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Book - Molavi > Chapter 17 - Uterus > Flashcards

Chapter 17 - Uterus Flashcards

1
Q

For what indications are endometrial biopsies performed?

A
  • Abnormal vaginal/uterine bleeding - Thickened endometrial stripe on ultrasound - Infertility workup - Follow up for hyperplasia treated with hormones
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2
Q

Distinguish atrophic and proliferative endometrium.

A

Atrophic: Low gland-to-stroma ratio, thin (cuboidal) epithelium, no mitoses. Comes off in strips that resemble hair pins.

Proliferative: Fuller, blue look to the stroma. Gland-to-stroma ratio approaches 1:1. Glands are more donut-like and columnar.

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3
Q
A

Atrophic endometrium

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4
Q
A

Proliferative endometrium

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5
Q

Distinguish secretory and progestin-treated endometrium.

A

Secretory: Prominent spiral arterioles, edematous stroma. Secretory vacuoles and luminal secretions. May decidualize (turns pink, ragged).

Progestin-treated: Decidualized stroma but with flattened gland epithelium.

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6
Q
A

(late) Secretory endometrium

Arrow: Subnuclear cytoplasmic vacuoles
Arrowhead: Decidualization around the spiral arteries

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7
Q
A

Progestin-treated endometrium

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8
Q

Describe the morphology of a benign endometrial polyp.

A

Fibrotic stroma, thick-walled vessels and usually atrophic or cystically dilated glands.

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9
Q

Describe the morphology of endometrial stromal breakdown.

A

The stroma takes on a blurry blue look and condenses into aggregates. The surface epithelium shows eosinophilic metaplasia–almost turns oncocytic. Fibrin thrombi in vessels and neutrophils are common.

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10
Q
A

Benign endometrial polyp;

  1. Cystic gland dilation
  2. Secretory-type epithelium
  3. Thickened arteries
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11
Q
A

Endometrial stromal breakdown

Arrow: Dense mass of packed glands
Arrowhead: Ciliated metaplasia

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12
Q

Describe the morphology of acute and chronic endometritis.

A

Acute: Microabscesses and epithelial destruction (neutrophils alone could just be menses)

Chronic: Plasma cells, with blue spindled stroma and more lymphocytes.

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13
Q
A

Chronic endometritis

Arrow: Spindly, swirling blue stroma
Arrowhead: Proliferative endometrium

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14
Q

Describe the morphology of disordered proliferative endometrium.

A

Mixture of cystically dilated, budding, and tubular glands in a proliferative setting, with focal glandular crowding.

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15
Q

What are some possible causes of bleeding in an endometrial biopsy?

A

Benign polyp

Endometrial stromal breakdwon

Endometritis

Atrophy

Disordered proliferation

Hyperplasia / Carcinoma

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16
Q

Describe the morphology of endometrial hyperplasia.

How do architecture and cytology figure in the diagnosis?

What is dysplasic endometrium?

A

Increase in gland-to-stroma ratio with crowded glands in a proliferative background.

Architecture determines simple vs complex, cytology for atypia.

Trick; Dysplasia is not applied to endometrium.

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17
Q

Distinguish simple vs complex hyperplasia.

Define atypia.

A

Simple: No atypia, crowded glands.

Complex: Back-to-back glands with increasingly complex, branched outlines. May have atypia.

Atypia: Nuclei become round and pale or vesicular. Nucleoli may be prominent.

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18
Q

Describe the morphology and significance of complex atypical hyperplasia (CAH).

A

Very crowded or back-to-back glands with irregular branching lumens, with vesicular chromatin.

CAH is a precursor lesion to carcinoma, and is analogous to carcinoma in situ.

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19
Q
A

Complex atypical hyperplasia

A: Crowded branching glands
B: Hyperplastic glands (arrow) with adjacent normal gland (arrowhead). Note vesicular nuclei.

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20
Q
A

Simple hyperplasia

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21
Q

Describe the role of the endometrial biopsy in the infertility workup.

A

First, rule out bloody lesions like polyps, hyperplasia, etc. Then, date the endometrium to evalute for luteal phase defect (calendar discrepancy).

22
Q

How is proliferative endometrium dated?

A

Trick question, it cannot be dated.

23
Q

What features are most useful in dating secretory endometrium on Days 16-20?

Describe histologic criteria for each of these days.

A

Glands are the most helpful feature.

Day 16: Subnuclear vacuoles, pseudostratified nuclei
Day 17: Subnuclear vacuoles, with orderly row of nuclei
Day 18: Vacuoles above and below nuclei
Day 19: Few supranuclear vacuoles, orderly nuclei
Day 20: Peak secretions in lumen and ragged luminal border.

24
Q

What features are most useful in dating secretory endometrium days 21-28?

Describe the histologic criteria for these days.

A

Stroma is most useful.

Day 21: Luminal secretion & start of stromal edema.
Day 22: Peak stromal edema with naked nuclei.
Day 23: Spiral arteries become prominent.
Day 24: Periarteriolar cuffing with predecidua
Day 25: Predecidual change under the surface epithelium
Day 26: Decidual islands, lymphocytes
Day 27: Neutrophils, focal hemorrhage & necrosis
Day 28: Prominent necrosis

25
Q

Describe the morphology of gestational endometrium.

