Common pathologies of the female reproductive system

Question 1

Facts about endometrial cancer

Answer 1

• Most common invasive cancer of the female genital tract (7%)
• Abnormal uterine bleeding
• Childbearing age
• Change in menstrual cycles
• Postmenopausal
• bleeding at least 12 months after cessation of menses OR unpredictable bleeding on HRT for 12months

Question 2

Aetiology of endometrial cancer

Answer 2

• median age at diagnosis - 60 years
• 75% occur in post menopausal women
  
  • only 8% less than 45
  • no screening test
  • diagnosis/once symptoms have started
  • Adenocarcinoma

Question 3

Label the diagram

Answer 3

Question 4

Types of endometrial cancer

Answer 4

• Type 1
• Type 2

Question 5

Explain Type I endometrial cancer

Answer 5

• Younger/peri menopausal women
• Obesity
• Associated with excess oestrogen
• Well differentiated
• Superficial invasion
• Metastasis – infrequent
• Association with hyperplasia
• Genetic mutations KRAS, PTEN, MLH1
• Better prognosis

Question 6

Explain Molecular changes – Type I endometrial cancer

Answer 6

Question 7

Grade the tumour

Answer 7

Well-differentiated (grade 1) endometrioid adenocarcinoma with preserved glandular architecture but lack of intervening stromadistinguishing it from hyperplasia.

Question 8

Grade the tumour

Answer 8

Left

Moderately differentiated (grade 2) endometrioid adenocarcinoma with glandular architecture admixed with solid areas.

Right

Poorly differentiated (grade 3) endometrioid adenocarcinoma with predominantly solid growth

Question 9

Explain Type II endometrial cancer

Answer 9

• Older/post menopausal women
• Poorly differentiated carcinoma
  
  • papillary serous
  • Clear cell (less common)
• Deep myometrial invasion
• Often large bulky tumours
• Frequent lymph node metastasis
• Associated with atrophy
• Genetic mutations in p53 & Erb-B2

Question 10

Explain the development of type II endometrial cancer

Answer 10

• P53 most common mutation
• Histology
  
  • Pattern consisting of malignant cells with marked cytologic atypia including high nuclear-to-cytoplasmic ratio, atypical mitotic figures, and hyperchromasia
  • Accumulation of p53 protein in the nucleus Immunocytochemistry

Question 11

Risk factors of endometrial cancer (type II)

Answer 11

• Exposure to Oestrogen – Key risk factors
  
  • Risk is increased with dose and time
• Endogenous oestrogen
  
  • Obesity
  • Polycystic ovary syndrome
  • Oligomenorrhea
• Exogenous Oestrogen
  
  • HRT
  • Tamoxifen (Tamoxifen oestrogen agonist in the endometrium)

Question 12

What are some important histology implications of endometrial cancer (type II)?

Answer 12

• Aggressive
• Frequent metastasis
• Often spread outside of the uterus at diagnosis
• The tumor cells are irregular in size and have hyperchromatic nuclei with numerous mitotic figures (arrows). → atropic bodies

Question 13

What is endometriosis?

Answer 13

The presence of endometrial-like tissue outside of the uterus, which induces a chronic, inflammatory reaction

Question 14

Explain localisation of endometriosis

Answer 14

• Occurs in the following sites in descending order of frequency:

1. Ovaries
2. Uterine ligament
3. Pelvic peritoneum
4. Large and small bowel
5. Appendix
6. Cervical mucosa

Question 15

What does endometriosis cause?

Answer 15

Important clinical condition causes:

• Infertility (20-50% of infertile women)
• Dysmenenorrhea
• Pelvic pain
• Features of invasion and metastasis – similar to malignant tumours

Question 16

What are the theories of endometriosis?

Answer 16

The metastatic theory (most widely accepted)

Spread of endometrial tissue to distant sites through heamatogenous and lymphatic metastases

The metaplastic theory

Endometrium could arise directly from mesothelium of the pelvis or abdomen or embryonic development

Question 17

What is seen here?

Answer 17

Higher magnification reveals the presence of both endometrial glands and stroma.