Uterine tumours

From Libre Pathology
Jump to navigation Jump to search

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.

Leiomyomas

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.

Variants

Gross

  • Sharply circumscribed.
  • Gray-white.
  • Whorled appearance.

Look for...

  • Haemorrhage.
  • Cystic degeneration.
  • Necrosis.

Microscopy

Look for ...

  • Necrosis (low power) -- suggestive of leiomyosarcoma.
  • Hypercellularity.

IHC

Work-up of suspicious leiomyomas:[2]

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

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]

Carcinosarcoma

  • AKA malignant mixed muellerian tumour, abbreviated MMMT.

General

  • Associated with previous radiation exposure.
  • Metstasize as adenocarcinoma.
  • Aggressive/poor prognosis;[7] in one series 5 year survival ~= 30-35%.[8]
  • Considered to be a poorly differentiated endometrial carcinoma with metaplastic changes.[9]
  • Case reports of MMMT in ovary and fallopian tube.

Microscopic

Features:[10]

  • 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

Features:[11]

  • Benign glands with an abnormal shape.

DDx:

  • Benign polyp.

Tx:

  • TAH + BSO.

Leiomyocarcoma

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.

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.[12]
  • Can be subclassified into four groups - as per Stanford.

Management:

  • Long-term follow-up.[12]

Microscopic

Features associated with recurrence:[12]

  • Nuclear atypia.

IHC

Features associated with recurrence:[12]

  • p16 +ve.
  • p53 +ve.

Endometrial stromal tumours

Overview

WHO classification:[13]

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

Notes:

  • Some believe in a "high grade ESS"... some don't.[14]

Low grade endometrial stromal sarcoma

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:[15]
    • 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. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 12.0 12.1 12.2 12.3 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.
  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. URL: http://www.nature.com/modpathol/journal/v19/n1/full/3800475a.html. Accessed on: 5 August 2010.