Uterine corpus

Uterine corpus

• benign diseases:• - endometritis• - endometriosis and adenomyosis• - endometrial polyps• precursor lesions of endometrial carcinoma• endometrial carcinoma• mesenchymal tumors of the uterus

Endometritis

Pregnancy-related• after a vaginal delivery 2-3%• after Cesarean delivery 13-

90%• - enterococcus• - streptococcus• - chlamydia …

• puerperal sepsis

Unrelated to pregnancy• usually ascending infection• IUD• acute• - neutrophils within endometrial

glands• - Neisseria gonorrhoeae• - Chlamydia trachomatis• chronic• - plasma cells• - pelvic inflammatory disease

Puerperal sepsis• bacterial infection• contracted during childbirth or abortion• usually treatable with antibiotics• can be fatal!

• between 1991 and 2001: 137 women died up to 42 day after the delivery (12,5 / 100 000 deliveries) - in the Czech Republic

• only 5 of them (4,3%) died because of infection

• common condition – historically• during the 18th century it took on

epidemic proportions• particularly when home delivery

practice changed to delivery lying-in hospital

• - at those times, there still was a total ignorance of asepsis

Endometriosis

• presence of endometrial tissue outside the endometrium and myometrium

• pathogenesis (two theories):• 1) metastatic theory: implantation of

endometrial tissue to its ectopic location• 2) metaplastic theory: development of the

endometrial tissue at the ectopic site

Endometriosis• true prevalence is unknown

as many patients are asymptomatic

• estimated prevalence in women of reproductive age is 10-15%

• >80% of patients are in reproductive age group

• sites of endometriosis: • - peritoneum• - urinary bladder• - ovaries• - uterine ligaments• - large bowel, skin• -lungs, bone, stomach

Adenomyosis• presence of endometrial

glands and stroma within the myometrium

• common condition, detected in 15-30% of hysterectomy specimen

• clinical features:• - pre- or perimenopausal

women• - abnormal bleeding and

dysmenorrhea• - uterus is enlarged

Endometrial polyps• common• 2-23% of patients undergoing

endometrial biopsy because of abnormal uterine bleeding

• probably related to hyperestrogenism

• may be single or multiple• increased frequency of polyps

in patients taking tamoxifen

Precursor lesions

Endometrial hyperplasia• hyperplasia without

atypia • atypical hyperplasia

Natural history of hyperplasia

• hyperplasia without atypia• fewer than 2% progress to carcinoma

• atypical hyperplasia• 23% progress to carcinoma

Endometrial intraepithelial carcinoma• precursor lesion of invasive

endometrial serous carcinoma• formerly also had been referred

to as „carcinoma in situ“• can be associated with

metastatic disease

• histological features:• - numerous mitotic figures• - high-grade nuclear atypias• - enlarged nuclei• - prominent nucleoli• - can be papillary arrangement

Tumors of the uterine corpus

Tumors of the uterine corpus

Epithelial• Carcinoma:• endometrioid • mucinous • serous • clear cell

Mixed epithelial and mesenchymal• carcinosarcoma

Mesenchymal• Benign• leiomyoma• endometrial stromal nodule

• Malignant• leiomyosarcoma• endometrial stromal

sarcoma

Endometrial carcinoma dualistic model of carcinogenesis

Type I• low-grade carcinomas• associated with estrogenic

stimulation• indolent behaviour• histologic subtypes:• - low grade endometrioid• - mucinous

• precursor lesion:• - atypical hyperplasia

Type II• high-grade carcinoma• not related to estrogenic

stimulation• aggresive behaviour• histologic subtypes:• - high-grade endometrioid• - serous• - clear cell

• precursor lesion:• - endometrial intraepithelial

carcinoma

Feature Type I Type IIFrequency 80-85% 10-15%

Histologic subtypes Endometrioid (low grade)Mucinous

SerousClear cellEndometrioid (high grade)

Tumor grade low high

Precursor lesion atypical hyperplasia - endometrial glandular dysplasia- endometrial intraepithelial carcinoma

Unopposed estrogen present absent

Menopausal status pre- and perimenopausal postmenopausal

Prognosis good poor

Genetic alterations PTENMSIk-ras

p53Her2/neuE-cadherin

Etiology (type I)Risk factors• hormonal stimulation• - unopossed estrogen stimulation

(after 2 years – 2-3fold increase in the risk of EC)

• constitutional factors• - obesity• - diabetes mellitus• increased total caloric intake• high-fat diet• genetic alterations• - mutation of PTEN• - microstallite instability (HNPCC –

lynch syndrome)

Protective factors• increased physical exercise• addition of progestin to HRT• smoking• diet rich in vegetables• parity

Clinical features

• initial manifestation: • - abnormal vaginal bleeding• - rarely asymptomatic

• most women postmenopausal• in young women – generally low grade,

minimally invasive, excelent prognosis

Gross findings

• almost uniformly exophytic

• focal or diffuse• myometrial invasion

may result in enlargement of the uterus

• involvement of the cervix – approximately 20% cases

Tumors of the uterine corpus

Epithelial• Carcinoma:• endometrioid • mucinous • serous • clear cell

Mixed epithelial and mesenchymal• carcinosarcoma

Mesenchymal• Benign• leiomyoma• endometrial stromal nodule

• Malignant• leiomyosarcoma• endometrial stromal

sarcoma

PrognosisUterine factors• histologic type• grade• hormone receptor status• depth of myometrial

invasion• cervical involvement• vascular invasion

Extrauterine factors• adnexal involvement• intraperitoneal metastasis• lymph node metastasis

PrognosisUterine factors• histologic type• grade• hormone receptor status• depth of myometrial

invasion• cervical involvement• vascular invasion

Extrauterine factors• adnexal involvement• intraperitoneal metastasis• lymph node metastasis

stage

Architectural grading of endometrioid carcinoma G1 ≤ 5% solid masses G2 6-50% solid masses G3 > 50% solid masses 1) notable nuclear atypia raises a grade 1 or grade 2 tumor by one grade 2) squamous and morular components are excluded from grading

3

Tumors of the uterine corpus

Epithelial• Carcinoma:• endometrioid • mucinous • serous • clear cell

Mixed epithelial and mesenchymal• carcinosarcoma

Mesenchymal• Benign• leiomyoma• endometrial stromal nodule

• Malignant• leiomyosarcoma• endometrial stromal

sarcoma

Leiomyoma

• the most common uterine tumors• noted clinically in 20-30% of women over 30

years of age• when systematically searched – 75% of

women

Gross findings• location:• - submucosal (rare pedunculated)• - intramural (most common)• - subserosal (can be pedunculated)• multiple tumors in 2/3 of women• spherical, firm• sharply demarcated• cut surface: • - white to tan• - whorled trabecular pattern

Clinical features

• most asymptomatic, only a minority requires treatment

• therapy is indicated if:• - tumors are symptomatic (metrorrhagia,

abdominal pain, urination problems)• - interfere with fertility• - rapidly enlarge• - pose a diagnostic problem

Leiomyosarcoma

• about 1.3% of uterine malignancies• more than 50% of uterine sarcomas• most intramural• averages 6-9 cm in diameter• soft, fleshy, poorly defined margins• cut surface: gray-yellow or pink, often with areas of

necrosis and hemorrhage• poor prognosis: 5 year survival rate 15-25%

Carcinosarcoma (malignant mixed Müllerian tumor)

• composed of malignant epithelial and mesenchymal components

• frequently polypoid• poor prognosis