Difference between revisions of "Uterine tumours"

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=Common benign=
=Common benign=
==Uterine leiomyoma==
==Uterine leiomyoma==
{{Main|Leiomyoma}}
*Often called ''fibroids''.
*Often called ''fibroids''.
*''Fibroid uterus'' redirects here.
{{Main|Uterine leiomyoma}}
===General===
*Extremely common... 40% of women by age 40.
*Benign.
**Can be a cause of [[abnormal uterine bleeding]] (commonly abbreviated ''AUB'').
*Large & multiple associated with infertility.
*May be treated medically with a selective progesterone receptor modulator, e.g. ''ulipristal'' (''Fibristal'').<ref name=pmid24712276>{{Cite journal  | last1 = Delev | first1 = DP. | title = Ulipristal acetate--a review of the new therapeutic indications and future prospects. | journal = Folia Med (Plovdiv) | volume = 55 | issue = 3-4 | pages = 5-10 | month =  | year =  | doi =  | PMID = 24712276 }}</ref>
 
===Gross===
Feature:
* Sharply circumscribed.
* Gray-white.
* Whorled appearance.
 
Factor that raise concern for leiomyosarcoma:
* Haemorrhage.
* Cystic degeneration.
* [[Necrosis]].
 
===Microscopic===
Features:
* Spindle cells arranged in fascicles.
** Fascicular appearance: adjacent groups of cells have their long axis perpendicular to one another; looks somewhat like a braided hair that was cut.
* Whorled arrangement of cells.
 
Negatives:
* Necrosis (low power) - suggestive of leiomyosarcoma.
* Hypercellularity.
* Nuclear atypia seen at low power.
* Few mitoses.
 
Images:
*[http://commons.wikimedia.org/w/index.php?title=File:Cutaneous_leiomyosarcoma_-_a_-_intermed_mag.jpg Fascicular pattern - leiomyosarcoma (WC)].
 
====Variants====
*Lipoleiomyoma - with adipose tissue.
**Image: [http://commons.wikimedia.org/wiki/File:Lipoleiomyoma1.jpg Lipoleiomyoma - low mag. (WC)].
*Hypercellular leiomyoma - hypercellularity associated with more mutations.<ref name=pmid_none>{{Cite journal  | last1 = Pandis | first1 = N. | last2 = Heim | first2 = S. | last3 = Willén | first3 = H. | last4 = Bardi | first4 = G. | last5 = Flodérus | first5 = U-M. | last6 = Mandahl | first6 = N. | last7 = Mitelman | first7 = F. | title = Histologic—cytogenetic correlations in uterine leiomyomas. | journal = International Journal of Gynecological Cancer | volume = 1 | issue = 4 | pages = 163-68 | month = Jan | year = 1991 | doi = | PMID =  |url=http://www3.interscience.wiley.com/journal/119360394/abstract }}</ref>
*Atypical leiomyoma (AKA ''symplastic leiomyoma'') - leiomyoma with nuclear atypia.
**Image: [http://commons.wikimedia.org/wiki/File:Atypical_leiomyoma_intermed_mag.jpg Atypical leiomyoma (WC)].
*Benign metastasizing leiomyoma.<ref name=pmid16357844>{{Cite journal  | last1 = Patton | first1 = KT. | last2 = Cheng | first2 = L. | last3 = Papavero | first3 = V. | last4 = Blum | first4 = MG. | last5 = Yeldandi | first5 = AV. | last6 = Adley | first6 = BP. | last7 = Luan | first7 = C. | last8 = Diaz | first8 = LK. | last9 = Hui | first9 = P. | title = Benign metastasizing leiomyoma: clonality, telomere length and clinicopathologic analysis. | journal = Mod Pathol | volume = 19 | issue = 1 | pages = 130-40 | month = Jan | year = 2006 | doi = 10.1038/modpathol.3800504 | PMID = 16357844 |url=http://www.nature.com/modpathol/journal/v19/n1/full/3800504a.html}}</ref>
**This is just what it sounds like.  Some believe these are low grade [[leiomyosarcoma]]s.
 
