germ cell tumours typically require multimodal therapy including surgery and systemic platinum-based chemotherapy. Most patients are cured, with survival rates exceeding 95%. CASE: This report describes an unusual case of ovarian germ cell tumour (GCT) recurring 15 years after surgery and manifesting as metastatic disease to the liver, lung, and retroperitoneal lymph nodes. CONCLUSION: Thymic hyperplasia was a confounding finding in this case, and it should be considered in the differential diagnosis of a mediastinal mass in heavily treated patients with GCT.

Intradepartmental consultations in surgical pathology: Review of a standardized process and factors influencing consultation rates and practices in an academic and community hospital setting.

Intradepartmental consultations (ICs) are important for quality assurance (QA) and ensuring diagnostic accuracy in surgical pathology. Few studies have reviewed pathologist factors that influence IC rates. Our study reviews IC data and factors that influence both formal (written) and informal (verbal) consultation practices among pathologists in academic and community hospital settings. Formal IC records from the academic hospital were collected and academic and community pathologists were invited to complete a survey about their IC practices. All centers had a formalized process for documenting ICs; however, 92% of academic and 90% of community pathologists also requested informal IC. The top reasons for selecting a particular colleague for IC was perceived level of expertise; however, interpersonal relationships and office proximity had a greater impact on informal IC practice. Top reasons for requesting a formal IC were mandatory (subspecialty defined) consultation and uncertainty regarding pathological findings. Advice on wording was a common reason for informal IC. Written documentation of IC aids in QA and determination of IC metrics; however, informal, undocumented ICs still occur. Reasons for IC and choice of consulting pathologist are multifactorial, and identifying these can help target quality improvement initiatives.

Long-term clinical outcomes following resectoscopic endometrial ablation of non-atypical endometrial hyperplasia in women with abnormal uterine bleeding.

STUDY OBJECTIVE: To determine the feasibility, efficacy, and long-term clinical outcomes of resectoscopic endometrial ablation as primary treatment of simple endometrial hyperplasia (SH) and complex endometrial hyperplasia (CH) without atypia in women with abnormal uterine bleeding (AUB). DESIGN: Prospective follow-up study (Canadian Task Force classification II-2). SETTING: Teaching hospital. PATIENTS: One hundred sixty-one women with hyperplasia, either SH (n = 107) or CH (n = 54). INTERVENTIONS: From January 1990 through December 2012, one of us performed 4729 primary resectoscopic endometrial ablation procedures in women with AUB. This group included 161 women with endometrial hyperplasia, identified either at office biopsy (n = 62) or incidentally during routine hysteroscopic endometrial ablation (n = 99). Endometrial tissue obtained at dilation and curettage and/or resected during resectoscopic surgery enabled identification of atypical hyperplasia in 6 patients (4 CH, 2 SH) and 1 patient with adenosarcoma. One patient with atypical CH and the patient with adenosarcoma underwent hysterectomy. The remaining 159 women, including 5 with atypical hyperplasia (3 CH, 2 SH), underwent resectoscopic endometrial ablation (102 SH, 52 CH) as primary treatment. Patient median age was 50 years (range, 30-87 years), and body mass index was 32 (range, 17-59). Comorbidities included hypertension in 25 patients, diabetes in 14, cerebrovascular disease in 3, cardiovascular disease in 7, and hypothyroidism in 8. Office biopsy demonstrated proliferative endometrium in 68 patients, SH in 43, CH in 19, and inadequate findings in 13. In 18 women, we were unable to perform biopsy because of cervical stenosis, morbid obesity, or patient intolerance. Endometrium was resected in 120 patients, electrocoagulated in 34, and a combination of procedures in 5, using a 9-mm (26F) resectoscope, 1.5% glycine, and 120W power. Patients were followed up annually. Three patients were lost to follow-up, and 1 died of an unrelated cause 5 years after surgery. MEASUREMENTS AND MAIN RESULTS: One uterine perforation occurred, which required no additional treatment. After endometrial ablation, SH was identified in 70 patients, and CH in 35 patients. At a median follow-up of 7 years (range, 1.5-18), 12 patients underwent hysterectomy to treat persistent bleeding (n = 6), benign ovarian cyst (n = 2), pelvic organ prolapse (n = 1), chronic pelvic pain (n = 2), or myomas (n = 1). Uterine histopathology in 11 patients demonstrated no residual endometrial hyperplasia. We were unable to obtain a pathology report for 1 patient. The remaining 138 women were satisfied with the treatment, with no further bleeding or pain in 132 (95.7%). Six patients (4.3%) had monthly spotting. CONCLUSION: When performed by surgeons experienced in hysteroscopy, resectoscopic endometrial ablation is feasible, safe, and effective for treatment of SH and CH without atypia in women with AUB.

