Uterine malignancy

Question 1

Causes of DUB?

Answer 1

Endometrial polyps 
Endometrial hyperplasia 
(simpla/complex/atypical)

Question 2

Endometrial hyperplasia 
-presentation?
-describe the appearance of simple, complex and atypical hyperplasia in terms of:
Distribution
Component
Glands
Cytology

Answer 2

-abnormal vaginal bleeding (DUB, PMB)

-Simple 
Distribution: general
Component: glands and stroma
Glands: dilated not crowded
Cytology: normal

Complex
Distribution: focal
Component: glands
Glands: crowded
Cytology: normal

Atypical 
Distribution:focal
Component: glands
Glands: crowded
Cytology: atypical

Question 3

Endometrial carcinoma

• age group?
• 2 main types?
• presentation?
• spread?
• risk factors? (2)

Answer 3

-50-60 yrs, if young then consider PCOS or lynch syndrome

-endometrioid carcinoma: precursor is atypical hyperplasia
Serous carcinoma: precursor serous intraepithelial carcinoma

-abnormal bleeding

• directly into myometrium and cervix
  also lymphatic and haematogenous

-Obesity
Lynch syndrome

Question 4

explain the pathogenesis of the 2 main types?
-endometrioid (and mucinous) (2)
+mutations involved?
associated with? (2)

-serous (and clear cell) (3)
+precursor lesion?
spread?
treatment?

Answer 4

-type 1 tumours 
related to unopposed oestrogen 
associated with atypical hyperplasia as precursor 
PTEN, KRAS, PIK3CA
Micro satellite instability
HNPPC

-type 2 tumours
not associated with unopposed oestrogen
affect elderly post menopausal women
TP53 often mutated
serous endometrial intraepithelial carcinoma
along fallopian tube mucosa and peritoneal surface
more extensive surgery and adjuvant chemo

Question 5

Wy is obesity a risk factor?

Answer 5

adipocytes express aromatase that converts ovarian androgens into eostrogens which induce endometrial proliferation
sex hormone binding globulins are lower in obese women and the level of unbound biologically active hormone is higher
there is increased free insulin and this has a proliferative effect on the endometrium

Question 6

Lynch syndrome

• HNPCC?
• high risk of what?
• inheritance?
• associated with what?

Answer 6

• Hereditary non-polyposis colorectal cancer
• colorectal cancer, endometrial cancer and ovarian cancer.
• Autosomal dominant
• microsatellite instability

Question 7

Staging & grading endometrial carcinoma

• how are they graded?
• Describe stages I-IV? (8)

Answer 7

-endometrioid carcinoma graded by architecture:
Grade 1: 5% or less solid growth
Grade 2: 6-50% solid growth
Grade 3: >50% solid growth

serous and clear cell not graded formally

-Stage I: Tumour confined to the uterus
IA: no or < 50% myometrial invasion
IB: Invasion equal to or > 50% of myometrium

II: Tumour invades cervical stroma

III: Local and or regional tumour spread
IIIA: Tumour invades serosa of uterus and/or annexe
IIIB: Vaginal and/or parametrial involvement
IIIC: Metastases to pelvic and/or para-aortic lymph nodes

IV: Tumour invades bladder and or bowel mucosa (IVA) and/or distant metastases (IVB)

Question 8

Other endometrial tumours:
-where does an Endometrial stromal sarcoma arise from?
where does it infiltrate?
presentation?
-where does a carcinosarcoma arise from?
components?

Answer 8

-endometrial stroma
can be low or high grade
often infiltrates lymphovascular space
as DUB or lung mets

-mixed, malignant epithelial and stromal elements
Heterologous elements commonly seen in about 50% cases (rhabdomyosarcoma, chrondrosarcoma, osteosarcoma)

Question 9

Give 2 abnormalities of the myometrium?

Answer 9

Leiomyoma (fibroid)

Leiomyosarcoma (malignant smooth muscle tumour)