Difference between revisions of "Uterine tumours"

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This article deals with '''uterine tumours''', excluding tumours that arise from the endometrium.  
This article deals with '''uterine tumours''', excluding tumours that arise from the endometrium.
Uterine tumours are like water in the sea - very very common.  Many hysterectomies are done for 'em... the most common are leiomyomata ([[AKA]] fibroids).
Uterine tumours are like water in the sea - very very common.  Many hysterectomies are done for 'em... the most common are leiomyomata ([[AKA]] fibroids).


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


=Common benign=
==Leiomyomas==
==Leiomyomas==
{{Main|Leiomyoma}}
===General===
===General===
*Often called "fibroids".
*Often called "fibroids".
Line 11: Line 14:
**Can be a cause of [[AUB]] (abnormal uterine bleeding).
**Can be a cause of [[AUB]] (abnormal uterine bleeding).
**Large & multiple associated with infertility.
**Large & multiple associated with infertility.
====Variants====
*Lipoleiomyoma - with adipose tissue.
**Image: [http://commons.wikimedia.org/wiki/File:Lipoleiomyoma1.jpg Lipoleiomyoma - low mag. (WC)].
*Hypercellular leiomyoma - hypercellularity assoc. with more mutations.<ref>[http://www3.interscience.wiley.com/journal/119360394/abstract 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)].


===Gross===
===Gross===
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* Whorled appearance.
* Whorled appearance.


Look for...
Factor that raise concern for leiomyosarcoma:
* Haemorrhage.
* Haemorrhage.
* Cystic degeneration.
* Cystic degeneration.
* [[Necrosis]].
* [[Necrosis]].


===Microscopy===
===Microscopic===
Look for ...
Features:
* Necrosis (low power) -- suggestive of leiomyosarcoma.
* 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.
* Hypercellularity.
* Nuclear atypia seen at low power.
* Few mitoses.
====Variants====
*Lipoleiomyoma - with adipose tissue.
**Image: [http://commons.wikimedia.org/wiki/File:Lipoleiomyoma1.jpg Lipoleiomyoma - low mag. (WC)].
*Hypercellular leiomyoma - hypercellularity assoc. with more mutations.<ref>[http://www3.interscience.wiley.com/journal/119360394/abstract 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)].


===IHC===
===IHC===
Line 41: Line 51:
*Desmin (+ve).
*Desmin (+ve).


=Uncommon benign=
==Adenomatoid tumour==
==Adenomatoid tumour==
===General===
===General===
Line 72: Line 83:
*CK7 +ve.<ref>LAE. 9 December 2009.</ref>
*CK7 +ve.<ref>LAE. 9 December 2009.</ref>


=Uncertain malignant potential=
==Smooth muscle tumour of uncertain malignant potential (STUMP)==
===General===
*Like ''[[ASAP]]'' and ''[[ASCUS]]'' - a [[waffle diagnosis|waffle category]]... when one isn't sure it is a ''leiomyoma'' vs. ''leiomyosarcoma''.
*Clinical behaviour: 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.
Management:
*Long-term follow-up.<ref name=pmid19417585/>
===Microscopic===
Features associated with recurrence:<ref name=pmid19417585/>
*Nuclear atypia.
===IHC===
Features associated with recurrence:<ref name=pmid19417585/>
*p16 +ve.
*p53 +ve.
=Malignant=
==Carcinosarcoma==
==Carcinosarcoma==
* AKA ''malignant mixed muellerian tumour'', abbreviated ''MMMT''.
* AKA ''malignant mixed muellerian tumour'', abbreviated ''MMMT''.
Line 97: Line 128:


==Adenosarcoma==
==Adenosarcoma==
===General===
*Uncommon.
Tx:
*TAH + BSO.
===Microscopic===
Features:<ref name=Ref_PBoD1089>{{Ref PBoD|1089}}</ref>
Features:<ref name=Ref_PBoD1089>{{Ref PBoD|1089}}</ref>
*Benign glands with an abnormal shape.
*Benign glands with an abnormal shape.
Line 102: Line 139:
DDx:  
DDx:  
*Benign polyp.
*Benign polyp.
Tx:
*TAH + BSO.


==Leiomyocarcoma==
==Leiomyocarcoma==
Line 138: Line 172:
**Smooth muscle myosin.
**Smooth muscle myosin.


==Smooth muscle tumour of uncertain malignant potential (STUMP)==
=Endometrial stromal tumours=
===General===
==Overview==
*Like ''[[ASAP]]'' and ''[[ASCUS]]'' - a [[waffle diagnosis|waffle category]]... when one isn't sure it is a ''leiomyoma'' vs. ''leiomyosarcoma''.
*Clinical behaviour: 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.
 
Management:
*Long-term follow-up.<ref name=pmid19417585/>
 
===Microscopic===
Features associated with recurrence:<ref name=pmid19417585/>
*Nuclear atypia.
 