Combined transurethral and laparoscopic partial cystectomy and robotically assisted bladder repair for the treatment of bladder endocervicosis: case report and review of the literature.

BACKGROUND: Endocervicosis, endosalpingiosis, endometriosis, and adenomyosis represent choristomas of Mullerian origin and are referred to as mullerianosis. These conditions frequently coexist, and they may present with pelvic pain, mass lesions, and/or infertility. Clinically, they are indistinguishable from one another, and histologically their epithelium is that of the endocervix, endosalpinx, or endometrium. Endocervicosis can be found in the urinary tract, frequently presenting as a bladder lesion or bladder dysfunction. CASE: We report here a case of bladder endocervicosis in a woman with extensive endometriosis and a bladder tumour who presented with chronic pelvic pain and infertility. Pelvic endometriosis was excised and vaporized with the CO2 laser, and the bladder lesion was excised in a combined transurethral and laparoscopic approach using the CO2 laser and robotic monopolar electrosurgical scissors. The cystotomy was then repaired using the robot, and the patient had an uneventful recovery with good clinical outcomes including spontaneous conception. CONCLUSION: Endocervicosis of the urinary bladder is a rare Mullerian choristoma. Symptomatic lesions can be removed surgically by various surgical techniques, and a collaborative team-based approach is in the patient's best interest.

Contexte : L'endocervicose, l'endosalpingiose, l'endométriose et l'adénomyose constituent des choristomes d'origine müllérienne et sont connues sous le nom de mullérianose. Ces pathologies coexistent fréquemment et peuvent donner lieu à de la douleur pelvienne, à des lésions de masse et/ou à une infertilité. Sur le plan clinique, elles ne peuvent être distinguées l'une de l'autre et, sur le plan histologique, leur épithélium est celui de l'endocol, de l'endosalpinx ou de l'endomètre. La présence d'une endocervicose peut être constatée dans les voies urinaires et prend fréquemment la forme d'une lésion ou d'une dysfonction vésicale. Cas : Nous signalons ici un cas d'endocervicose vésicale chez une femme qui présentait une endométriose étendue et une tumeur vésicale, et qui connaissait des douleurs pelviennes chroniques et une infertilité. L'endométriose pelvienne a été excisée et vaporisée au moyen d'un laser CO2, et la lésion vésicale a été excisée au moyen d'une approche combinée transurétrale et laparoscopique faisant appel au laser CO2 et à des ciseaux électrochirurgicaux monopolaires robotisés. La cystotomie a par la suite été réparée au moyen du robot et la patiente a connu une récupération sans incidents s'accompagnant de bonnes issues cliniques (y compris une conception spontanée). Conclusion : L'endocervicose de la vessie constitue un rare choristome d'origine müllérienne. Les lésions symptomatiques peuvent être retirées au moyen de chirurgies faisant appel à diverses techniques; le recours à une approche d'équipe concertée constitue la mesure qui est la plus favorable pour la patiente.

Added-value of SPECT/CT to lymphatic mapping and sentinel lymphadenectomy in gynaecological cancers.