A

Solid sheet of decidualized cells (plump polygonal pink cells) with almost papillary, hypersecretory epithelium.

26
Q

What is the Arias-Stella reaction?

A

A normal reaction to pregnancy with ballooning cytoplasm and wildly pleomorphic nuclei. No mitoses or infiltration.

27
Q

What is a placental site nodule?

A

The benign remnant of an old implantation site; aggregates of intermediate trophoblastic cells with scattered large nuclei. Well-circumscribed.

28
Q
A

Aria-stellis reaction

29
Q

Recall 5 forms of metaplasia seen in the endometrium.

A

Tubal metaplasia: Luminal cilia in a plump epithelium

Squamous metaplasia

Mucinous metaplasia: Endocervical-type cells

Eosinophilic metaplasia: Can have proliferation to the point of papillary architecture

Clear cell change

30
Q

What is interval endometrium?

A

Endometrium just at the start of the secretory phase, with a few clear subnuclear vacuoles in an otherwise proliferative-looking background.

31
Q

What is the most common endometrial cancer? Who does it normally affect?

Describe its morphology.

A

Endometrioid carcinoma; normally arises in post-menopausal women.

Complex, fused glands without intervening stroma. May appear cribriform or villoglandular.

32
Q

What is papillary syncytial metaplasia?

A

A form of eosinophilic metaplasia with papillary growth and merged syncytial cells

33
Q

Describe the grading of endometrioid carcinoma.

A

Grading is based on cytology and architecture.

FIGO 1: Tumor is <5% solid (squamous metaplasia does not count)
FIGO 2: Tumor is 6-50% solid
FIGO 3: Tumor is >50% solid.

*significant nuclear atypia can increase grade*

34
Q

Briefly list some variants of endometrioid carcinoma.

A
  • with squamous differentiation
  • villoglandular variant
  • secretory variant
  • ciliated cell variant
35
Q

Distinguish serous carcinoma from endometrioid carcinoma.

A

Serous carcinoma arises in older women, is considerably more aggressive, and is not graded (high-grade by definition). It arises from a separate tumor pathway.

36
Q

Describe the morphology of serous carcinoma.

A

Papillary architecture (usually), with complex branching. Cells are extremely atypical and have cherry-red nucleoli and bizarre mitoses. Psammoma bodies are common.

37
Q

Describe the precursor lesion to serous carcinoma.

A

Endometrial epithelial carcinoma: Transofmration of surface epithelium, especially in polyps. It has metastatic potential itself.

38
Q

Describe the tumor pathways that give rise to endometrioid and serous carcinomas.

A

Type I (endometrioid) carcinoma: Increase signaling through PI3K/AKT (PTEN, PIK3CA, K-RAS, ARID1A)

Type II (serous, clear cell): TP53, aneuploidies

39
Q

Briefly summarize clear cell carcinoma of the uterus.

A

A high-grade neoplasm that also arises from TP53 mutation, with clear cell morphology.

40
Q

What is endometrial stroma sarcoma?

A

A rare malignancy of endometrial stromal cells. Look for an infiltrative lesion with minimal atypia and plexiform vascular proliferation.

41
Q

Describe the morphology of a MMMT.

A

Mixed tumor consisting of malignant glands in a sarcomatous stroma. Other soft tissue elements (skeletal muscle / cartilage) may also appear.

42
Q

What is an adenosarcoma?

What is an adenofibroma?

A

A neoplasm with benign glands and a malignant stroma.

A neoplasm with benign glands and benign stroma; similar to phyllodes tumors.

43
Q
A

Endometrioid carcinoma

44
Q
A

Serous carcinoma

Circle: Note prominent nucleoli

45
Q
A

Endometrial intraepithelial carcinoma

Arrow: Abrupt transition from normal epithelium (left) to malignant cells (right)

46
Q
A

MMMT

Arrow: Carcinomatous epithelium

Circle: Sarcomatous stroma

47
Q

What are some of the various morphologies that fibroids can take on?

Summarize their typical morphology.

A

They can be myxoid or necrotic while still being benign.

Spindle cell lesion with intersecting fascicles, corkscrew nuclei, and a fibrotic to myxoid or even hemorrhagic stroma.

48
Q

Describe three morphologic criteria of leiomyosarcomas.

A

Many mitoses (>10/10hpf)

Cytologic atypia

Coagulative necrosis

49
Q

Should you be more or less willing to diagnose leiomyosarcoma in the outside the uterus?

A

More willing

50
Q

What is an adenomatoid tumor?

A

A benign proliferation of mesothelial origin that resembles a leiomyoma but has clefted spaces between the bundles. Looks epithelioid. Calretinin+

51
Q
A

Leiomyoma

Arrow/Arrowhead: Parallel and perpendicular bundles

Inset: “Corkscrew” nuclei

52
Q
A

Leiomyosarcoma

Arrow: Mitosis

Circle: Atypical and pleomorphic cells

Book - Molavi (29 decks)

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