Difference between revisions of "Uterine tumours"
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**Can be a cause of [[abnormal uterine bleeding]] (commonly abbreviated ''AUB''). | **Can be a cause of [[abnormal uterine bleeding]] (commonly abbreviated ''AUB''). | ||
*Large & multiple associated with infertility. | *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> | *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=== | ===Gross=== | ||
Revision as of 18:34, 3 January 2017
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
Main article: Leiomyoma
- Often called fibroids.
- Fibroid uterus redirects here.
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).[1]
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.
- Image: Lipoleiomyoma - low mag. (WC).
- Hypercellular leiomyoma - hypercellularity associated with more mutations.[2]
- Atypical leiomyoma (AKA symplastic leiomyoma) - leiomyoma with nuclear atypia.
- Image: Atypical leiomyoma (WC).
- Benign metastasizing leiomyoma.[3]
- This is just what it sounds like. Some believe these are low grade leiomyosarcomas.
IHC
Work-up of suspicious leiomyomas:[4]
- CD10 +ve.[5]
- SMA +ve.
- Desmin +ve.
- Ki-67 -ve.
Others:
Sign out
Uterine Cervix, Uterus, Bilateral Tubes and IUD, Total Hysterectomy and Bilateral Salpingectomy: - Uterine leiomyomas. - Mild atherosclerosis. - Inactive endometrium. - Intrauterine device (IUD) - gross only. - Uterine cervix within normal limits. - Left uterine tube with small paratubal cyst, negative for significant pathology. - Right uterine tube with paratubal cyst, negative for significant pathology. - NEGATIVE for malignancy.
Block letters
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.
Myomectomy
UTERINE MASSES ("FIBROIDS"), MYOMECTOMY:
- LEIOMYOMATA.
UTERINE MASS, HYSTEROSCOPIC MYOMECTOMY: - BENIGN SMOOTH MUSCLE FRAGMENTS COMPATIBLE WITH LEIOMYOMA. - SECRETORY PHASE ENDOMETRIUM.
Uncommon benign
Uterine adenofibroma
- AKA adenofibroma of the uterus.
General
- Uncommmon.
- Benign looking lesions can reoccur.[7]
- It has been proposed that these lesions are in fact well-differentiated adenosarcomas.[8]
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:
- Appearance similar to fibroadenoma.
DDx:
- Adenosarcoma.
Images:
- Adenofibroma of the uterus - low mag. (webpathology.com).
- Adenofibroma of the uterus - high mag. (webpathology.com).
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.
- Fascicular architecture.
- Malignant histomorphologic features - two of three required - key features:[9]
- Nuclear pleomorphism.
- 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.
- 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.[10]
DDx:
- Endometrial stromal sarcoma.
- Uterine carcinosarcoma.
- Undifferentiated endometrial sarcoma.
- Smooth muscle tumour of uncertain malignant potential.
- Uterine leiomyoma.
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:[11]
- 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.[12]
Endometrial stromal nodule
- Abbreviated ESN.
General
- Benign.
Microscopic
Features:
- Well-circumscribed - key feature.
- No vascular invasion.
DDx:
- Endometrial stromal sarcoma (ESS), UES - myometrial invasion or vascular invasion.
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.[14]
General
- Malignant.
- Rare.
- This can be thought of as pleomorphic undifferentiated sarcoma in the uterus.
Microscopic
Features:
- Marked nuclear atypia.
- Mitoses+++.
- 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:[15]
- SMA ~50% +ve.
Typically negative:[15]
- 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.
Atypical polypoid adenomyoma of the uterus
- Abbreviated APA.
- AKA atypical polypoid adenomyoma.
Main article: Atypical polypoid adenomyoma of the uterus
See also
References
- ↑ Delev, DP.. "Ulipristal acetate--a review of the new therapeutic indications and future prospects.". Folia Med (Plovdiv) 55 (3-4): 5-10. PMID 24712276.
- ↑ Pandis, N.; Heim, S.; Willén, H.; Bardi, G.; Flodérus, U-M.; Mandahl, N.; Mitelman, F. (Jan 1991). "Histologic—cytogenetic correlations in uterine leiomyomas.". International Journal of Gynecological Cancer 1 (4): 163-68. http://www3.interscience.wiley.com/journal/119360394/abstract.
- ↑ 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.
- ↑ STC. 25 February 2009.
- ↑ 5.0 5.1 Zhu, XQ.; Shi, YF.; Cheng, XD.; Zhao, CL.; Wu, YZ. (Jan 2004). "Immunohistochemical markers in differential diagnosis of endometrial stromal sarcoma and cellular leiomyoma.". Gynecol Oncol 92 (1): 71-9. PMID 14751141.
- ↑ 6.0 6.1 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 15.0 15.1 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.