===IHC===
Work-up of suspicious leiomyomas:<ref>STC. 25 February 2009.</ref>
*CD10 +ve.<ref name=pmid14751141>{{Cite journal  | last1 = Zhu | first1 = XQ. | last2 = Shi | first2 = YF. | last3 = Cheng | first3 = XD. | last4 = Zhao | first4 = CL. | last5 = Wu | first5 = YZ. | title = Immunohistochemical markers in differential diagnosis of endometrial stromal sarcoma and cellular leiomyoma. | journal = Gynecol Oncol | volume = 92 | issue = 1 | pages = 71-9 | month = Jan | year = 2004 | doi =  | PMID = 14751141 }}</ref>
*SMA +ve.
*Desmin +ve.
*Ki-67 -ve.
 
Others:
*p16 usually -ve.<ref name=pmid18156978>{{Cite journal  | last1 = Gannon | first1 = BR. | last2 = Manduch | first2 = M. | last3 = Childs | first3 = TJ. | title = Differential Immunoreactivity of p16 in leiomyosarcomas and leiomyoma variants. | journal = Int J Gynecol Pathol | volume = 27 | issue = 1 | pages = 68-73 | month = Jan | year = 2008 | doi = 10.1097/pgp.0b013e3180ca954f | PMID = 18156978 }}</ref>
**Often +ve in leiomyosarcoma.
*H-caldesmon +ve.<ref name=pmid14751141/>
 
===Sign out===
<pre>
UTERUS WITH CERVIX, UTERINE TUBES AND LEFT OVARY, TOTAL HYSTERECTOMY, BILATERAL SALPINGECTOMY
AND LEFT OOPHRECTOMY:
- LEIOMYOMATA WITH FOCAL CALCIFICATION AND HYALINE CHANGE.
- SECRETORY PHASE ENDOMETRIUM.
- LEFT OVARY WITHIN NORMAL LIMITS.
- UTERINE TUBES WITHIN NORMAL LIMITS.
- UTERINE CERVIX WITHIN NORMAL LIMITS.
</pre>
 
====Myomectomy====
<pre>
UTERINE MASSES ("FIBROIDS"), MYOMECTOMY:
- LEIOMYOMATA.
</pre>
 
<pre>
UTERINE MASS, HYSTEROSCOPIC MYOMECTOMY:
- BENIGN SMOOTH MUSCLE FRAGMENTS COMPATIBLE WITH LEIOMYOMA.
- SECRETORY PHASE ENDOMETRIUM.
</pre>


=Uncommon benign=
=Uncommon benign=
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Images:
Images:
*[http://www.webpathology.com/image.asp?n=6&Case=572 Adenofibroma of the uterus - low mag. (webpathology.com)].
*[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496288/figure/F2/ Adenofibroma (nlm.nih.gov)].<ref>{{cite journal |authors=Chawla L, Vatsa R, Roy KK, Kumar S |title=Uterine Adenofibroma: An Unsual Cause of Nonpuerperal Uterine Inversion in Postmenopausal Female |journal=J Midlife Health |volume=8 |issue=2 |pages=95–97 |date=2017 |pmid=28706412 |pmc=5496288 |doi=10.4103/jmh.JMH_27_17 |url=}}</ref>
*[http://www.webpathology.com/image.asp?n=7&Case=572 Adenofibroma of the uterus - high mag. (webpathology.com)].


