Pathology of the Uterus

single polyp dilated

A. A __ ( arrows ) extends into the endometrial cavity. The necrotic tip ( arrowhead ) is responsible for clinical bleeding. B. On microscopic section, a polyp exhibits slightly __ endometrial glands embedded in a markedly fibrous stroma.

Group A strep, staph polymicrobial microabscesses glandular epithelium Antibiotics, curettage

Acute Endometritis -Bacterial infection •__,___, __ (vaginal flora) -Typically due to retained products of conception post-delivery or miscarriage or due to instrumentation -Clinical: fever, pelvic tenderness/pain, vaginal discharge or bleeding -Micro: Must see __ plus infiltration and destruction of __, as neutrophils are common in cycling endometrium -TX: __,__

myometrium Enlarged

Adenomyosis •Presence of endometrial glands and stroma tissue within the __ of the uterus •It may represent down-growth of endometrium into the myometrium •Some consider adenomyosis to be a form of endometriosis •1/3 of cases are asymptomatic • Patients may have pelvic pain, dyspareunia, abnormal bleeding, and infertility. •Signs: ___ uterus

glands and stroma

Adenomyosis. In adenomyosis, endometrial tissue is displaced deep into the myometrium. The presence of both ___ -purple indicates that this is not invasive endometrial adenocarcinoma (which would consist of glands only). Adenomyosis can cause pelvic pain and infertility.

Scarring basalis Amenorrhea adhesions

Asherman Syndrome •__ with destruction of __ layer (stratum basalis) of endometrium -__ may be observed when there is extensive intrauterine scarring and loss of stratum basalis -In less severe cases, patients may present with hypomenorrhea or with recurrent pregnancy loss due to failure of normal placentation. •Endometrial damage may follow vigorous curettage, usually in association with postpartum hemorrhage, miscarriage, or elective abortion complicated by infection. •In a series of 1856 women with Asherman syndrome, 88 percent followed postabortal or postpartum uterine curettage (Schenker, 1982). •Damage may also result from other uterine surgery, including metroplasty, myomectomy, or cesarean delivery. •The scarring process may result in ___

hyperplasia

Endometrial Carcinoma •Most common malignant tumor of female genital tract •Peak age: 55-65 (not typically seen before age 40) •Most often arises in endometrial __ (about 75-80% of cases) •Risk factors: obesity, diabetes, nulliparity, endometrial hyperplasia, prolonged estrogen replacement, tamoxifen, estrogen producing tumors, polycystic ovarian disease •Symptoms: postmenopausal bleeding, irregular bleeding, sometimes asymptomatic

hyperplasia Endometrioid PTEN 1 P53 2

Endometrial Carcinoma •Origins -Arises in endometrial __ (~75-80% of cases) •__ pattern of endometrial carcinoma •Middle age (50-60 yo) •__ mutations •Indolent •AKA Type __ carcinoma -Sporadic, develops in atrophic endometrium (~20-25% of cases) •Papillary serous pattern of endometrial carcinoma •Elderly (>70 yo) •__ mutations •Very aggressive •AKA Type __ carcinoma

lush polypoid glands to stroma cytologic atypia

Endometrial Hyperplasia •Clinical: Abnormal uterine bleeding, usually postmenopausal •Gross: __ __ endometrium •Micro -Non-atypical •Simple: increased ratio of glands to stroma •Complex: increased ratio of __ ro __, increased budding of glands and crowding of glands -Atypical (Also Known as EIN [endometrial intraepithelial neoplasia]): increased ratio of glands to stroma, __ __ (usually focal), background of complex or rarely simple hyperplasia

anovulatory cycles, perimenopausal, obesity, estrogen-producing ovarian tumors, estrogen replacement therapy without progestational agent, tamoxifen simple or complex atypia endometrial carcinoma atypia

Endometrial Hyperplasia •Proliferation of endometrium due to estrogen excess with reduced progestational activity ("unopposed estrogen") •Risk factors: __,__,__,__,__,__therapy •May be __ or __, may or may not have __ •Usual predecessor to __ •Risk of developing carcinoma is increased (greatest increased risk when __ is present)

Benign chromosomal translocation slough upon menstruation intermenstrual tamoxifen Excision

Endometrial Polyp •__ outgrowths of endometrial stromal cells altered by __ with polyclonal glandular elements •Stroma and glands of endometrial polyps respond poorly to hormonal stimulation, and do not ___. •Endometrial polyps typically present with __ bleeding, owing to surface ulceration or hemorrhagic infarction. •Polyps develop in 2 to 36 percent of postmenopausal women treated with __ •TX: __

papillary serous 2 p53

Endometrial carcinoma, (__) __ type (Type __) C, Serous carcinoma of the endometrium with papillary growth pattern consisting of malignant cells with marked cytologic atypia including high nuclear-to-cytoplasmic ratio, atypical mitotic figures, and hyperchromasia. D, As with the previous lesion, there is an accumulation of __ protein in the nucleus.

