Endometrium Pathology Flashcards
what parts of the female repro system lie within the pelvic cavity?
ovaries
uterine tubes
uterus
superior part of vagina
what parts of the female repro system lie within perineum?
inferior part of vagina perineal muscles bartholins glands clitoris labia
what are the 3 layers of the uterus?
perimetrium
myometrium
endometrium
what holds the uterus in place?
number of ligaments
endopelvic fascia
muscles of pelvic floor (eg levator ani)
what does broad ligament do?
hold uterus in midline position
(sheet covering ovary)
fallopian tube also contained within upper part of ligament
what is the round ligament?
embryological remnant
band sitting at top of broad ligament
4 divisions of fallopian tube? (in order from uterus end to open end)
isthmus
ampulla
infundibulum
fimbriae
where does fimbriae open into?
peritoneal cavity
what does the cervix do?
holds the walls of the vagina apart forming a fornix
what are the 4 parts of the fornix?
anterior
posterior
two lateral sides
where do most uterine malignancies arise from?
endometrium
most common type of uterine cancer?
adenocarcinoma
what increases risk of endometrial cancer?
usually post-menopausal anything that increases oestrogen level - PCOS - late menopause - nulliparity - obesity - unopposed oestrogen HRT - tamoxifen - carbohydrate intolerance - oestrogen secreting tumours
why does obesity increase oestrogen levels?
adipose tissue converts androgens into oestrogens
types of oestrogen secreting tumours?
granulosa cell tumour
theca cell tumour
how does oral contraceptive pill change endometrial cancer risk?
decreased risk
common presenting symptoms of endometrial cancer?
abnormal uterine bleeding (main symptom)
less commonly can have abnormal vaginal discharge
pain is rare in early stages so can indicate metastases if present
where might endometrial cancer spread?
usually direct spread and can involve myometrium, cervix, fallopian tubes and local tissue
investigations of suspected endometrial cancer?
trans-vaginal US = first line
endometrial biopsy
hysteroscopy
dilation and curettage (done alongside hysteroscopy)
how is TV US used in endometrial caner?
measures endometrial thickness
- normal findings = smooth, regular endometrium <4mm
what is dilation and curettage?
cervix is dilated to allow a curette to scrape the endometrium which can then be sent for histological analysis
done under GA
usually combined with hysteroscopy
types of endometrial pathology?
endometrial hyperplasia
endometrial carcinoma
endometrial sarcoma
carcinosarcoma
what is endometrial hyperplasia?
increased number of endometrial cell leading to thick endometrium
can be simple, complex or atypical
can be due to persistent oestrogen stimulation
simple hyperplasia without atypia is usually seen in anovulatory teenagers and peri-menopausal women
atypical hyperplasia can progress to endometrial carcinoma
how does endometrial hyperplasia present?
abnormal bleeding
how is endometrial hyperplasia diagnosed?
biopsy showing increase in gland:stroma ratio
how is endometrial hyperplasia managed?
progestrogens in young women/premenopausal
- mirena IUD
hysterectomy recommended in atypical hyperplasia
who does endometrial carcinoma usually affect and what type is most common?
peaks in age 50-60
usually adenocarcinoma
macroscopic features of endometrial carcinoma?
large uterus
polypoid
histological appearence of endometrial carcinoma?
varies purely glandular areas of squamous differentiation papillary clear cell pattern
how does endometrial carcinoma usually spread?
usually direct spread into the myometrium and cervix
can also have haematological or lymphatic spread
what are the 2 types of endometrial carcinoma?
type 1 (endometrioid) = most common, occurs shortly after menopause type 2 = (serous and clear cell), more aggressive with worse prognosis, occurs in older women
features of type 1 (endometrioid) endometrial carcinoma?
oestrogen dependent
usually diagnosed at early stage
precursor lesion = atypical hyperplasia
what genetic changes can increase risk of type 1 endometrial carcinoma?
PTEN
KRAS
PIK3CA
microsatellite instability (lynch syndrome)
how is type 2 endometrial carcinoma different to type 1?
more aggressive and rapid
not associated with unopposed oestrogen
precursor lesion = serous endometrial intraepithelial carcinoma
how does type 2 endometrial carcinoma spread?
along fallopian tube mucosa and peritoneal surfaces so may present with extra-uterine disease
what genetic mutation can cause type 2 endometrial carcinoma?
TP53 mutation
type 2 endometrial carcinoma histology?
characterised by complex papillary and/or glandular architecture with diffuse, marked nuclear pleomorphism
how is type 2 endometrial carcinoma managed?
usually requires more extensive surgery then type 1
adjuvant chemo/radiotherapy used more frequently than in type 1
describe endometrial sarcoma?
rare
locally aggressive and metastasizes early (lung or ovary are common)
poor prognosis
where does endometrial sarcoma arise from?
endometrial stroma
what is an endometrial carcinosarcoma?
mixed tumours with malignant epithelial and stromal elements
rare (<5% of endometrial tumours)
poor outcome
general prognosis of endometrial cancer?
good
how is endometrial cancer staged?
FIGO staging
1A = <1/2 myometrial invasion
1B = >1/2 myometrial invasion
2 = cervical stroma invasion but not beyond uterus
3A = tumour invades serosa or adnexa
3B = vaginal and/or parametrial involvement
3C1 = pelvic node involvement
3C2 = para-aortic involvement
4A = tumour invasion of bladder and/or bowel mucosa
4B = distant metastases including abdominal metastases and/or inguinal lymph nodes
how is endometrial cancer graded?
grade 1 = 5% or less solid growth
grade 2 = 6-50% solid growth
grade 3 = >50% solid growth
how is endometrial cancer treated in most cases?
surgical (hysterectomy + bilateral salpingo-oophrectomy, lymphadenectomy sometimes done
radiotherapy may be used as an adjuvant to prevent recurrence
chemotherapy if widespread disease
how is endometrial cancer managed in patients who are not suitable for surgery?
radiotherapy or high dose progestogens
where does endometrial cancer recurrence usually occur and how is this managed?
most cases dont recur
vault of vagina is the commonest site of recurrence
radiotherapy used in isolated vault recurrence if the patient has never had radiotherapy before
if theyve had previous radiotherapy then hormonal therapy (progestogens) + chemotherapy is used
2 main pathologies of myometrium?
leiomyoma (fibroid)
leiomyosarcoma
(both are types of smooth muscle tumours)
how do fibroids present?
menorrhagia
infertility
how do leiomyosarcomas present?
women >50
abnormal vaginal bleeding
palpable pelvic mass and pelvic pain