==Adenomatoid tumour==
==Adenomatoid tumour==
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==Smooth muscle tumour of uncertain malignant potential==
==Smooth muscle tumour of uncertain malignant potential==
*Abbreviated ''STUMP''.
*Abbreviated ''STUMP''.
===General===
{{Main|Smooth muscle tumour of uncertain malignant potential}}
*Like ''[[ASAP]]'' and ''[[ASCUS]]'' - a [[waffle diagnosis|waffle category]]... when one isn't sure it is a ''leiomyoma'' vs. ''leiomyosarcoma''.
*Clinical behaviour in uterus: usually benign.<ref name=pmid19417585>{{cite journal |author=Ip PP, Cheung AN, Clement PB |title=Uterine smooth muscle tumors of uncertain malignant potential (STUMP): a clinicopathologic analysis of 16 cases |journal=Am. J. Surg. Pathol. |volume=33 |issue=7 |pages=992–1005 |year=2009 |month=July |pmid=19417585 |doi=10.1097/PAS.0b013e3181a02d1c |url=}}</ref>
*Can be subclassified into four groups - as per Stanford.
*May be seen in the [[prostate gland]].<ref name=pmid21572264>{{Cite journal  | last1 = Nagar | first1 = M. | last2 = Epstein | first2 = JI. | title = Epithelial proliferations in prostatic stromal tumors of uncertain malignant potential (STUMP). | journal = Am J Surg Pathol | volume = 35 | issue = 6 | pages = 898-903 | month = Jun | year = 2011 | doi = 10.1097/PAS.0b013e318214f2f2 | PMID = 21572264 }}</ref>
 
Management:
*Long-term follow-up.<ref name=pmid19417585/>
 
===Microscopic===
Features associated with recurrence:<ref name=pmid19417585/>
*Nuclear atypia.
 
DDx:
*[[Uterine leiomyoma]].
*[[Uterine leiomyosarcoma]].
 
===IHC===
Features associated with recurrence:<ref name=pmid19417585/>
*p16 +ve.
*p53 +ve.


=Malignant=
=Malignant=
==Uterine carcinosarcoma==
==Uterine carcinosarcoma==
* [[AKA]] ''malignant mixed muellerian tumour'', abbreviated ''MMMT''.
* [[AKA]] ''malignant mixed muellerian tumour'', abbreviated ''MMMT''.
 
{{Main|Uterine carcinosarcoma}}
===General===
* Associated with previous radiation exposure.
* Metstasize as adenocarcinoma.
* Aggressive/poor prognosis;<ref name=pmid15688674>{{Cite journal  | last1 = Ivy | first1 = JJ. | last2 = Unger | first2 = JB. | title = Malignant mixed mullerian sarcomas of the uterus--the LSUHSC Shreveport experience. | journal = J La State Med Soc | volume = 156 | issue = 6 | pages = 324-6 | month =  | year =  | doi =  | PMID = 15688674 }}</ref> in one series 5 year survival ~= 30-35%.<ref name=pmid14967435>{{Cite journal  | last1 = Callister | first1 = M. | last2 = Ramondetta | first2 = LM. | last3 = Jhingran | first3 = A. | last4 = Burke | first4 = TW. | last5 = Eifel | first5 = PJ. | title = Malignant mixed Müllerian tumors of the uterus: analysis of patterns of failure, prognostic factors, and treatment outcome. | journal = Int J Radiat Oncol Biol Phys | volume = 58 | issue = 3 | pages = 786-96 | month = Mar | year = 2004 | doi = 10.1016/S0360-3016(03)01561-X | PMID = 14967435 }}</ref>
*Considered to be a poorly differentiated endometrial carcinoma with metaplastic changes.<ref name=pmid19853898>{{Cite journal  | last1 = D'Angelo | first1 = E. | last2 = Prat | first2 = J. | title = Uterine sarcomas: a review. | journal = Gynecol Oncol | volume = 116 | issue = 1 | pages = 131-9 | month = Jan | year = 2010 | doi = 10.1016/j.ygyno.2009.09.023 | PMID = 19853898 }}</ref>
*Case reports of MMMT in [[ovary]] and [[fallopian tube]].
 