Lymphatic mapping and sentinel lymphadenectomy (LM/SL) have been successfully used in pre-treatment nodal staging of gynaecological cancers. We hypothesised the added-value of LM/SL plus SPECT/CT in patients with early stage of cervical cancer and vulvar cancer. A prospective, single-center, diagnostic, open label, active control, non-randomized clinical trial has been conducted in 7 patients with FIGO IA-IB1 cervical cancer and 7 patients with FIGO stage I-II-IIIcN0 vulvar cancer. All patients underwent LM/SL plus SPECT/low-dose CT and complete lymph node dissection (CLND) according to the standard of care. In case of negative hematoxylin-eosin staining, serial sections of the SLNs were analysed by immunohistochemistry and high molecular weight cytokeratin. Primary outcome measures were the detection rate, the sensitivity (SV), the negative predictive value (NPV), the diagnostic accuracy (DA) for anatomic localisation of SLNs, and the impact on management of SPECT/CT guided LM/SL versus CLND. The secondary outcome measure was the patient tolerability and operating time of LM/SL guided SPECT/CT versus CLND. http://clinicaltrials.gov/show/NCT00773071 All 14 patients were enrolled into the 1-day research protocol with dual-tracer LM/SL and SPECT/CT. Additional SLNs were detected on SPECT/CT compared to conventional planar imaging. Hot and cold > 1cm SLNs were detected on SPECT/CT. Detection rate, SV, NPV, DA were 100% in both groups; false negative rate was 0%. Rate of SLN metastases was 28.5% in cervical cancer and 42.9% in vulvar cancer. Impact on treatment was 28.5% and 14.3% in cervical cancer and vulvar cancer patients, respectively. SPECT/CT was well tolerated by all patients and operating time for LM/SL was within 30 min. No adverse events were reported with a time frame of 1-to-3 years. In early stage of gynaecological cancers, SPECT/low-dose CT is technically feasible and of clinical added-value for LM/SL.

Granulosa cells in the uterosacral ligament: case report and review of the literature.

Granulosa cells are components of the sex cord-stromal cells in the ovary responsible for steroidogenesis. Uncommonly, extraovarian granulosa cells have been reported to be associated with malignant processes of the ovary. We report a unique case of benign granulosa cells, found during routine laparoscopic evaluation, in the uterosacral ligaments in a 20-year-old patient with chronic pelvic pain and infertility. Possible mechanisms include implantation of released granulosa cells from a normal ovary or arising from a focus of müllerianosis. Of note, a focus of endosalpingiosis and endometriosis was also identified within the specimen.

Uterine smooth muscle tumors of uncertain malignant potential: diagnostic challenges and therapeutic dilemmas. Report of 2 cases and review of the literature.

Morphologically, there exist variants of uterine smooth muscle tumors that cannot be clearly interpreted and classified as benign or malignant. Because their behavior and clinical prognosis is also uncertain, the World Health Organization has termed these "smooth muscle tumors of uncertain malignant potential" (STUMP). Herein we describe 2 cases, present a review of the literature, and highlight the diagnostic challenges and therapeutic dilemmas associated with uterine STUMP in myomectomy specimens from women who wish to maintain or enhance their fertility. The clinical course of residual STUMP remains speculative.

Should preoperative pathology be used to select patients for surgical staging in endometrial cancer?

INTRODUCTION: The decision to offer surgical staging in endometrial cancer is often based on preoperative histology and grade from endometrial biopsy or dilatation and curettage. The primary objective of this study was to evaluate the concordance between preoperative and final pathology from a population-based study of endometrial cancer to address whether preoperative biopsy is a reliable determinant in selecting patients for surgical staging. METHODS: Retrospective cohort study in Ontario, Canada, from 1996 to 2000. The study included all women with a preoperative diagnosis of endometrioid adenocarcinoma on endometrial biopsy or dilatation and curettage, followed by definitive surgery. All other histological types were excluded. Surgical staging rates were compared according to preoperative pathology. Primary outcome measure was the concordance between preoperative and final pathology, expressed as a Spearman correlation coefficient (rho). A multivariable logistic regression estimated the effects of demographic variables and grade on our outcome measure. RESULTS: There were 1804 evaluable cases in this study. For preoperative grades 1, 2, and 3 endometrioid adenocarcinoma, surgical staging rates were 9.1%, 13.7%, and 25.6%, respectively. Concordance rates with final pathology were 73%, 52%, and 53%, respectively. There was only moderate concordance between preoperative and final pathology (rho = 0.52). There was no significant difference in concordance rates according to age, year, or hospital volume, but lower concordance rates among teaching hospitals. CONCLUSION: Preoperative biopsy has only a moderate ability to predict final pathology in endometrial cancer, and therefore, additional factors should be considered in selecting patients for a surgical staging procedure.

Miscellaneous uterine malignant neoplasms detected during hysteroscopic surgery.

