Uterus Pathology Flashcards
What are the 5 types of endometrial pathology in the uterus?
Endometriosis Adenomyosis Benign endometrial polyps Endometrial hyperplasia (typical/atypical) Endometrial malignancy
What are the 3 types of endometrial malignancy?
Endometrial adenocarcinoma
Endometrial stromal tumour
Malignant mixed Mullerian tumour (MMMT)
What are the 2 types of myometrial pathology in the uterus?
Benign leiomyomas (fibroids) Malignant leiomyosarcomas
What are the 3 types of gestational pathology in the uterus?
Partial moles
Complete moles
Chorioncarcinoma
List the 2 layers of the endometrium.
Which layer has 2 sublayers? What are they?
Stratum basalis
Stratum functionalis
Stratum functionalis:
a. Stratum spongiosum
b. Stratum compactum
Briefly outline the normal uterine cycle of menstruation. Consider the 3 phases:
a) Proliferative phase (2)
b) Secretory phase (4)
c) Menstruation (3)
PROLIFERATIVE PHASE
- Epithelium: secretory columnar
- Endometrial cells proliferate extensively
SECRETORY PHASE
- Uterine glands become more spiral
- Uterine glands become bigger
- Uterine glands are filled with an eosinophilic secretion
- Endometrium thickens
MENSTRUATION
- Spiral arteries constrict, making the stratum functionalis ischaemic and necrotic
- Spiral arteries relax again - blood gushes out under high pressure, which flushes away necrotic functional layer
- Basal layer is supplied by straight arteries, so the basal layer remains & regenerates functional layer
Which problems in the uterus are associated with excess oestrogen? (3)
Overstimulation of endometrium
Endometrial hyperplasia
Endometrial adenocarcinoma
List some causes of excess oestrogen. Consider:
a) Endogenous oestrogen excess (4)
b) Exogenous oestrogen excess (2)
ENDOGENOUS OESTROGEN: Obesity (fat contains aromatase) Polycystic ovarian disease Oestrogen-secreting ovarian tumours Longer ovulation lifespan
EXOGENOUS OESTROGEN:
Tamoxifen
Older forms of HRT
List 7 common sites of endometriosis.
Ovaries (endometrioma) Uterine ligaments Pouch of Douglas Pelvic peritoneum Appendix Scars Colon
Describe the clinical features of endometriosis. (4)
What are the complications? (2)
Dysmenorrhoea
Pelvic pain
Haemorrhage during menstruation
Blood-filled cysts after menstrual cycle
COMPLICATIONS:
Infertility
Increased risk of malignancy
What is endometriosis caused by? (3)
Retrograde menstruation through fallopian tubes
Mullerian metaplasia of coelomic mesothelium
Spread of endometrial tissue via blood/lymphatics
What is adenomyosis?
A condition in which the endometrium herniates into the myometrium
List some clinical features of adenomyosis. (4)
What is the main complication of adenomyosis? (1)
Dysmenorrhoea
Severe menstrual cramps
Lower abdominal pressure
Heavy periods
COMPLICATIONS:
Infertility
List some clinical features of benign endometrial polyps. (5)
Irregular menstrual bleeding Bleeding between periods Heavy periods Vaginal bleeding after menopause Infertility
Define the 2 types of endometrial hyperplasia.
TYPICAL HYPERPLASIA
Def.: “endometrial hyperplasia with normal nuclear features”
ATYPICAL HYPERPLASIA
Def. “endometrial hyperplasia with abnormal nuclear features, causing an increased risk of carcinoma development”
What are the 2 types of typical endometrial hyperplasia?
SIMPLE HYPERPLASIA:
Increased number of uterine glands
Increased complexity of uterine glands
Slight crowding of uterine glands
COMPLEX HYPERPLASIA:
Crowded uterine glands
List 7 risk factors for endometrial adenocarcinoma.
Obesity Nulliparity Early menarche, late menopause Diabetes Family history Middle age Tamoxifen use
Describe the staging of endometrial carcinoma.