===Microscopic===
Features:<ref name=Ref_WMSP428>{{Ref WMSP|428}}</ref>
*Biphasic tumour:
*#Malignant glandular component (adenocarcinoma).
*#Malignant stromal component (one of the following):
*#*Homologous type (tissue native to uterus):
*#*#Smooth muscle ([[leiomyosarcoma]]).
*#*#Fibrous tissue ([[fibrosarcoma]]).
*#*Heterologous type (tissue not native to the uterus):
*#*#Skeletal muscle ([[rhabdomyosarcoma]]).
*#*#Cartilage ([[chondrosarcoma]]).
*#*#Bone ([[osteosarcoma]]).
*#*Undifferentiated sarcoma ([[pleomorphic undifferentiated sarcoma]]).
 
DDx:
*[[Undifferentiated endometrial sarcoma]].
*[[Adenosarcoma of the uterus]].
 
====Images====
<gallery>
Image:Carcinosarcoma_-_low_mag.jpg | MMMT - low mag. (WC)
Image:Carcinosarcoma_-_high_mag.jpg | MMMT - high mag. (WC)
Image:MalignantMixedMullerianTumor.JPG | MMMT - crappy (WC)
</gallery>
www:
*[http://path.upmc.edu/cases/case227.html MMMT - case 1 - several images (upmc.edu)].
*[http://path.upmc.edu/cases/case328.html MMMT - case 2 - several images (upmc.edu)].


==Adenosarcoma of the uterus==
==Adenosarcoma of the uterus==
*[[AKA]] ''uterine adenocarcinoma''.  
*[[AKA]] ''uterine adenosarcoma''.  
===General===
{{Main|Adenosarcoma of the uterus}}
Features:<ref name=pmid20179434>{{Cite journal  | last1 = McCluggage | first1 = WG. | title = Mullerian adenosarcoma of the female genital tract. | journal = Adv Anat Pathol | volume = 17 | issue = 2 | pages = 122-9 | month = Mar | year = 2010 | doi = 10.1097/PAP.0b013e3181cfe732 | PMID = 20179434 }}</ref>
*Uncommon.
*May prolapse through cervical os and thus present as [[cervical polyp]].
*Most commonly uterine corpus, occasionally cervix and ovary, rarely in the vagina, fallopian tube, peritoneal surfaces, intestine.
*Typically 30-40 years old.
 
Clinical:<ref name=pmid17506376>{{Cite journal  | last1 = Abu | first1 = J. | last2 = Ireland | first2 = D. | last3 = Brown | first3 = L. | title = Adenosarcoma of an endometrial polyp in a 27-year-old nulligravida: a case report. | journal = J Reprod Med | volume = 52 | issue = 4 | pages = 326-8 | month = Apr | year = 2007 | doi =  | PMID = 17506376 }}</ref>
*Most common presentations of Müllerian adenosarcoma (percentages based on series of 41 individuals<ref name=pmid9625851>{{Cite journal  | last1 = Verschraegen | first1 = CF. | last2 = Vasuratna | first2 = A. | last3 = Edwards | first3 = C. | last4 = Freedman | first4 = R. | last5 = Kudelka | first5 = AP. | last6 = Tornos | first6 = C. | last7 = Kavanagh | first7 = JJ. | title = Clinicopathologic analysis of mullerian adenosarcoma: the M.D. Anderson Cancer Center experience. | journal = Oncol Rep | volume = 5 | issue = 4 | pages = 939-44 | month =  | year =  | doi =  | PMID = 9625851 }}</ref>):
**Vaginal bleeding ~ 70%.
**Pelvic mass ~ 40%.
**Uterine polyp ~ 30%.
*Prognosis (based on series of ~500 individuals<ref name=pmid20688363>{{Cite journal  | last1 = Arend | first1 = R. | last2 = Bagaria | first2 = M. | last3 = Lewin | first3 = SN. | last4 = Sun | first4 = X. | last5 = Deutsch | first5 = I. | last6 = Burke | first6 = WM. | last7 = Herzog | first7 = TJ. | last8 = Wright | first8 = JD. | title = Long-term outcome and natural history of uterine adenosarcomas. | journal = Gynecol Oncol | volume = 119 | issue = 2 | pages = 305-8 | month = Nov | year = 2010 | doi = 10.1016/j.ygyno.2010.07.001 | PMID = 20688363 }}</ref>):
**Favourable outcome - most detected at an early stage.
***~80% five year survival for stage I tumours.
**Outcome better than [[uterine carcinosarcoma|carcinosarcoma]].
 