===IHC===
Features associated with recurrence:<ref name=pmid19417585/>
*p16 +ve.
*p53 +ve.
 
==Endometrial stromal tumours==
===Overview===
WHO classification:<ref name=Ref_WMSP426>{{Ref WMSP|426}}</ref>
WHO classification:<ref name=Ref_WMSP426>{{Ref WMSP|426}}</ref>
*Endometrial stromal nodule - not a tumour.
*Endometrial stromal nodule - not a tumour.
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*[[Melanoma]].
*[[Melanoma]].


==Weird stuff==
=Weird stuff=
===Uterine tumors resembling ovarian sex cord tumours (UTROSCT)===
==Uterine tumors resembling ovarian sex cord tumours (UTROSCT)==
*Look like sex cord tumour:<ref>URL: [http://www.nature.com/modpathol/journal/v19/n1/full/3800475a.html http://www.nature.com/modpathol/journal/v19/n1/full/3800475a.html]. Accessed on: 5 August 2010.</ref>
*Look like sex cord tumour:<ref>URL: [http://www.nature.com/modpathol/journal/v19/n1/full/3800475a.html http://www.nature.com/modpathol/journal/v19/n1/full/3800475a.html]. Accessed on: 5 August 2010.</ref>
**May have: anastomosing cords, [[trabeculae]], small nests and/or tubules.
**May have: anastomosing cords, [[trabeculae]], small nests and/or tubules.


==See also==
=See also=
*[[Gynecologic pathology]].
*[[Gynecologic pathology]].
*[[Endometrial carcinoma]].
*[[Endometrial carcinoma]].
*[[Endometrial hyperplasia]].
*[[Endometrial hyperplasia]].


==References==
=References=
{{reflist|2}}
{{reflist|2}}




[[Category:Gynecologic pathology]]
[[Category:Gynecologic pathology]]

Revision as of 16:43, 2 June 2011

This article deals with uterine tumours, excluding tumours that arise from the endometrium. Uterine tumours are like water in the sea - very very common. Many hysterectomies are done for 'em... 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

Leiomyomas

Main article: Leiomyoma

General

  • Often called "fibroids".
  • Extremely common... 40% of women by age 40.
  • Benign.
    • Can be a cause of AUB (abnormal uterine bleeding).
    • Large & multiple associated with infertility.

Gross

  • 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.

Variants

IHC

Work-up of suspicious leiomyomas:[2]

  • CD10 (+ve).
  • Ki-67 (-ve).
  • SMA (+ve).
  • Desmin (+ve).

Uncommon benign

Adenomatoid tumour

General

  • Grossly mimics leiomyoma.[3]
  • Benign tumour - derived from mesothelium.

Notes:

Microscopy

Features:[4]

  • Well-circumscribed lesion; however, not encapsulated.
  • Small tubulocystic spaces lined by cytologically normal mesothelium.

Images:

DDx:

  • Lymphangioma.
  • Leiomyoma.

IHC

Features:[5]

  • Calretin +ve.
  • AE1/AE3 +ve.
  • CD31 -ve.
  • CK7 +ve.[6]

Uncertain malignant potential

Smooth muscle tumour of uncertain malignant potential (STUMP)

General

  • Like ASAP and ASCUS - a waffle category... when one isn't sure it is a leiomyoma vs. leiomyosarcoma.
  • Clinical behaviour: usually benign.[7]
  • Can be subclassified into four groups - as per Stanford.

Management:

  • Long-term follow-up.[7]

Microscopic

Features associated with recurrence:[7]

  • Nuclear atypia.

IHC

Features associated with recurrence:[7]

  • p16 +ve.
  • p53 +ve.

Malignant

Carcinosarcoma

  • AKA malignant mixed muellerian tumour, abbreviated MMMT.

General

  • Associated with previous radiation exposure.
  • Metstasize as adenocarcinoma.
  • Aggressive/poor prognosis;[8] in one series 5 year survival ~= 30-35%.[9]
  • Considered to be a poorly differentiated endometrial carcinoma with metaplastic changes.[10]
  • Case reports of MMMT in ovary and fallopian tube.

Microscopic

Features:[11]

  • Biphasic tumour:
    1. Malignant glandular component (adenocarcinoma).
    2. Malignant stromal component (one of the following):
      • Skeletal muscle.
      • Smooth muscle.
      • Cartilage.
      • Bone.
      • Undifferentiated sarcoma.

Image: MMMT (WC).

Adenosarcoma

General

  • Uncommon.

Tx:

  • TAH + BSO.

Microscopic

Features:[12]

  • Benign glands with an abnormal shape.

DDx:

  • Benign polyp.