STUDY OBJECTIVES: To estimate the incidence of incidental miscellaneous uterine malignant neoplasms other than endometrioid adenocarcinoma detected during routine resectoscopic surgery in women with abnormal uterine bleeding (AUB) and to examine the effect of hysteroscopic surgery on long-term clinical outcome. DESIGN: Prospective cohort study (Canadian Task Force classification II-3). SETTING: University-affiliated teaching hospital. PATIENTS: Women with AUB. INTERVENTION: From January 1, 1990, through December 31, 2008, one of the authors (G.A.V.) and several fellows performed primary hysteroscopic surgery at St. Joseph's Health Care in 3892 women with AUB. Of the 7 with malignant disease, one underwent hysteroscopic partial (n = 1) or complete (n = 6) rollerball electrocoagulation or endomyometrial resection. After diagnosis of uterine cancer, the women were counseled about the disease and management in accord with established clinical practice guidelines. Follow-up with office visits and telephone interviews ranged from 2 to 8 years (median, 6 years). MEASUREMENTS AND MAIN RESULTS: Of the 3892 women, 4 had undiagnosed and 3 had suspected miscellaneous uterine malignant neoplasms including 1 endometrial stromal sarcoma, 2 carcinosarcomas, 2 atypical polypoid adenomyomas of the endometrium, 1 minimal deviation adenocarcinoma of the cervix, and 1 smooth-muscle tumor of uncertain malignant potential. At 2 to 8 years of follow-up, 1 patient died accidentally after 1 year, 1 died of carcinomatosis of either coexisting breast cancer or a carcinosarcoma (postmortem examination was declined) after 1 year, and 5 were alive and well. CONCLUSION: Resectoscopic surgery in women with miscellaneous uterine malignant lesions not adversely affect 5-year survival and long-term prognosis.

When is a pathology review indicated in endometrial cancer?

OBJECTIVE: Discrepancies may exist between an original pathology report and formal pathology review, with subsequent implications for treatment. We conducted a study of pathology review in endometrial cancer from a population-based study to identify areas of discrepancy and effect on treatment. METHODS: This was a retrospective cohort study in Ontario, Canada from 1996 to 2000. We identified hysterectomy cases from patients with endometrial cancer that were subject to formal pathology review by a gynecologic pathologist at one of six tertiary care centers. Sarcomas and other rare histologic subtypes with fewer than five cases were excluded. We evaluated discrepancy between original pathology and review by demographics, stage, grade, and risk group. Four risk groups were defined: 1) low (stage I), 2) intermediate (stage I and II), 3) high-risk (stage I and II), and 4) advanced stage (all stage III and IV). Reclassification from one risk group to another upon pathology review represented a potential change in treatment. Factors associated with significant discrepancy were identified by a multivariable logistic regression model. RESULTS: Formal pathology review was available on 450 cases. There were no differences by age, year, or hospital type. The overall discrepancy rate was 42.7% (95% confidence interval 38.2-47.3%). The intermediate-risk group had the highest rate of reclassification into another group (33.1%). The most significant rates of discrepancy were associated with endometrioid grades 2 and 3 tumors and stage IIA disease (39.8%, 50.9%, and 79.6%, respectively). CONCLUSION: There was significant discrepancy between original pathology and formal review in endometrial cancer, with implications for guidelines on pathology review at a population level. LEVEL OF EVIDENCE: III

Hysteroscopic surgery does not adversely affect the long-term prognosis of women with endometrial adenocarcinoma.

STUDY OBJECTIVE: To determine the effect of hysteroscopic surgery on the long-term clinical outcome of women diagnosed with endometrial cancer. DESIGN: Prospective cohort study (Canadian Task Force classification II-3). SETTING: University-affiliated teaching hospital. PATIENTS: From January 1990 through December 2005, the principal author (GAV) performed primary hysteroscopic surgery in 3401 women with abnormal uterine bleeding. Among these women, there were 16 occult and 3 known endometrial cancers. INTERVENTIONS: All women underwent hysteroscopic evaluation and partial (n = 8) or complete (n = 11) rollerball electrocoagulation and/or endomyometrial resection. After diagnosis of endometrial malignancy, women were counseled regarding their disease and management, in accordance with established clinical practice guidelines. Follow-up ranged from 1 to 14 years and was conducted by office visits and telephone interviews. MEASUREMENTS AND MAIN RESULTS: Among the 3401 women, there were 19 women with endometrial adenocarcinoma, 3 of whom were known to harbor cancer before hysteroscopic surgery. One woman refused hysterectomy and remains alive and well 5 years after total hysteroscopic endomyometrial resection. Two women wished to maintain fertility; 1 consented to hysterectomy after incomplete resection of her lesion. The other was treated with progestins. Her cancer reverted to complex hyperplasia, and she requested hysterectomy 4 years later. No residual cancer was found. After 5 years of follow-up, 1 patient died from carcinoma of the gallbladder (2 years), and 2 died at 4 years; 1 at the age of 87 years of natural causes and the other at the age of 86 years from acute renal failure unrelated to her cancer. Fourteen women remain alive and well at 5 to 14 years of follow-up. Two additional women remain alive and well at 1 and 4 years of follow-up. CONCLUSION: Resectoscopic surgery did not adversely affect the 5-year survival and the long-term prognosis in 14 women with endometrial cancer.