Treatment:
*TAH-BSO.
**Tumours are estrogen responsive.
*Chemotherapy (platin-based).<ref name=pmid9625851/>
 
===Microscopic===
Features:<ref name=Ref_PBoD1089>{{Ref PBoD|1089}}</ref><ref name=pmid20179434/>
*"Malignant stroma" - '''key feature'''.
**Stromal nuclear pleomorphism - usually low grade.
**WHO criteria: 2+ mitoses / 10 HPF -- definition suffers from [[HPFitis]].
***Mitotic rate criteria often ignored as mitotically inactive tumours metastasize.<ref name=pmid20179434/>
*Benign glands with an abnormal shape.
*"Cambium layer" = increased cellularity around the epithelial elements.<ref name=pmid20179434/><ref name=medilexicon_cambium/>
 
Notes:
*Tumour may vaguely resemble a [[phyllodes tumour]].<ref name=pmid20179434/>
*''Cambium layer'' - seen in: adenosarcoma, botryoid [[RMS]].<ref name=medilexicon_cambium>URL: [http://www.medilexicon.com/medicaldictionary.php?t=48297 http://www.medilexicon.com/medicaldictionary.php?t=48297]. Accessed on: 9 August 2011.</ref>
 
DDx:
*[[Benign endometrial polyp]].
*[[Uterine adenofibroma]].
 
====Images====
<gallery>
Image:Uterine_adenosarcoma_-_low_mag.jpg | Uterine adenosarcoma - low mag. (WC)
Image:Uterine_adenosarcoma_-_intermed_mag.jpg | Uterine adenosarcoma - intermed. mag. (WC)
Image:Uterine_adenosarcoma_-_high_mag.jpg | Uterine adenosarcoma - high mag. (WC)
</gallery>
 
===IHC===
*CD10 +ve.<ref name=pmid20179434/>
*ER +ve.
*PR +ve.


==Uterine leiomyosarcoma==
==Uterine leiomyosarcoma==

Latest revision as of 15:26, 10 January 2022

This article deals with uterine tumours, with the exception of the tumours that arise from the endometrium.

Uterine tumours are like water in the sea - very very common. Many hysterectomies are done for them. The most common are leiomyomata (AKA fibroids).

Pre-malignant endometrium and endometrial tumours are dealt with in the articles, endometrial hyperplasia and endometrial carcinoma.

Common benign

Uterine leiomyoma

  • Often called fibroids.
Main article: Uterine leiomyoma

Uncommon benign

Uterine adenofibroma

General

  • Uncommmon.
  • Benign looking lesions can reoccur.[1]
    • It has been proposed that these lesions are in fact well-differentiated adenosarcomas.[2]

Microscopic

Features:

  • Moderately demarcated lesion with:
    • Pale stroma and epithelioid/spindle cells.
    • Simple cuboidal (or columnar) epithelium with eosinophilic cytoplasm.
  • Low mitotic rate.
  • Nuclear atypia minimal.

Note:

DDx:

  • Adenosarcoma.