HINT: there are 4 stages.
Stage 1: confined to uterus
1A - no/inner half of myometrium involved
1B - outer half of myometrium involved
Stage 2: confined to uterus; cervical stromal involvement
Stage 3: local/regional spread
3A - serosal surface, uterine adnexae
3B - vagina, parametrium
3C - pelvic nodes, para-aortic lymph nodes
Stage 4: spread to bladder/bowel mucosa; distant metastases
4A - invasion of bladder, bowel
4B - distant metastases
List 3 other pathological features of endometrial carcinoma, other than staging.
Grading (1, 2 or 3)
Lymphovascular space invasion (LVSI)
Positive peritoneal washings (i.e. tumour cells in peritoneal cavity)
What is the treatment of endometrial carcinoma? Consider:
a) Normal endometrial carcinoma (3)
b) High risk endometrial carcinoma (4)
NORMAL ENDOMETRIAL CARCINOMA:
Hysterectomy
Salpingo-oopherectomy
Peritoneal cavity washings
HIGH RISK ENDOMETRIAL CARCINOMA: All of above Lymphadenectomy Radiotherapy Chemotherapy
What is a malignant mixed Mullerian tumour (MMMT)?
“A poorly differentiated metaplastic endometrioid or serous adenocarcinoma; more often endometrial, with a poor prognosis”
What investigations would you do for endometrial adenocarcinomas? (4)
Vaginal exam Endometrial biopsy Transvaginal ultrasound (shows thickened endometrium) Hysteroscopy (shows endometrium)
What are leiomyomas?
What are they caused by?
Benign tumours of the smooth muscle cells in the myometrium (also called fibroids)
CAUSED BY:
Hormones, esp. high oestrogen levels
List the clinical features of leiomyomas. (4)
Describe their gross appearance. (2)
Often asymptomatic
Dysmenorrhoea
Uterine enlargement
Pain
GROSS APPEARANCE:
Well-circumscribed, white nodule
Whorled, “watered silk” appearance when cut
How are leiomyomas treated?
Hormone suppression
Hysterectomy (only if very big)
What are leiomyosarcomas?
Malignant tumours of the smooth muscle cells in the myometrium
List the clinical features of leiomyosarcomas. (6)
Softer masses Poorly circumscribed tumours Haemorrhage Necrosis Vascular invasion Metastasis to lungs
What is a partial mole?
A pregnancy in which the embryo has a 69XXY chromosome
Non-viable foetus may be present
What causes a partial mole? (2)
Endoreduplication (replication of genome after fertilisation without cell division)
Dispermic fertilisation
What is a complete mole?
A pregnancy in which the embryo has either a 46XX or 46XY genome, but the chorionic villi are swollen and the placenta develops into an abnormal mass of cysts
No foetus develops
What causes a complete mole? (1)
1 sperm fertilises an empty egg
What are the consequences of partial and complete moles? (2)
Persistent trophoblastic disease (10-15%)
Chorioncarcinoma (2%)
What is a molar pregnancy?
Condition in which there are swollen chorionic villi, but no foetus
What is a choriocarcinoma?
Malignant tumour of the chorion during pregnancy
Describe the 2 types of choriocarcinoma. For each, consider:
a) Origin of tumour cells
b) Prognosis
GESTATIONAL CHORIONCARCINOMA
Origin: foetus
Prognosis: better (more sensitive to chemo)
NON-GESTATIONAL CHORIONCARCINOMA
Origin: ovary/tests
Prognosis: much worse
Describe the treatment of choriocarcinoma. (2)
Chemotherapy
hCG monitoring
List 3 common locations of leiomyomas/fibroids.
Subserosal (outside myometrium)
Intramural (middle of myometrium)
Submucosal (near endometrium)
Sometimes benign leiomyomas/fibroids can mimic malignant leiomyosarcomas. It can then be quite difficult to tell them apart histologically.
Which 2 features always suggest that it is a fibroid, NOT a malignant leiomyosarcoma?
No mitoses
No necrosis
