Endometrial carcinoma

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Endometrial carcinoma is a common gynecologic malingnancy[1] that often arises from endometrial hyperplasia. The incidence of endometrial carcinoma is increasing, as the proportion of obese individuals is increasing.

An introduction to the endometrium is in the article endometrium.

Clinical

Risk factors

Risk factors for endometrial carcinoma - mnemonic COLD NUT:[2]

  • Cancer Hx (ovarian, breast, colon).
  • Obesity.
  • Late menopause.
  • Diabetes.
  • Nulliparity.
  • Unopposed estrogen (polycystic ovarian syndrome (PCOS), anovulation, hormone replacement therapy (HRT)).
  • Tamoxifen use.
    • Used for breast cancer; the risk is quite small[3] or possibly negligent.[4]

Family history

Several syndromes are seen in association with endometrial cancer:[5]

  • Cowden syndrome (PTEN mutation) - most common.
    • Associated with endometrioid endometrial carcinoma.
  • Lynch syndrome (mutation of a mismatch repair gene - there are several[6]).
    • Associated with non-endometrioid endometrial carcinoma.[5]
    • Autosomal dominant.

Management

  • Hysterectomy is the standard treatment for endometrial carcinoma.
    • In low-grade carcinomas (i.e. low grade endometrioid type), if the woman isn't done with their childbearing, the treatment may be hormones and surveillance biopsies.[7]

Details:

  • Low grade and low stage endometrioid carcinoma: total hysterectomy (includes cervix).
  • Non-endometrioid or high stage endometrioid or high-grade endometrioid: radical hysterectomy (includes cervix, vaginal cuff, parametrial tissue).

Subtypes - overview

They are commonly grouped based on clinicopathologic features:[8][9]

Feature Type I Type II
Histologic types endometrioid endometrial carcinoma, mucinous endometrial carcinoma serous carcinoma of the endometrium, clear cell carcinoma of the endometrium, undifferentiated carcinoma
Clinical
characteristics 		premneopausal, estrogen excess, endometrial hyperplasia postmenopausal, no estrogen excess, atrophic endometrium
Prognosis good poor
Genetic
abnormalities 		microsatellite instability, PTEN & KRAS mutations p53 mutations

Grading (FIGO)

Based on gland formation & adjusted by nuclear pleomorphism:[10][11][12][13]

  • Grade 1: <5% solid component.
  • Grade 2: 5-50% solid component.
  • Grade 3: >50% solid component.

Modifiers/adjustment:

  • High grade nuclei upgrades cancer by one; high grade nuclei = increased size, irregular large nucleoli, irregular chromatin pattern (clumped, coarse).[14]

Notes:

Staging

  • Stage I: confined to uterine body.
    • Ia = endometrium only.
    • Ib = less than half of myometrium.
    • Ic = greater than half of myometrium.
  • Stage II: uterus + cervix.
    • IIa = endocervical glands only.
    • IIb = cervix stroma.
  • Stage III: outside uterus - but inside pelvis.
    • IIIa = serosal or adnexal involvement or peritoneal cytology positive.
    • IIIb = vaginal metstases.
    • IIIc = pelvic or paraaortic nodes.
  • Stage IV: outside true pelvis or in mucosa of bladder or GI tract.
    • IVa = bladder or bowel mucosa.
    • IVb = distant mets (intraabdominal, inguinal nodes).

References: [15], [16], [17].

Specific types

Endometrioid endometrial carcinoma

  • AKA endometrioid endometrial adenocarcinoma.

General

  • Good prognosis - usually.
  • Women in 40s & 50s.
  • Associated with estrogen excess.
    • Typical patient is obese.

Microscopic

Features:

  • Atypical (ovoid) glands with - one of the following four:[18][19][20]
    1. Desmoplastic stromal response.
    2. Confluent cribriform growth. †
    3. Extensive papillary growth. †
    4. Severe cytologic atypia. †
  • Squamous metaplasia - very common.
    • Look for squamous morules:
      • Ball of cells with an intensely eosinophilic cytoplasm - key feature.
      • Central nucleus.
      • Intercellular bridges - may be hard to find.
      • +/-Dyskeratotic cells.

