Gu Path - 7 - Uterine Pathology

Front 1

Two areas of pathology in the uterus ?

Back 1

Myometrium and endometrium

Front 2

Ovaries are where to the fallopian tube ?

Back 2

Back

Front 3

What is dating the endometrium ?

Back 3

It is dating to assess hormonal status, document ovulation and determine causes of bleeding.

Front 4

Part of the endometrium that are dated ?

Back 4

Upper 2/3rd (functionalis) responds to hormones and sheds with menstrual cycle
Lower 1/3rd does not shed and does not respond to hormones

Front 5

2 distinct phases of endometrium ?

Back 5

Proliferative - preovulatory; cannot be precisely dated

Secretory - post ovulatory ; changes daily

Front 6

Know this slide 1

Back 6

Prolif - estrogen
Secretory - progesterone

Front 7

Glandular features in phases

Back 7

Glandular features - in P phase, they are regular. in S phase they are single layer, push out, making the gland serrated

Front 8

Basal vacuolaization

Back 8

Not present in P phase, but present in S phase

Front 9

Stromal edema

Back 9

Two peaks : smaller in P phase, bigger in S phase. The big curve is called point of maximal edema

Front 10

What is decidua?

Back 10

Stromal cells or whatever cells take on more cytoplasm and start revving up thinking about implantation. They are filling up with energy sources.

In the proliferative phase they are just growing and making more cells, whereas in the secretory phase, they increase their cytoplasm and get ready, therefore decidualizing

Front 11

If you were in decidua what phase would you be in ?

Back 11

Progesterone dependent phase

Front 12

When do you see inflammation in the endometrium ?

Back 12

Not typically seen. The one time inflamm is seen is at the start of the menstrual cycle, due to breakdown of endometrium, and the other time is chronic endometritis. (However in this case, plasma cells are seen instead of neutrophils)

Front 13

Proliferative endometrium
-hormone, length, histological features

Back 13

estrogen

variable length (if ovulation occurs then 14 days of secrE. for sure)

Tall columnar cells,
Tubular glands which become increasingly tortuous
Pseudostratified dark nuclei
Mitotic figures - due to proliferation

Front 14

What day does prolifE begin ? and what triggers it ?

Back 14

Day 4, since menses occur d(1-4)

Follicle maturation triggers this phase. So abnormal cycling, which starts in the ovary drives this

Front 15

Secretory endometrium is seen, what has happened

Back 15

O V U L A T I O N

Front 16

Indeterminant SecrE ?

Back 16

2 days after ovulation. Features are not clear

Front 17

By what day is it usually apparent and what are the histological features ?

Back 17

Day 17

Subnuclear glycogen vacuoles
Palisading nuclei
PIANO KEYS
And EVERY cell in a gland must be this way with 50% of the glands showing this change

Front 18

3 features of secretory endometrium ?

Back 18

Tortuous glands
Basal vacuoles
Progesterone

Triggered by ovulation

Front 19

Day 18
Day 19-20
Day 21
Day 22
Day 23-28
Secretory exhuastion

Back 19

18- vacuoles migrate to above nuclei and nuclei line up basally
19-20 : secretion of contents of vacuoles in lumen
22 - maximal stromal edema
23-28 - epithelial projections with irregular outline giving it SAWTOOTH appearance
Secretory exhaustion - thin epithelium that is devoid of secretion

Front 20

What is the one thing you need to know about menstrual endometrium and metaplasia

Back 20

The less regular menses happen the more metaplasia that is seen. It looks more irregular

Front 21

What should menstrual endometrium look like ?

Back 21

We need to see secretory phase in the background. It is not going to have pseudostratification or mitosis, however it will have BLUE BALL STROMA, which is lined by fragmented glands in the background with NEUTROPHILS AND BLOOD present

Front 22

what does post menopausal endometrium look like

Back 22

Inactive with cystic change

Endometrium is normal in thickness

Tubular glands with no mitoses, minimal psuedostratification

Front 23

Atrophic postmenopausal endometrium ?