Leiomyocarcoma

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:

  1. Cellular atypia - common.
  2. Necrosis.
    • Should be patchy/multifocal.
    • Zonal necrosis is suggestive of vascular cause.
  3. Mitoses - key feature.
    • 10 mitoses/HPF.
    • 5 mitoses/HPF - if epithelioid.
    • 2 mitoses/HPF - if myxoid.

IHC

  • CD10 -ve.
  • Positive for SMC markers.
    • Desmin - present in all three types of muscle.
    • Caldesmon.
    • Smooth muscle myosin.

Endometrial stromal tumours

Overview

WHO classification:[13]

  • 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.[14]

Endometrial stromal nodule

  • Abbreviated ESN.

General

  • Benign. (???)

Microscopic

Features:

  • Well-circumscribed - key feature.
    • The interface of lesion may not have more than three finger-like irregularities/projections into the surround myometrium that are >= 3 mm.[15]
  • No vascular invasion.

Notes:

  • Myometrial invasion or vascular invasion = ESS or UES.

Images:

Endometrial stromal sarcoma

  • Abbreviated ESS.
  • AKA low grade endometrial stromal sarcoma.

General

Microscopic

Features:

  • Highly cellular Islands with a wavy irregular border.
    • Border has finger-like projections/tongue-like projections.
    • Benign uterine smooth muscle between islands of tumour cells.
  • Epithelioid cells.
  • High NC ratio.
  • Thin blood vessels within islands of cells.
    • Tumour cells pallisade around the vessels.

Image(s):

Notes:

  • Vaguely resembles the stroma of proliferative endometrium.

Undifferentiated endometrial sarcoma

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:

Weird stuff

Uterine tumors resembling ovarian sex cord tumours (UTROSCT)

  • Look like sex cord tumour:[17]
    • May have: anastomosing cords, trabeculae, small nests and/or tubules.

See also

References

  1. ↑ http://www3.interscience.wiley.com/journal/119360394/abstract
  2. ↑ STC. 25 February 2009.
  3. ↑ Huang, CC.; Chang, DY.; Chen, CK.; Chou, YY.; Huang, SC. (Sep 1995). "Adenomatoid tumor of the female genital tract.". Int J Gynaecol Obstet 50 (3): 275-80. PMID 8543111.
  4. ↑ Nucci, Marisa R.; Oliva, Esther (2009). Gynecologic Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 346. ISBN 978-0443069208.
  5. ↑ Canedo-Patzi, AM.; León-Bojorge, B.; de Ortíz-Hidalgo, C.. "[Adenomatoid tumor of the genital tract. Clinical, pathological and immunohistochemical study in 9 cases]". Gac Med Mex 142 (1): 59-66. PMID 16548294.
  6. ↑ LAE. 9 December 2009.
  7. ↑ 7.0 7.1 7.2 7.3 Ip PP, Cheung AN, Clement PB (July 2009). "Uterine smooth muscle tumors of uncertain malignant potential (STUMP): a clinicopathologic analysis of 16 cases". Am. J. Surg. Pathol. 33 (7): 992–1005. doi:10.1097/PAS.0b013e3181a02d1c. PMID 19417585.
  8. ↑ Ivy, JJ.; Unger, JB.. "Malignant mixed mullerian sarcomas of the uterus--the LSUHSC Shreveport experience.". J La State Med Soc 156 (6): 324-6. PMID 15688674.
  9. ↑ Callister, M.; Ramondetta, LM.; Jhingran, A.; Burke, TW.; Eifel, PJ. (Mar 2004). "Malignant mixed Müllerian tumors of the uterus: analysis of patterns of failure, prognostic factors, and treatment outcome.". Int J Radiat Oncol Biol Phys 58 (3): 786-96. doi:10.1016/S0360-3016(03)01561-X. PMID 14967435.
  10. ↑ D'Angelo, E.; Prat, J. (Jan 2010). "Uterine sarcomas: a review.". Gynecol Oncol 116 (1): 131-9. doi:10.1016/j.ygyno.2009.09.023. PMID 19853898.
  11. ↑ Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 428. ISBN 978-0781765275.
  12. ↑ Cotran, Ramzi S.; Kumar, Vinay; Fausto, Nelson; Nelso Fausto; Robbins, Stanley L.; Abbas, Abul K. (2005). Robbins and Cotran pathologic basis of disease (7th ed.). St. Louis, Mo: Elsevier Saunders. pp. 1089. ISBN 0-7216-0187-1.
  13. ↑ 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.
  14. ↑ 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.
  15. ↑ 15.0 15.1 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.
  16. ↑ Chew, I.; Oliva, E. (Mar 2010). "Endometrial stromal sarcomas: a review of potential prognostic factors.". Adv Anat Pathol 17 (2): 113-21. doi:10.1097/PAP.0b013e3181cfb7c2. PMID 20179433.
  17. ↑ URL: http://www.nature.com/modpathol/journal/v19/n1/full/3800475a.html. Accessed on: 5 August 2010.
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