Note:

  • † There is a size cut-off for criteria 2, 3 and 4: > 2.1 mm.[19]
  • Dyskeratosis = abnormal keratinization;[21] classically have intensely eosinophilic cytoplasm +/- nuclear fragmentation (karyorrhexis) - see: several dyskeratotic cells.
  • Squamous morules in endometrioid endometrial carcinoma - not associated with HPV infection.[22]

DDx:

Image:

Mucinous carcinoma of the endometrium

  • AKA endometrial mucinous carcinoma.

General

  • Type II endometrial carcinoma.
  • Good prognosis.

Microscopic

Features:[9]

  • Cells with intracytoplasmic mucin (>50% of tumour).

IHC

Features:[23]

  • ER-alpha +ve.
  • PR-alpha +ve.
  • PR-beta +ve.

Serous carcinoma of the endometrium

  • AKA serous endometrial carcinoma.
  • AKA serous carcinoma of the uterus.
  • AKA uterine serous carcinoma.
  • AKA uterine papillary serous carcinoma.

General

  • Arising in the setting of atrophy.
  • Usu. post-menopausal.

Microscopic

Features - serous:

  • Architecture - classically papillary.
    • May be glomeruloid, tubulocystic, solid (uncommon).
  • Cytology:
    • Columnar or cuboidal cells.
      1. Moderate to marked nuclear pleomorphism - variation of size, shape and staining.
        • Large nuclear size variation between cells often esp. prominent.
      2. Singular prominent, classically red, nucleolus.
  • +/-Psammoma bodies.

DDx:

Images:

IHC

  • p16 +ve.[24]
  • p53 +ve[25] > 50% or 75%% of the tumour - depending on the paper one reads.
  • ER often -ve.[26]
  • PR often -ve.[26]

Clear cell carcinoma of the endometrium

  • AKA clear cell endometrial carcinoma.

General

  • Ten-year survival ~ 40%.[27]

Microscopic

Features:

  • Clear cells:
    • Classically clear cells... but not always.
  • Hobnail pattern -- apical cytoplasm > cytoplasm on basement membrane.

IHC

Features:[28]

Note:

See also

References

  1. ↑ Fowler W, Mutch D (September 2008). "Management of endometrial cancer". Womens Health (Lond Engl) 4 (5): 479–89. doi:10.2217/17455057.4.5.479. PMID 19072487.
  2. ↑ Greenwald, J.; Heng, M. (2007). Toronto Notes for Medical Students 2007 (2007 ed.). The Toronto Notes Inc. for Medical Students Inc.. pp. GY40. ISBN 978-0968592878.
  3. ↑ Brown, K. (Sep 2009). "Is tamoxifen a genotoxic carcinogen in women?". Mutagenesis 24 (5): 391-404. doi:10.1093/mutage/gep022. PMID 19505894.
  4. ↑ Ashraf, M.; Biswas, J.; Majumdar, S.; Nayak, S.; Alam, N.; Mukherjee, KK.; Gupta, S.. "Tamoxifen use in Indian women--adverse effects revisited.". Asian Pac J Cancer Prev 10 (4): 609-12. PMID 19827879.
  5. ↑ 5.0 5.1 Okuda T, Sekizawa A, Purwosunu Y, et al. (2010). "Genetics of endometrial cancers". Obstet Gynecol Int 2010: 984013. doi:10.1155/2010/984013. PMC 2852605. PMID 20396392. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852605/.
  6. ↑ Online 'Mendelian Inheritance in Man' (OMIM) 120435
  7. ↑ Zivanovic O, Carter J, Kauff ND, Barakat RR (December 2009). "A review of the challenges faced in the conservative treatment of young women with endometrial carcinoma and risk of ovarian cancer". Gynecol. Oncol. 115 (3): 504–9. doi:10.1016/j.ygyno.2009.08.011. PMID 19758691.
  8. ↑ Lim, D.; Oliva, E. (Nov 2010). "Nonendometrioid endometrial carcinomas.". Semin Diagn Pathol 27 (4): 241-60. PMID 21309259.
  9. ↑ 9.0 9.1 Nucci, Marisa R.; Oliva, Esther (2009). Gynecologic Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 241. ISBN 978-0443069208.
  10. ↑ 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. 1087-8. ISBN 0-7216-0187-1.
  11. ↑ URL: http://www.pathologyoutlines.com/uterus.html#endometrialcarc.
  12. ↑ URL: http://www.emedicine.com/med/topic2832.htm.
  13. ↑ Ayhan A, Taskiran C, Yuce K, Kucukali T (January 2003). "The prognostic value of nuclear grading and the revised FIGO grading of endometrial adenocarcinoma". Int. J. Gynecol. Pathol. 22 (1): 71–4. PMID 12496701.
  14. ↑ Tadrous, Paul.J. Diagnostic Criteria Handbook in Histopathology: A Surgical Pathology Vade Mecum (1st ed.). Wiley. pp. 240. ISBN 978-0470519035.
  15. ↑ 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. 1088. ISBN 0-7216-0187-1.
  16. ↑ http://www.emedicine.com/med/topic2832.htm
  17. ↑ Staging with groovy graphics (cancerfacts.com)
  18. ↑ Nucci, Marisa R.; Oliva, Esther (2009). Gynecologic Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 239. ISBN 978-0443069208.
  19. ↑ 19.0 19.1 Kurman, RJ.; Norris, HJ. (Jun 1982). "Evaluation of criteria for distinguishing atypical endometrial hyperplasia from well-differentiated carcinoma.". Cancer 49 (12): 2547-59. PMID 7074572.
  20. ↑ URL: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Endometrium_11protocol.pdf. Accessed on: 12 January 2012.
  21. ↑ URL: http://dictionary.reference.com/browse/dyskeratosis. Accessed on: 5 September 2011.
  22. ↑ Chinen, K.; Kamiyama, K.; Kinjo, T.; Arasaki, A.; Ihama, Y.; Hamada, T.; Iwamasa, T. (Sep 2004). "Morules in endometrial carcinoma and benign endometrial lesions differ from squamous differentiation tissue and are not infected with human papillomavirus.". J Clin Pathol 57 (9): 918-26. doi:10.1136/jcp.2004.017996. PMID 15333650.
  23. ↑ Shabani, N.; Mylonas, I.; Jeschke, U.; Thaqi, A.; Kuhn, C.; Puchner, T.; Friese, K.. "Expression of estrogen receptors alpha and beta, and progesterone receptors A and B in human mucinous carcinoma of the endometrium.". Anticancer Res 27 (4A): 2027-33. PMID 17649817.
  24. ↑ Chiesa-Vottero, AG.; Malpica, A.; Deavers, MT.; Broaddus, R.; Nuovo, GJ.; Silva, EG. (Jul 2007). "Immunohistochemical overexpression of p16 and p53 in uterine serous carcinoma and ovarian high-grade serous carcinoma.". Int J Gynecol Pathol 26 (3): 328-33. doi:10.1097/01.pgp.0000235065.31301.3e. PMID 17581420.
  25. ↑ Yemelyanova, A.; Ji, H.; Shih, IeM.; Wang, TL.; Wu, LS.; Ronnett, BM. (Oct 2009). "Utility of p16 expression for distinction of uterine serous carcinomas from endometrial endometrioid and endocervical adenocarcinomas: immunohistochemical analysis of 201 cases.". Am J Surg Pathol 33 (10): 1504-14. doi:10.1097/PAS.0b013e3181ac35f5. PMID 19623034.
  26. ↑ 26.0 26.1 Kounelis, S.; Kapranos, N.; Kouri, E.; Coppola, D.; Papadaki, H.; Jones, MW. (Apr 2000). "Immunohistochemical profile of endometrial adenocarcinoma: a study of 61 cases and review of the literature.". Mod Pathol 13 (4): 379-88. doi:10.1038/modpathol.3880062. PMID 10786803.
  27. ↑ Abeler, VM.; Vergote, IB.; Kjørstad, KE.; Tropé, CG. (Oct 1996). "Clear cell carcinoma of the endometrium. Prognosis and metastatic pattern.". Cancer 78 (8): 1740-7. PMID 8859187.
  28. ↑ Nucci, Marisa R.; Oliva, Esther (2009). Gynecologic Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 250. ISBN 978-0443069208.
  29. ↑ Fadare, O.; Liang, SX. (Apr 2012). "Diagnostic Utility of Hepatocyte Nuclear Factor 1-Beta Immunoreactivity in Endometrial Carcinomas: Lack of Specificity For Endometrial Clear Cell Carcinoma.". Appl Immunohistochem Mol Morphol. doi:10.1097/PAI.0b013e31824973d1. PMID 22495362.
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