Uterine Malignancy Flashcards
what can cause disordered uterine bleeding?
endometrial polyps endometral hyperplasia (simple/complex/atypical)
what are the main things to look for on endometrial biopsy?
malignancy
inflammation
presence/absence of hyperplasia
what can cause endometrial hyperplasia?
possibly persistent oestrogen stimulation
what categories are used to describe hyperplasia?
distribution
component
glands
cytology
features of simple hyperplasia?
general distribution
component = glands and stroma
glands = dilated, not crowded
cytology = normal
features of complex hyperplasia?
focal distribution
component = glands only
glands = crowded, not round
cytology = normal
features of atypical hyperplasia?
focal distribution
component = glands only
glands = more crowded, irregular in shape
cytology = atypical
what change in glands is classed as malignancy?
once the glands start to fuse
peak age for endometrial cancer?
50-60 yrs
uncommon under 40
what can pedispose to endometrial carcinoma in young women?
PCOS
lynch syndrome
2 main groups of endometrial carcinoma with different precursor lesions?
endoemtrioid carcinoma (precursor = atypical hyperplasia) serous carcinoma (precursor = serous intra-epithelial carcinoma)
how does endometrial carcinoma generally present?
abnormal bleeding
- post menopausal
macroscopic features of endometrial carcinoma?
large uterus
polypoid
microscopic features of endometrial carcinoma?
most are adenocarcinomas
most are well differentiated
how might endometrial carcinoma spread?
directly into myometrium and cervix
lymphatic
haematogenous
staging via direct spread?
into inner half of myometrium = stage 1A
into outer half of myometrium = 1B
into cervix = stage 2
what mutation is typically present in serous (and clear cell) endometrial carcinoma?
P53
type 1 endometrial carcinoma?
endometroid (and mucinous)
- 80% of cancers
related to unopposed oestrogen and associated with atypical hyperpalsia
type 2 endometrial carcinomas?
serous (and clear cell)
- not associated with unopposed oestrogen and affect elderly post-menopausal women
what is type 1 endometrial carcinoma associated with?
endometrioid and mucinous phenotypes
PTEN, KRAS and PIK3CA mutations
atypical hyperplasia as precursor lesion
microsatelite instablity (lynch syndrome)
name a large risk factor for endometrial cancer and why?
obesity
associated with the endocrine and inflammatory effects of adipose tissue
how does obesity increase risk of endometrial cancer?
adipocytes express aromatase that converts ovarian androgens into oestrogens which induce endometrial proliferation
sex hormone-binding globulin levels are lower in obesity therefore the level of unbound biologically active hormone is lower
lower level of insulin-binding globulins and free insulin levels are elevated (insulin and IGF exert proliferative effect on endometrium)
does weight loss affect endometrial cancer risk?
yes
reduces it
what is lynch syndrome?
cancer predisposition syndrome (AKA hereditary non-polyposis colorectal cancer)
causes high risk of colorectal, endometrial and ovarian cancer
what causes lynch syndrome?
AD inheritance of defective DNA mismatch repair gene
features of lynch syndrome tumours?
can be identified via immunohistochemistry staining of tumour for mismatch repair proteins
tumours show microsatellite instability (MSI) - a characteristic of defective mismatch repair
how do type 2 endometrial carcinomas develop?
precursor leison = serous endometrial intraepithelial carcinoma
this spreads along fallopian tube mucosa and peritoneal surfaces so can present with extra-uterine disease
how are type 2 endometrial carcinomas managed generally?
extensive surgery and adjuvant chemo/radiotherapy
histology features of serous?
jaggy glands
inflammation
histology of clear cell?
hobnail changes
general prognosis of endometrial carcinoma?
depends on stage but generally good
serous invades peritoneal cavity early
staging of endometrial carcinoma?
depends on histology and depth of invasion
- 1A = none or <50% myometrial invasion
- 1B = 50+% invasion of myometrium
- 2 = tumour invades cervical stroma
- 3 = local/regional tumour spread
- 3A = tumour invades serosa of uterus and/or adnexae
- 3B = vagina and/or parametrial involvement
3C = metastases to pelvic and/or para-aortic lymph nodes
- 4A = invades bladder and/or bowel mucosa
- 4B = distant metastases
grading of endometrial carcinoma?
grade 1 = 5% or less solid growth, well differentiated
grade 2 = 6-50% solid growth
grade 3 = .50% solid growth, poorly differentiated
(serous and clear cell generally not graded)
what other endometrial tumours can occur?
endometrial stromal sarcoma (arises from endometrial stroma)
carcinosarcoma (mixed with malignant epithelial and stromal elements)
used to be called malignant mixed mullerian tumour
describe endometrial stromal sarcoma?
can be low or high grade
cells resemble endometrial stroma
infiltrate myometrium and often the lymphovascular spaces
typically presents with abnormal uterine bleeding but initial presentation may be as a metastases
describe carcinosarcoma?
rare (<5%)
high grade carcinomatous and sarcomatous elements
heterologous elements commonly seen in 50% of cases (rhabdomyosarcoma, chondrosarcoma, osteosarcoma)
- presence of rhabdomyosarcoma has worst prognosis
generally bad outcome
what is a leiomyoma and how does is present?
benign smooth muscle tumour (fibroid)
associated with menorrhagia and infertility
what is a leiomyosarcoma?
malignant smooth muscle tumour commonly displaying a spindle cell morphology
most common uterine sarcoma
features of leiomyosarcoma?
usually in women >50
causes vaginal bleeding, palpable pelvic mass and pelvic pain
