Uterine tumours

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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.
  • Fibroid uterus redirects here.

General

  • Extremely common... 40% of women by age 40.
  • Benign.
  • Large & multiple associated with infertility.

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:

Variants

  • Lipoleiomyoma - with adipose tissue.
  • Hypercellular leiomyoma - hypercellularity associated with more mutations.[1]
  • Atypical leiomyoma (AKA symplastic leiomyoma) - leiomyoma with nuclear atypia.
  • Benign metastasizing leiomyoma.[2]
    • This is just what it sounds like. Some believe these are low grade leiomyosarcomas.

IHC

Work-up of suspicious leiomyomas:[3]

  • CD10 +ve.[4]
  • SMA +ve.
  • Desmin +ve.
  • Ki-67 -ve.

Others:

  • p16 usually -ve.[5]
    • Often +ve in leiomyosarcoma.
  • H-caldesmon +ve.[4]

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UTERUS, UTERINE TUBES AND LEFT OVARY, TOTAL HYSTERECTOMY, BILATERAL SALPINGECTOMY AND LEFT OOPHRECTOMY:
- LEIOMYOMATA WITH FOCAL CALCIFICATION AND HYALINE CHANGE.
- SECRETORY PHASE ENDOMETRIUM.
- RIGHT OVARY WITHIN NORMAL LIMITS.
- UTERINE TUBES WITHIN NORMAL LIMITS.
- UTERINE CERVIX WITHIN NORMAL LIMITS.

Myomectomy

UTERINE MASSES ("FIBROIDS"), MYOMECTOMY:
- LEIOMYOMATA.

Uncommon benign

Uterine adenofibroma

General

  • Uncommmon.
  • Benign looking lesions can reoccur.[6]
    • It has been proposed that these lesions are in fact well-differentiated adenosarcomas.[7]

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 Adamantinoma - a bone tumour.

General

  • Grossly mimics leiomyoma.[8]
  • Benign tumour - derived from mesothelium.
  • May be seen paratesticular.[9]

Microscopic

Features:[10]

  • Well-circumscribed lesion; however, not encapsulated.
  • Small tubulocystic spaces lined by cytologically normal mesothelium.
    • These pseudotubular spaces are crossed by "thread-like bridging strands" - key feature.[11][12]

DDx:

Images

IHC

Features:[13]

  • Calretinin +ve.
  • AE1/AE3 +ve.
  • CD31 -ve.
  • CK7 +ve.[14]

Uncertain malignant potential

Smooth muscle tumour of uncertain malignant potential

  • Abbreviated STUMP.

General

  • Like ASAP and ASCUS - a waffle category... when one isn't sure it is a leiomyoma vs. leiomyosarcoma.
  • Clinical behaviour in uterus: usually benign.[15]
  • Can be subclassified into four groups - as per Stanford.
  • May be seen in the prostate gland.[16]

Management:

  • Long-term follow-up.[15]

Microscopic

Features associated with recurrence:[15]

  • Nuclear atypia.

DDx:

IHC

Features associated with recurrence:[15]

  • p16 +ve.
  • p53 +ve.

Malignant

Uterine carcinosarcoma

  • AKA malignant mixed muellerian tumour, abbreviated MMMT.

General

  • Associated with previous radiation exposure.
  • Metstasize as adenocarcinoma.
  • Aggressive/poor prognosis;[17] in one series 5 year survival ~= 30-35%.[18]
  • Considered to be a poorly differentiated endometrial carcinoma with metaplastic changes.[19]
  • Case reports of MMMT in ovary and fallopian tube.

Microscopic

Features:[20]

DDx:

Images

www:

Adenosarcoma of the uterus

  • AKA uterine adenocarcinoma.

General

Features:[21]

  • 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:[22]

  • Most common presentations of Müllerian adenosarcoma (percentages based on series of 41 individuals[23]):
    • Vaginal bleeding ~ 70%.
    • Pelvic mass ~ 40%.
    • Uterine polyp ~ 30%.
  • Prognosis (based on series of ~500 individuals[24]):
    • Favourable outcome - most detected at an early stage.
      • ~80% five year survival for stage I tumours.
    • Outcome better than carcinosarcoma.

Treatment:

  • TAH-BSO.
    • Tumours are estrogen responsive.
  • Chemotherapy (platin-based).[23]

Microscopic

Features:[25][21]

  • "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.[21]
  • Benign glands with an abnormal shape.
  • "Cambium layer" = increased cellularity around the epithelial elements.[21][26]

Notes:

DDx:

Images

IHC

  • CD10 +ve.[21]
  • ER +ve.
  • PR +ve.

Uterine 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:[27]
    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/HPF.
      • 5 mitoses/HPF - if epithelioid.
      • 2 mitoses/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.[28]

DDx:

IHC

  • CD10 -ve.
  • Positive for SMC markers.
    • Desmin - present in all three types of muscle.
    • Caldesmon.
    • Smooth muscle myosin.
  • p16 +ve.[5]
    • Useful for differentiation from leiomyoma.

Endometrial stromal tumours

This grouping includes the gamut from benign to malignant.

Overview

WHO classification:[29]

  • 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.[30]

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.[31]
      • 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.

Undifferentiated endometrial sarcoma

  • Abbreviated as UES.

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:[32]

  • SMA ~50% +ve.

Typically negative:[32]

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

Weird stuff

Trophoblastic tumours

Uterine tumors resembling ovarian sex cord tumours

  • Abbreviated UTROSCT.

General

  • Super rare.

Microscopic

Features:

  • Look like sex cord tumour:[33]
    • May have: anastomosing cords, trabeculae, small nests and/or tubules.

Atypical polypoid adenomyoma of the uterus

  • Abbreviated APA.
  • AKA atypical polypoid adenomyoma.

General

  • Very rare.[34]
  • Benign.[35]
  • Reproductive age women.

Gross

  • Lower uterine segment.

Microscopic

Features:[35]

  • Glands with irregular (non-ovoid) shapes.
  • Benign smooth muscle around the glands - key feature.
  • Morular squamous metaplasia - balls of squamous cells - very common.
  • Nuclear atypia (mild).

DDx:

Images

www:

IHC

Features (glandular component):[34]

  • AE1/AE3 +ve.
  • CK7 +ve.
  • ER +ve.
  • PR +ve.

Significant negative (glandular component):[34]

  • CK20 -ve.
  • CEA -ve.

See also

References

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  2. Patton, KT.; Cheng, L.; Papavero, V.; Blum, MG.; Yeldandi, AV.; Adley, BP.; Luan, C.; Diaz, LK. et al. (Jan 2006). "Benign metastasizing leiomyoma: clonality, telomere length and clinicopathologic analysis.". Mod Pathol 19 (1): 130-40. doi:10.1038/modpathol.3800504. PMID 16357844. http://www.nature.com/modpathol/journal/v19/n1/full/3800504a.html.
  3. STC. 25 February 2009.
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  14. Latta, E. 9 December 2009.
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