Back 23

Grossly thinned, fragile, cuboidal epitheliumwith cystic change. On curettage specimens, thin strips of epithelium like NECKLACES

Front 24

Gestational endometrium

Back 24

HYPERsecretory - "FERNING"
DECIDUALIZED - prominent cell borders

ARIAS STELLA - scary looking
big cells with enlarged nuclei and cytoplasm. It is hyperchromatic irregular chromatin and it may show HOBNAILING. Careful with diagnosing as a malignancy

Front 25

Dysfxnal uterine bleeding

Back 25

Due to ANOVULATORY cycle

This is due to prolonged estrogen stimulation from endocrine disorder,
functioning ovarian lesion
or metabolic disorder

Persistent proliferative endometrial glands dilate and cause breakdown. - MIXED PATTERN OF GLANDULAR BREAKDOWN

Front 26

Abnormal uterine bleeding

Back 26

Inadequate luteal phase - low progestrone due to poor function of the corpus leuteum.

COMMON cause of INFERTILITY and AMENORRHEA

Endometrial biopsy lags behing the expected menstrual date.

Treated with progesterone to regulate them.

Front 27

Endometritis

Back 27

Not very common

Acute - usually due to Staph or strep
with post partum
Seen with neutrophils in epithelium and stroma and microabscesses

Chronic - usually due to TB
-funny looking stroma
-impossible to date
-look for Fibrous spindly stroma
-plasma cells - KEY TO DIAGNOSIS
typically due to INFECTIOUS etiology

Front 28

Organisms which cause Endometritis

Back 28

Chlaymydia
Mycoplasma
Anerobic gram negative
TB (unusual)
Fungus ( Actino - most common)
CMV
Parasites (unusual)

Front 29

What is endometritis due to ? How do you identify it ?

Back 29

Chronic inflammation due to chronic PID, retained products, IUDs, TB

Diagnosed with even ONE plasma cell with macs and lyphms

Front 30

What is the OCP effect ? Birth control pills

Back 30

Pseudodecidualized stroma with atrophic little glands

Edema between cells

Front 31

Progesterone effect of OCP - endogenous decidualization ?

Back 31

Its the kind seen in pregnancy. This is more robust with a hypercellular spindly stroma

Front 32

Most commonly encountered hormonal abnormality

Back 32

Anovulation - due to inadequate hormones, which leads to dilated glands with pseudostratified cells and mitosis going on. It can be called disordered proliferative endometrium, since it is not happening normally with the normal cycle

Front 33

Endometriosis in the myometrial wall ?

Back 33

Adenomyosis : - Glandular with muscle

Glands are present 2-3mm beneath endometrial surface, which produce enlargement of the myometrial wall.

Presents as cause of menorrhagia and pelvic pain

Front 34

Endometriosis ?

Back 34

Presence of endometrial glands and stroma in abnormal locations.

Causes INFERTILITY AND PELVIC PAIN

Affects 10% women

Front 35

2 out of 3 features for Endometriosis ?

Back 35

Endometrial glands

Stroma

Hemosiderin

Tumors can develop in these lesions, however rare. Birthcontrol pills help avoid, due to downregulation of hormones

Front 36

Polyps

Back 36

Stroma more fibrous and pinker than normal

Most donot cycle with hromones

Classified into hypertrophic, atrophic and functional

Front 37

Pathological presentation of polyps and microscopical appearance ?

Back 37

Polyps may cause bleeding
Can lead to rise of adenocarcinomas
Cytogenetic studies show a 6p21 rearrangement
Microscopically - glands, thick walled vessels and fibrous stroma

Front 38

Which carcinoma in polyps has a bad prognosis ?

Back 38

Endometrial intraepithelial carcinoma or serous carcinoma arising in atrophic polyps OVER 65
Poor prognosis
Easy to overlook !!!!!!

