6. Uterus Flashcards
What is the physiology of the endometrium?
- Endometrium: outer layer of mucosal lining
- Myometrium: muscular layer beneath the endometrium
Has stroma and glands
Hormonally sensitive:
1) Estrogen: proliferative —> growth of endo
2) Progesterone: secretory —> preparation of endo for implantation AND loss of progesterone causes endo to shed it’s lining (meneustration)
What is a polyp?
Common, non neoplastic, outgrowth of stroma
Hyperplastic protrusion
- CP: uterine bleeding
- can be due to SEs of Tamoxifen (pro-estrogenic effects on endometrium)
What is endometritis? Differentiate between acute and chronic endometritis.
What are the clinical presentations of both acute and chronic endometritis?
Where can it be found?
(3)
Acute endometritis: bacterial infection of endometrium
- CP: abnormal uterine bleeding, fever, pelvic pain
- Cause: delivery, miscarriage, retained products of contraception
Chronic endometritis: chronic inflammation of endometrium
- CP: miscarriage, IUCD, PID (Chlamydia, Neisseria, Mycoplasma), TB (haematogenous or spread from ovaries)
LOCATIONS
- Umbilicus
- Peritoneum
- Laparotomy scar
What is the premalignant stage of endometrial neoplasia? What is it’s cause?
What is the clinical presentation?
Explain simple hyperplasia and atypia vs. Complex hyperplasia and atypia.
Endometrial hyperplasia: hyperplasia of endometrial glands relative to stroma
Due to:
- Increased estrogen (POS, obesity, estrogen replacement) = increased gland to stromal ratio
- Inactivation of PTEN (TSG becomes more sensitive to estrogen)
CP: postmenopausal uterine bleeding
Cytology: atypia = atypical cells (architectural growth pattern defines the type of hyperplasia)
- Simple hyperplasia: <1% progress to carcinoma
- Simple atypia hyperplasia: 8% progress to carcinoma
- Complex hyperplasia: 3% progress to carcinoma
- Complex atypia hyperplasia: 29% progress to carcinoma
What is endometriosis?
Where is it found?
(3)
What is adenomyosis?
How do you diagnosis endometriosis?
Endometrial glands and stroma OUTSIDE of the endometrial lining
LOCATIONS
- Genital tract: ovary (chocolate cyst), uterine ligaments (pelvic pain), fallopian tubes
- Pouch of Douglas: pain with defecation
- Bladder wall: pain with urination
Adenomyosis: endometrium (inner lining) breaks through myometrium (muscle wall)
DX: endometrial tissue found in a non-endometrial location
- risk of carcinoma increases @ site of endometriosis, especially in ovary
What are the primary malignant tumours of the endometrium?
(4)
- these are epithelial derived *
Describe endometrial carcinoma.
- Endometriod adenocarcinoma
- Mucionuos
- Serous: papillary architecture, high grade pleomorphic nuclei (smudge cells), worse prognosis = b/c it spreads along tubes
- Carcinosarcoma: malignant mixed Mullerian tumours, composed of epithelial cells and non epithelial elements
- Glands and muscle (spindle cells)
- Aggressive
- Usually polypod
- Affects: elderly patients and history of radiation treatment
ENDOMETRIAL CARCNIOMA
Malignant proliferation of endometrial glands
- Most common invasive carcinoma of the female genital tract
- Arises in 2 ways:
1. Hyperplasia (75%): increase in estrogen (OCP, obesity) = endometrial hyperplasia // age 60 // histo: endometrioids
2. Sporadic (25%): no evidence of precursor lesion, atrophic endometrium // age 70 // histo: papillary structures, serous, psammona body, p53 mutation
How do you grade and stage an endometrial carcinoma?
What is PTEN?
Grade: gland architecture and nuclear features
- more aggressive tumours have less glands and are increasingly solid
Stage: depth of invasion
- if tumour invades outer half of myometrium, prognosis = worse
- involvement of other organs
PTEN: TSG, 10q23
- Regulates cell proliferation and apoptosis
- In normal endometrium: high levels in the proliferative phase and absent in mid-late secretory phase
- Lost in 97% of cancers
- Isolated in negative cancers is earliest precursor
What is the difference between type 1 and type 2 views of endometrial carcinoma?
Type 1: estrogen dependent
- Younger patients = better prognosis
- Pre-existing hyperplasia
- Micro-satellite instability and mutations in K-ras and PTEN
- Beta-catenin —> deregulation causes malignancy
Type 2: non-estrogen dependent
- Older patients = worse prognosis
- p53 mutations
- LOH on many chromosomes
What is the benign tumour of the myometrium? Describe.
What are its gross features?
Leiomyoma (fibroids): benign neoplastic proliferation of smooth muscle of myometrium
- Clonal abnormalities and DOESN’T transform to become leiomyoscarcoma
- Most common tumours in females
- CP: usually asymptomatic, but when symptomatic, get abnormal uterine bleeding, infertility, and pelvic masses
- Related to estrogen exposure, enlarged during pregnany and shrinks after menopause
GROSS FEATURES
- Round, well circumscribed, unencapsulated, white whorled myometrial mass(es)
- Intramural, submucosal, subserosal
- No haemorrhage
- No necrosis
What is the malignant tumour of the myometrium? Describe.
What are its gross and microscopic features?
Sarcoma —> Leiomyosarcoma: malignant proliferation of smooth muscle of myometrium
- Arises de novo, age 40-60(post meno)
- Recur and metastasize to lungs, bone, and brain
GROSS FEATURES
- Haemorrhage
- Necrosis
- Round
- Intramural
MICROSCOPIC
- Mitotic activity
- Necrosis
- Atypia
What are the stomal tumours?
3
- (Pure) Stromal Tumours
A) Stromal nodule: well circumscribed, benign
B) Stromal sarcoma: infiltration margin, lymphatic invasion, may recur approx 11-12 years
C) Undifferentiated endometrial sarcoma: aggressive - Other Tumours with Stromal Differentiation
A) Adenosarcoma: benign glands, malignant stroma
B) Carcinosarcoma: malignant glands, malignant stroma
C) Stromal tumours (stroma only): stromal nodules and sarcoma - Secondary
A) Malignant tumours of uterus may be metastasis from tumour elsewhere
—> ex: metastatic colon cancer can look identical to primary endometrial cancer
