this lecture was the 2nd half of the uterine pathology series and focused on uterine neoplasms. the first and most common type are leiomyomas, also known as uterine fibroids. leiomyomas are the most common neoplasms in women and can have multiple manifestations within the uterine wall and yet still be benign and asymptomatic. they are almost always found within the myometrium, appear round, discrete, gray white with smooth muscle "whorling" patterns. histologically, muscle cells appear uniform and have oval nuclei, and there are no mitotic figures present. leiomyomas have a few rare variants, such as benign metastasizing leiomyoma (metastasis via the vascular system, commonly to the lung) and disseminated peritoneal leiomyomatosis (multiple nodules in the peritoneal cavity). clinically, it can present as abnormal bleeding, sudden pain, frequent urination, and decreased fertility.
leiomyosarcomas are a rare malignant type of uterine tumor that generally occurs in the myometrium or the endometrial layer undergoing smooth muscle differentiation. they have two common morphologies: a bulky fleshy mass that invades the uterine wall, or a polypoid mass that projects into the uterine lumen. histologically, they can be distinguished from leiomyomas by the mitotic index and degree of necrosis and atypia.
endometrial carcinoma accounts for 7% of all invasive cancer in women and can manifest either as polypoid masses or diffuse tumors over the entire surface of the endometrium. there are two relatively distinct etiological pathways, the first which has a more favorable prognosis and is associated with prolonged estrogen stimulation and endometrial hyperplasia. it is also characterized by well differentiated cells that mimic normal endometrial glands. the second pathway has much less differentiated cells, a greater capacity to invade neighboring structures, and a poorer prognosis.
adenocarcinoma is another type of endometrial tumor that presents with vaginal bleeding with leukorrhea, enlarged uterus, and abnormal cells on pap smear. 80% of cases are stage 1, meaning confined to the corpus of the uterus. a rare variant is the papillary serous / clear cell adenocarcinoma. if adenocarcinoma also involves malignant differentiation of the stromal layer, it is categorized as carcinosarcoma. malignant stromal differentiation also occurs in adenosarcoma, producing large polypoid masses that are managed with oophorectomy.
questions
leiomyomas...
1. what is another name for leiomyomas and how common are they?
2. what is the average number of tumors that a woman with leiomyomas would have?
3. leiomyomas are almost always found...
4. what is the gross morphological appearance of leiomyomas?
5. what is the histological morphology of leiomyomas?
6. what is "benign metastasizing leiomyoma"?
7. what is "disseminated peritoneal leiomyomatosis"?
8. what is the clinical presentation of a patient with leiomyoma?
9. how common is malignancy of leiomyomas?
leiomyosarcomas...
10. leiomyosarcomas arise from...
11. when do leiomyosarcomas commonly occur?
12. what are the two patterns of morphology seen in leiomyosarcomas?
13. how is a leiomyosarcoma differentiated from a leiomyoma histologically?
carcinoma...
14. what percentage of invasive cancers for women does endometrial carcinoma account for?
15. what are some risk factors for endometrial carcinoma?
16. what is the "first type" of pathogenesis of endometrial carcinoma associated with?
17. describe the characteristics of the first pathogenesis type.
18. describe the level of differentiation and prognosis of the second type.
19. what is the gross morphology of endometrial carcinoma?
classification systems...
20. what is FIGO?
21. what are the characteristics of grade 1 FIGO?
22. what are the characteristics of grade 2 FIGO?
23. what are the characteristics of grade 3 FIGO?
24. which structures are involved in stage 1 endometrial adenocarcinoma?
25. which structures are involved in stage 2 endometrial adenocarcinoma?
26. which structures are involved in stage 3 endometrial adenocarcinoma?
endometrial adenocarcinoma...
27. how does endometrial adenocarcinoma present clinically?
29. diagnosis of endometrial adenocarcinoma is made by...
30. what stage is most endometrial adenocarcinoma in the US?
31. what are some rare variants of endometrial adenocarcinoma?
stromal differentiation tumors...
32. what are carcinosarcomas?
33. what does the stroma differentiate into in carcinosarcomas?
34. what type of differentiation has the worse prognosis in carcinosarcomas?
35. what is the prognosis for carcinosarcomas?
36. what are adenosarcomas?
37. when do adenosarcomas typically occur?
38. how are adenosarcomas typically managed and why?
answers
1. uterine fibroids, the most common neoplasms in women.
2. 6.5.
3. in the myometrium of the corpus of the uterus.
4. discrete, round, gray-white with whorled pattern of smooth muscle bundles.
5. uniform muscle cell size with oval nuclei, no mitotic figures.
6. a rare variant of leiomyoma which involves metastasis of tumor, most commonly to lung.
7. a rare variant of leiomyoma which involves multiple small nodules on the peritoneum.
8. abnormal bleeding
urinary frequency
sudden pain
impaired fertility
[leo bleeding urine sudden fertility] [leo's fertility suddenly stopped when he bled urine]
9. very rare.
10. myometrium or endometrial stroma undergoing smooth muscle differentiation.
11. 40-60yo.
12. bulky fleshy masses that invade the uterine wall and polypoid masses that project into lumen. [fleshy walls and polypy lumen]
13. by mitotic index, necrosis, and degree of atypia.
14. 7%.
15. obesity, hypertension, diabetes, infertility, tamoxifen. [ohdit] [ditoh]
16. prolonged estrogen stimulation and endometrial hyperplasia.
17. tend to be well differentiated, mimics normal endometrial glands, and has a more favorable prognosis.
18. poorly differentiated and poor prognosis.
19. either a polypoid tumor or diffuse tumor that involves entire surface of endometrium.
20. a 3 step grading system for endometroid tumors.
21. moderate differentiation, easily identified glandular patterns.
22. poorly differentiated, well formed glands mixed with malignant cells.
23. solid sheets of malignant cells, barely identifiable glands, increased atypia and mitotic activity.
24. confined to corpus uteri.
25. involves corpus and cervix.
26. outside uterus but not involving pelvis.
27. extends beyond pelvis, or bladder / rectum.
28. vaginal bleeding with leukorrhea, uterine enlargement, abnormal cells on pap.
29. curettage (EMB) and histological exam.
30. 80% stage 1.
31. papillary serous and clear cell with positive or negative peritoneal and adnexal histology.
32. adenocarcinomas with malignant stromal differentiation.
33. mesoderm components- muscle, cartilage, osteoid.
34. serous differentiation.
35. highly malignant, 5 year survival is less than 30%.
36. large polypoid malignancies of the endometrial stroma.
37. 4th or 5th decade.
38. oopherectomy, because they are estrogen sensitive.
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