Images:

Adenomatoid tumour

Should not be confused with the bone tumour adamantinoma.
Main article: Adenomatoid tumour

Uncertain malignant potential

Smooth muscle tumour of uncertain malignant potential

  • Abbreviated STUMP.
Main article: Smooth muscle tumour of uncertain malignant potential

Malignant

Uterine carcinosarcoma

  • AKA malignant mixed muellerian tumour, abbreviated MMMT.
Main article: Uterine carcinosarcoma

Adenosarcoma of the uterus

  • AKA uterine adenosarcoma.
Main article: Adenosarcoma of the uterus

Uterine leiomyosarcoma

Main article: Leiomyosarcoma

General

  • Poor prognosis.
  • Do not (generally) arise from leiomyomas.
  • Often singular, i.e. one tumour; unlike leiomyomas (which are often multiple).

Gross

Features:

  • "Fleshy" appearance.
  • Necrosis.
  • Large size.
  • Often singular, i.e. one lesion; leiomyomata are often multiple.

Microscopic

Features:

  • Smooth muscle differentiation - essential.
    • Fascicular architecture.
      • Whorled look at low power.
      • Groups of spindle cells cut peripendicular to their long axis adjacent to groups of spindle cells cut in the plane of their long axis.
    • May rely on IHC - if poorly differentiated.
  • Malignant histomorphologic features - two of three required - key features:[4]
    1. Nuclear pleomorphism.
    2. Coagulative tumour cell necrosis
      • Should be patchy/multifocal.
      • Zonal necrosis is suggestive of vascular cause and may be a degenerative change.
        • Zonal necrosis may be seen in (benign) leiomyomas.
    3. Mitoses.
      • 10 mitoses/10 HPF.
      • 5 mitoses/10 HPF - if epithelioid.
      • 2 mitoses/10 HPF - if myxoid.

Note:

  • The mitotic rate seems to be a relatively weak predictor; a modest rate may be malignant and a high rate benign.[5]

DDx:

IHC

  • CD10 -ve.
  • Positive for SMC markers.
    • Desmin - present in all three types of muscle.
    • Caldesmon.
    • Smooth muscle myosin.
  • p16 +ve.[6]
    • Useful for differentiation from leiomyoma.

Endometrial stromal tumours

This grouping includes the gamut from benign to malignant.

Overview

WHO classification:[7]

  • Endometrial stromal nodule - not a tumour.
  • Endometrial stromal sarcoma (ESS), low grade.
  • Undifferentiated endometrial sarcoma (UES).

Notes:

  • Some believe in a "high grade ESS"... some don't.[8]

Endometrial stromal nodule

  • Abbreviated ESN.

General

  • Benign.

Microscopic

Features:

  • Well-circumscribed - key feature.
    • The interface of the lesion may not have more than three finger-like irregularities/projections into the surround myometrium that are >= 3 mm.[9]
      • If it does... it is an ESS.
  • No vascular invasion.

DDx:

Images:

Endometrial stromal sarcoma

  • Abbreviated ESS.
  • Previously known as low-grade endometrial stromal sarcoma.
Main article: Endometrial stromal sarcoma

Undifferentiated endometrial sarcoma

  • Abbreviated as UES.
  • Previously known as high-grade endometrial stromal sarcoma.[10]

General

Microscopic

Features:

  1. Marked nuclear atypia.
  2. Mitoses+++.
  3. Poorly differentiated - key feature
    • Looks nothing like low grade endometrial stromal sarcoma.
    • Negative for smooth muscle markers (to exclude leiomyosarcoma).

Notes:

  • Need IHC to diagnose.

DDx:

IHC

Features:[11]

  • SMA ~50% +ve.

Typically negative:[11]

  • Smooth muscle markers: desmin, h-caldesmon.
  • Skeletal muscle markers: Myf4, actin.
  • Melanoma: S100, HMB-45.
  • GIST: CD117.

