Uterus mass Biopsy - XL

Biopsy

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Histology of reproductive organs.

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Uterus Mass Biopsy - XL: Comprehensive Medical Test Information Guide

Section 1: Why is it done?
- Test Description: A uterus mass biopsy is a tissue sampling procedure that obtains cellular material from an abnormal mass or lesion identified in the uterus. The XL designation indicates an extended or large-sample biopsy, typically obtained through transvaginal ultrasound guidance or hysteroscopy for comprehensive histopathological analysis.
- Primary Indications: Evaluation of suspicious uterine masses detected on imaging; differentiation between benign and malignant lesions; diagnosis of endometrial cancer, uterine sarcoma, or other neoplastic conditions; assessment of abnormal uterine bleeding with structural pathology; characterization of polyps, fibroids, or other masses requiring definitive diagnosis
- Typical Timing/Circumstances: Performed when imaging studies (ultrasound, MRI, or CT) reveal abnormal uterine masses; typically scheduled after initial imaging and clinical evaluation; may be performed in outpatient surgical centers or hospital settings; usually conducted in early follicular phase of menstrual cycle when feasible; timing may be urgent if malignancy is suspected
Section 2: Normal Range
- Normal/Benign Findings: Histologically normal endometrial tissue; benign endometrial polyps with normal glandular and stromal components; benign smooth muscle tissue consistent with leiomyoma (fibroid); absence of malignant cells; normal endometrial architecture without atypia
- Positive Result (Abnormal): Presence of malignant cells indicating carcinoma; atypical hyperplasia requiring further intervention; evidence of uterine sarcoma; confirmation of endometrial cancer; identification of metastatic disease; presence of abnormal cellular features suggesting malignancy
- Borderline/Inconclusive Results: Atypical endometrial hyperplasia without clear malignancy; cellular atypia of undetermined significance (ACUS); inadequate sampling requiring repeat biopsy; findings suspicious but not diagnostic for malignancy; need for immunohistochemistry or molecular testing for definitive classification
- Units of Measurement: Qualitative histopathological analysis; grading systems such as Nottingham score or FIGO grade for endometrial cancer; immunohistochemistry scores (H-scores) if applicable; molecular markers reported as positive/negative or quantitative expression levels
Section 3: Interpretation
- Benign Pathology: Findings consistent with benign conditions such as endometrial polyps, leiomyomas (fibroids), or normal endometrial tissue indicate low cancer risk; management typically involves observation or conservative treatment; no oncologic intervention required; imaging may be repeated in specific intervals based on symptoms
- Malignant Pathology: Positive diagnosis of endometrial adenocarcinoma, sarcoma, or other malignancy necessitates immediate oncologic consultation and staging; determines treatment plan including hysterectomy, chemotherapy, radiation, or combinations thereof; grade and stage of cancer influence prognosis and therapeutic decisions; molecular testing may guide targeted therapy options
- Atypical Hyperplasia: Indicates increased cancer risk (20-40% progression to malignancy); requires close follow-up and consideration of prophylactic hysterectomy; may warrant increased surveillance imaging; in some cases, progesterone therapy or repeat sampling may be recommended; counseling regarding progression risk essential
- Factors Affecting Interpretation: Adequacy of tissue sampling; presence of fragmentation or crush artifact; inflammatory changes masking pathology; recent instrumentation or curettage affecting tissue appearance; endometrial dating and hormonal status; presence of hormonal therapy; immunohistochemical staining patterns; molecular markers including microsatellite instability and mismatch repair status in endometrial cancer
- Clinical Significance Patterns: Type I vs Type II endometrial carcinoma classifications; histologic subtype (adenocarcinoma, serous, clear cell, carcinosarcoma) influences prognosis; FIGO grade (1-3) correlates with survival and treatment intensity; molecular profiling (POLE mutation, MMR status, p53 status) increasingly important for treatment selection; presence of lymphovascular invasion indicates higher risk; depth of invasion into myometrium determines staging
Section 4: Associated Organs
- Primary Organ System: Female reproductive system; specifically the uterus (corpus uteri) and endometrium; tissues involved in hormone production and menstrual cycle regulation; part of overall gynecologic cancer screening and surveillance