Resectoscopic surgery may be an alternative to hysterectomy in high-risk women with atypical endometrial hyperplasia.

STUDY OBJECTIVE: Endometrial hyperplasia is found in 2% to 10% of women with abnormal uterine bleeding (AUB). Up to 43% of patients with cytologic atypia harbor coexisting adenocarcinoma, and approximately 20% to 52% of atypical hyperplasias, if untreated, progress to cancer. The objective of this study was to estimate the incidence of atypical endometrial hyperplasia encountered during routine resectoscopic surgery in women with AUB and to evaluate the role of resectoscopic surgery in the management of women with AUB and atypical endometrial hyperplasia who refused and/or were at high risk for hysterectomy. DESIGN: Prospective cohort study (Canadian Task Force classification II-3). SETTING: University-affiliated teaching hospital. PATIENTS: From January 1990 through December 2005, the senior author (GAV) performed primary resectoscopic surgery in 3401 women with AUB. Among these, there were 22 women with atypical (17 complex, 5 simple) endometrial hyperplasia. INTERVENTIONS: All women underwent hysteroscopic evaluation and partial (n = 3) or complete (n = 19) endometrial electrocoagulation and/or resection. Subsequently, 6 women had hysterectomy and bilateral salpingo-oophorectomy (BSO). MEASUREMENTS AND MAIN RESULTS: The median (range) for age, parity, and body mass index were 55 years (24-78 years), 2 (0-4), and 30.1 kg/m2 (22.5-52.2 kg/m2), respectively. Among the 3401 women, there were 22 cases of atypical endometrial hyperplasia, 12 of which were incidentally diagnosed at the time of hysteroscopy (complex 10, simple 2, incidence 0.35%). After hysteroscopic diagnosis or confirmation of diagnosis, 6 women underwent hysterectomy and BSO. Of the remaining 16 women, followed for a median of 5 years (range 1.5-12 years), 1 was lost to follow-up, 1 had only a biopsy to preserve fertility, 1 died from lung cancer after 4 years, and 1 died from colon cancer after 5 years. One patient developed endometrial cancer after 10.5 years with postmenopausal bleeding. She remains alive and well 3.5 years after hysterectomy and BSO. The remaining 11 patients are amenorrheic at a median follow-up of 6 years (range 1.5-12 years). CONCLUSIONS: Resectoscopic surgery in 3391 women with AUB detected 12 incidental cases of atypical endometrial hyperplasia (incidence 0.35%). Skillful resectoscopic surgery may be an alternative to hysterectomy in women with AUB and atypical endometrial hyperplasia, who refuse or are at high-risk for hysterectomy and who are compliant with regular and long-term follow-up.

Endometrioid adenocarcinoma treated by hysteroscopic endomyometrial resection.

A 53-year-old multiparous woman, with no identifiable risk factor for endometrial cancer, presented with menorrhagia. She had been treated with oral contraceptives for 3 years. Office endometrial biopsy indicated well-differentiated villoglandular adenocarcinoma of the endometrium. The patient refused hysterectomy and would consent only to hysteroscopic resection. She remains alive and well, with no clinical evidence of recurrence 5 years after resection. We propose that skillful resectoscopic surgery, under specific circumstance, may be an appropriate alternative treatment to hysterectomy for some early uterine malignancies.

Testicular epidermoid cyst: a case report and review of the clinicopathologic features.

Epidermoid cysts of the testicle are rare, benign lesions that are clinically indistinguishable from malignant germ cell tumors. A scrotal mass in a 27-year-old man was incidentally detected by his family physician, and confirmed to be intratesticular by ultrasound. Radical orchidectomy was performed revealing the pathologic diagnosis. The presentation, evaluation and management of epidermoid cysts are discussed.