Weird stuff

Trophoblastic tumours

Uterine tumour resembling an ovarian sex cord stromal tumour

  • Abbreviated UTROSCT.
Main article: Uterine tumour resembling an ovarian sex cord stromal tumour

Atypical polypoid adenomyoma of the uterus

  • Abbreviated APA.
  • AKA atypical polypoid adenomyoma.
Main article: Atypical polypoid adenomyoma of the uterus

See also

References

  1. ↑ Seltzer, VL.; Levine, A.; Spiegel, G.; Rosenfeld, D.; Coffey, EL. (Jun 1990). "Adenofibroma of the uterus: multiple recurrences following wide local excision.". Gynecol Oncol 37 (3): 427-31. PMID 2351327.
  2. ↑ Gallardo, A.; Prat, J. (Feb 2009). "Mullerian adenosarcoma: a clinicopathologic and immunohistochemical study of 55 cases challenging the existence of adenofibroma.". Am J Surg Pathol 33 (2): 278-88. doi:10.1097/PAS.0b013e318181a80d. PMID 18941402.
  3. ↑ Chawla L, Vatsa R, Roy KK, Kumar S (2017). "Uterine Adenofibroma: An Unsual Cause of Nonpuerperal Uterine Inversion in Postmenopausal Female". J Midlife Health 8 (2): 95–97. doi:10.4103/jmh.JMH_27_17. PMC 5496288. PMID 28706412. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5496288/.
  4. ↑ Ip, PP.; Cheung, AN. (Dec 2011). "Pathology of uterine leiomyosarcomas and smooth muscle tumours of uncertain malignant potential.". Best Pract Res Clin Obstet Gynaecol 25 (6): 691-704. doi:10.1016/j.bpobgyn.2011.07.003. PMID 21865091.
  5. ↑ Guo, L.; Liu, T.; Huang, H. (Oct 1996). "[Reappraisal of the pathological criteria for uterine leiomyosarcoma].". Zhonghua Bing Li Xue Za Zhi 25 (5): 266-9. PMID 9388868.
  6. ↑ Gannon, BR.; Manduch, M.; Childs, TJ. (Jan 2008). "Differential Immunoreactivity of p16 in leiomyosarcomas and leiomyoma variants.". Int J Gynecol Pathol 27 (1): 68-73. doi:10.1097/pgp.0b013e3180ca954f. PMID 18156978.
  7. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 426. ISBN 978-0781765275.
  8. ↑ Amant F, Vergote I, Moerman P (November 2004). "The classification of a uterine sarcoma as 'high-grade endometrial stromal sarcoma' should be abandoned". Gynecol. Oncol. 95 (2): 412–3; author reply 413. doi:10.1016/j.ygyno.2004.07.021. PMID 15491769. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WG6-4DF46J8-3&_user=1166899&_coverDate=11%2F01%2F2004&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1204975755&_rerunOrigin=google&_acct=C000051839&_version=1&_urlVersion=0&_userid=1166899&md5=d6ec1eee2941460a085d1dac6615b5a5.
  9. ↑ Baker, P.; Oliva, E. (Mar 2007). "Endometrial stromal tumours of the uterus: a practical approach using conventional morphology and ancillary techniques.". J Clin Pathol 60 (3): 235-43. doi:10.1136/jcp.2005.031203. PMID 17347285. http://jcp.bmj.com/content/60/3/235.full.
  10. ↑ Feng, W.; Malpica, A.; Skaland, I.; Gudlaugsson, E.; Robboy, SJ.; Dalen, I.; Hua, K.; Zhou, X. et al. (2013). "Can proliferation biomarkers reliably predict recurrence in world health organization 2003 defined endometrial stromal sarcoma, low grade?". PLoS One 8 (10): e75899. doi:10.1371/journal.pone.0075899. PMID 24146786.
  11. ↑ 11.0 11.1 Abeler, VM.; Nenodovic, M. (May 2011). "Diagnostic immunohistochemistry in uterine sarcomas: a study of 397 cases.". Int J Gynecol Pathol 30 (3): 236-43. doi:10.1097/PGP.0b013e318200caff. PMID 21464730.
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