endometrioid 1

Endometrial carcinoma, __ type (Type __)

simiple complex atypical

Endometrial hyperplasia left to right

Endometrial glands stroma

Endometriosis __and __ are seen at high magnification in the wall of the colon. Endometriosis is symptomatic during reproductive years when patients may present with dysmenorrhea, pelvic pain, and infertility

outside the uterine cavity cyclic carcinoma

Endometriosis •Endometrial glands and stroma____ •Found in ~7% of women of reproductive age •Sites: ovaries (most common site), uterine ligaments, fallopian tubes, rectovaginal septum/pouch of Douglas, pelvic peritoneum, intestinal wall, appendix, vagina, bladder, umbilicus, surgical scars, distant sites •Rarely found in lymph nodes, lung, pleura •Endometrium undergoes __ bleeding •Causes scarring, dysmenorrhea, pelvic pain, sterility (30% of pts) •Symptoms related to site: e.g bladder involvement leads to pain with urination •Increased risk for __ at site of endometriosis

powder chocolate cysts endometrial glands, endometrial stroma, hemorrhage

Endometriosis •Gross: __ burns, __ •Micro: contains at least two of three features - __,__,__

Gun powder

Endometriosis ("__") Upon closer view, these five small areas of endometriosis have a reddish-brown to bluish appearance. Typical locations for endometriosis may include: ovaries, uterine ligaments, rectovaginal septum, pelvic peritoneum, and laparotomy scars. Endometriosis may even be found at more distant locations such as appendix and vagina.

chocolate cyst

Endometriosis in ovary ("___")

regurgitation

Origins of Endometriosis •Currently favored theory is the __ theory -Endometrial tissue implants at ectopic sites via retrograde flow of menstrual endometrium •Multiple other theories

functionalis layer and basalis

The endometrium consists of two layers, the __ and __ layer. These layers are supplied by the spiral and basal arteries, respectively. Numerous glands also span these layers. As the menstrual cycle progresses, greater coiling of the spiral arteries and increased gland folding can be seen. Near the end of the menstrual cycle (day 27), the coiled arteries constrict, depriving the functionalis layer of its blood supply and leading to necrosis and sloughing of this layer. basal layer should always remain intact functionalis is cycling

leiomyoma

The microscopic appearance of a __ indicates that the cells do not vary greatly in size and shape and closely resemble normal smooth muscle cells. spindle shpaed nuclei-some say cigar shaped, clar space around some

Leiomyomas

__

Leiomyosarcoma

__

Endometrial adenocarcinoma

__ presenting as a fungating mass in the fundus of the uterus

Endometrial Hyperplasia

___-lush polypoid endometrium

Chronic endometritis. plasma cells

___The inflammatory infiltrate is composed largely of lymphocytes and __- nucleus is on one side of the cell not in the center.

pelvic inflammatory disease (PID) bleeding spindly neutrophils plasma cells lymphoid follicles Antibiotics, removal of IUD or curettage

Chronic Endometritis -In women with __, postpartum, post-abortion (retained tissue), IUD, tuberculosis (miliary or TB salpingitis), symptomatic bacterial vaginosis -Clinical: __, pelvic pain, infertility, uterine tenderness, cervical motion tenderness -Micro: __ stroma with edema; focal early breakdown with surface __; __ are characteristic-if you see one then thats enough to dx this, usually also histiocytes, lymphocytes and ___ are present -TX: __,__ or __

Fibroid

Leiomyoma •AKA "___" •Benign smooth muscle tumor of myometrium •Most common tumor of female genital tract -Present in ~75% of women at autopsy -More common in African-Americans •Stimulated by estrogen, may regress after menopause and enlarge during pregnancy •Most are asymptomatic •SX include menorrhagia, metrorrhagia, urinary frequency, pelvic pain, or infertility

multiple submucosal, intramural, subserosal fascicular

Leiomyoma •Gross: well-circumscribed, firm, round, white bulging mass, often __ •Locations: __,__,__ •Micro: __ pattern of smooth muscle bundles separated by well vascularized connective tissue

spindle

Leiomyosarcoma As with sarcomas in general, leiomyosarcomas have __ cells. Several mitoses are seen here, just in this one high power field. note the tri[plar mitosis pattern in center

hemorrhagic or necrotic MULTIPLE hypercellular

Leiomyosarcoma •Gross: bulky, fleshy tumor invading into myometrial wall or polypoid tumor projecting into lumen, __ or__; grossly appear invasive / infiltrative; usually 5 cm or more in size but NOT __ •Micro: : __ tumors composed of spindle cells somewhat resembling smooth muscle cells but with moderate to severe pleomorphism; 10+ mitotic figures per 10 high power fields (HPF) in most mitotically active area, abundant abnormal mitotic figures

Malignant 54 Necrosis

Leiomyosarcoma •Uncommon •___ tumor of smooth muscle •Can arise de novo or arise in pre-existing leiomyoma •Peaks at ages 40-69 years; mean is __ yo •__, hypercellular with atypical cells and lots of mitoses •About 50% recur after surgery •Often metastasizes to lungs •Poor prognosis (5 yr survival of ~40%)

Straight tubular Dilated tortuous glands serrated Fragmented

Main histologic features of the endometrial phases of the normal menstrual cycle. A. Proliferative phase. __ glands are embedded in a cellular monomorphic stroma. B. Secretory phase, day 24. __ with __ borders are situated in a predecidual stroma.-sawtooth pattern C. Menstrual endometrium. __ glands, dissolution of the stroma and numerous neutrophils are evident.