- Diseases Diagnosed or Monitored: Endometrial adenocarcinoma (most common uterine cancer); endometrial atypical hyperplasia; uterine sarcomas (leiomyosarcoma, endometrial stromal sarcoma); benign endometrial polyps; uterine fibroids (leiomyomas); carcinosarcoma (mixed Müllerian tumors); metastatic cancers to endometrium
- Medical Conditions Associated with Abnormal Results: Obesity and metabolic syndrome; diabetes mellitus type 2; polycystic ovary syndrome (PCOS); estrogen-producing tumors; tamoxifen use for breast cancer treatment; Lynch syndrome and hereditary nonpolyposis colorectal cancer (HNPCC); unopposed estrogen exposure; postmenopausal bleeding; abnormal uterine bleeding in premenopausal women
- Potential Complications/Risks: Uterine perforation during procedure; infection or endometritis; uterine hemorrhage; cervical laceration; anesthetic complications; dissemination of malignant cells (though debated); failure to obtain diagnostic tissue; need for repeat procedures; psychological impact of cancer diagnosis; progression to advanced cancer if diagnosis delayed
- Systemic Impact of Abnormal Results: Malignant diagnosis triggers oncology referral and systemic evaluation; potential for distant metastases to lungs, liver, bones, and lymph nodes; hormone-responsive tumors may affect systemic therapy options; impact on quality of life, fertility, and sexual function; need for long-term surveillance and follow-up imaging
Section 5: Follow-up Tests
- Recommended Testing Based on Malignancy Diagnosis: Pelvic MRI for staging and assessment of myometrial invasion; CT chest, abdomen, and pelvis for distant metastatic disease evaluation; PET-CT scanning in selected cases; transvaginal ultrasound for baseline documentation; tumor markers (CA-125); molecular testing for microsatellite instability, mismatch repair status, and POLE mutations
- Further Investigations for Atypical Hyperplasia: Repeat endometrial biopsy if initial sampling inadequate; immunohistochemistry panels to assess p53 and PTEN expression; repeat transvaginal ultrasound in 3-6 months; consideration of hysterectomy after discussion of malignancy risk; endometrial curettage for further tissue evaluation; hormone therapy trials with close surveillance
- Monitoring Frequency for Benign Diagnoses: Annual imaging if asymptomatic; symptom-directed evaluation if bleeding recurs; ultrasound in 6-12 months to document stability of fibroids; repeat biopsy if imaging shows growth or change in characteristics; no routine follow-up if mass remains stable and symptoms resolve
- Complementary Diagnostic Tests: Flow cytometry for ploidy analysis; in situ hybridization (FISH) for genetic abnormalities; gene expression profiling in selected centers; genomic testing for hereditary cancer syndromes if applicable; immunophenotyping for lymphomas or sarcomas; electron microscopy in specialized cases
- Post-Treatment Surveillance: Physical examinations every 3-6 months for first 2 years; imaging (ultrasound or CT) as clinically indicated; CA-125 monitoring if initially elevated; gynecologic examination for surveillance; imaging at 6, 12, and 24 months post-treatment; annual assessments thereafter; urgent imaging if recurrent symptoms develop
Section 6: Fasting Required?
- Fasting Requirement: Yes - fasting is typically required if biopsy performed under sedation or general anesthesia
- Fasting Duration: Typically 6-8 hours before procedure; nothing by mouth (NPO) from midnight if morning procedure; clear liquids may be permitted up to 2-4 hours before procedure depending on facility protocol and type of sedation planned
- Medications to Avoid: Hold anticoagulants (warfarin, dabigatran) 5-7 days prior unless otherwise directed; hold aspirin and NSAIDs 7-10 days before procedure; discontinue herbal supplements including vitamin E, ginkgo, and garlic 1-2 weeks before; continue regular medications as instructed; clarify with physician regarding blood pressure medications; specific antibiotic prophylaxis may be required based on cardiac history
- Pre-Procedure Preparation: Arrange for responsible adult to provide transportation (anesthesia required); confirm NPO status evening before procedure; schedule procedure during early follicular phase if menstruating; empty bladder and bowels before arrival; remove all jewelry, dentures, contact lenses, and prosthetics; wear comfortable, loose-fitting clothing; apply hair net if provided; establish IV access upon arrival
- Additional Instructions: Informed consent discussion regarding procedure risks and benefits; review of medical history and allergies; vital signs assessment pre-procedure; pregnancy test if applicable; baseline laboratory studies (CBC, comprehensive metabolic panel) may be required; discussion of expected recovery time (typically 24-48 hours); post-procedure activity restrictions; pain management plans; instructions for calling with complications

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