Front 39

Cause of endometrial hyperplasia ?

Back 39

Related to abnormally high and prolonged estrogenic stimulation

Front 40

Conditions seen with endometrial hyperplasia ?

Back 40

Polycystic ovarian disease, granulosa cell tumors, estrogen replacements

Gland to stroma ratio is over 1:1

Front 41

Simple hyperplasia ?

Back 41

Rarely atypical
Cells are still a single layer, and they can be treated medically

Front 42

Complex hyperplasia

Back 42

Can be seen with or w/o ATYPIA (Nuclear features define atypia. WHen these get hyperchromatic and ugly then 23% progress to carcinoma, if no atypia then 5% chance)

Glands with crowding and irregular shapes

Lining epithelium is more stratified

Front 43

How do you identify atypia in endo hyperplasia ?

Back 43

Round nuclei
Chromatin more vesicular
Nucleoli visible
Nuclear membranes irregular
Stratification - loss of polarity

Front 44

Endometrial carcinoma ?

Back 44

Most COMMON postmenopausal (55-65)

Associated with diabetes, HTN and infertility

2 types -
1. Prolonged estrogen stimulation (endometriod) and mutations in PTEN gene chromosome 10
2. Non estrogen dependent seen in the older age group, poorly differentiated with a poorer prognosis with p53 mutations

Front 45

Type I vs Type II

Back 45

Type I
Pre or perimenopausal
Background of atypical hyperplasia (due to estrogen stimulation)
Less aggressive, better prognosis
Endometroid

Type II
Post menopausa
Background of atrophy, associated EIC
Highly aggressive, poor prognosis
Histology - serous

Front 46

Microscopic appearance of endometrial carcinoma - She would remember

Back 46

85% are adenocarcinomas
Characterized by a back to back glandlike pattern with a atypical stratified epithelium

HORMONALLY DEPENDENT, and are graded. See next card

Front 47

Grade 1, 2 ,3 of endometroid cancer

Back 47

Grade 3 - no glandular features - wall to wall tumor cells

Grade 2 - solid areas and some glandular features

Grade 1 - less than 5% are solid pattern

Front 48

Adenosquamous carcinoma vs Adenocarcinoma with squamous metaplasia

Back 48

Histologically malignant squamous cells which make up more than 10% of the tumor

Front 49

Papillary serous carcinoma ?

Back 49

High grade
Made of papillary fibrovascular cores lined by serous or mucinous cells

Front 50

Clear cell carcinoma

Back 50

High grade
Made of clear to granular cells
HOBNAIL APPEARANCE

Front 51

Serous carcinoma

Back 51

Often papillary not always
Cytological atypia - smudgy, bizzare often hobnailed nuclei
Often has Psammoma bodies - not specific
High grade

Front 52

Staging of endometrial carcinomas ?

Back 52

1 - uterine corpus
2- corpus and cervic
3 - outside uterus but inside pelvis
4- outside pelvis or involves mucosa of the bladder or rectum

Front 53

Most common sarcomas ?

Back 53

These high grade ones are
Leiomyosarcomas and ednometrial stromal sarcomas

Front 54

MMMT

Back 54

Consist of ADENOCARCINOMAS and SARCOMA elements

Highly malignant

Front 55

Leiomyomas

Back 55

M O S T C O M M O N T U M O R in women

Estrogen responsive

May regress (menopause) or grow (pregnancy)

Front 56

Gross and histology ?

Back 56

Well circumscribed, uniform size and shape.

The cells are laced layers of smooth muscles, and cells are uniform with rare mitoses

Front 57

Leiomyosarcoma ?

Back 57

Peak 40-60
Arise from myometrium DE NOVO !
Frequent mitosies and necrosis, and metastazie THROUGH BLOOD

Front 58

Endometrial Stromal tumors

Back 58

Low grade - well differentiated ( bag of worms) stromal cells interlaced between myometrium

High grade - Infiltration and very ugly looking.