ENDOMETRIAL DATING.pptx

Discussion on Endometrial dating, Benign lesions of the endometrium. Referred from standard text books with lots of pictures from reliable sources

1. ENDOMETRIAL DATING Dr TAMIL NILA POST GRADUATE

2. NORMAL MENSTRUAL PHASES NAME OF THE PHASE AVERAGE DURATION RANGE MENSES 5 DAYS 1 – 7 DAYS PROLIFERATIVE PHASE 10 DAYS 9 – 20 DAYS SECRETORY PHASE 14 DAYS 14 DAYS (CONSTANT) MORPHOLOGICAL DATE CHRONOLOGICAL DATE VS

3. GLAND STROMAL RATIO (UNDER 10X) 1:1 MORE GLANDS MORE STROMA NORMAL CYCLING ENDOMETRIUM LATE SECRETORY ENDOMETRIA DECIDUA DYSFUNCTIONAL UTERINE BLEEDING MENSTRUATION ATROPHY INFERTILITY ENDOMETRIAL HYPERPLASIA CARCINOMAS MONOPHASIC SPINDLE CELL PROLIFERATIONS SMOOTH MUSCLE NEOPLASMS ENDOMETRIAL STROMAL NEOPLASM SPINDLED EPITHELIAL NEOPLASM UTERINE SARCOMAS

4. NORMAL PROLIFERATIVE ENDOMETRIUM EPITHELIUM PSEUDOSTRATIFIED MITOTICALLY ACTIVE ELONGATED CELLS STRATUM FUNCTIONALIS NON BRANCHING NON BUDDING SIMILAR SHAPED & EVENLY DISTRIBUTED GLANDS STROMA MITOTICALLY ACTIVE MONOMORPHOUS UNDIFFERENTIATED STROMAL CELLS SCANT CYTOPLASM INDISTINCT CELL MARGINS VASCULATURE UNIFORM, ARBORIZING AND THIN WALLED VESSELS

5. MID PROLIFERATIVE PHASE GLANDS DENSE, ELONGATED PSEUDO STRATIFIED NUCLEUS STROMA - EDEMA CONFUSION WITH PREDECIDUAL PATTERN GLAND CELLS’ NUCLEAR DETAILS STROMAL CELLS’ CYTOPLASMIC MARGINS

6. INTERVAL ENDOMETRIUM GLANDS COILED <50% OF EPITHELIAL CELLS WITH SUB NUCLEAR VACUOLATION EVIDENCE OF SECRETION EVIDENCE OF OVULATION APPEARANCE OF DISTINCTIVE NUCLEOLAR CHANNEL SYSTEM POD 1 & 2 ALSO SHOW THESE FINDINGS

7. EARLY SECRETORY PHASE (POD 2 – 5) GLANDS COILED >50% CELLS WITH LARGE SUBNUCLEAR CYTOPLASMIC VACUOLES MITOTIC FIGURES PRESENT STROMA NON PREDECIDUATED CLINICOPATH CORRELATION H/O MID CYCLE SPOTTING MITTELSCHMERZ

8. MID SECRETORY PHASE (POD 6 – 8) GLANDS FULLY COILED NO CYTOPLASMIC VACUOLATION VESICULAR ROUND NUCLEUS STROMA STROMAL EDEMA NO PREDECIDUA LUMINAL SECRETIONS PRESENT CLINICAL CORRELATION IMPLANTATION

9. LATE SECRETORY (POD 9 – 10) PROMINENT SPIRAL ARTERIOLES (UNDER LOW POWER) VESSEL WALL THICKENING STROMAL CELL CUFFING STROMA PREDECIDUATION BEGIN AROUND ARTERIES -> ISLANDS -> CONFLUENT

10. LATE SECRETORY PHASE POD 12 -13 GLANDS TIGHTLY COILED NON VACUOLATED SECRETORY EPITHELIUM STROMA EXTENSIVELY PREDECIDUATED PATCHY FASHION STROMAL GRANULOCYTES NATURAL KILLER CELLS BEAN SHAPED, DENSE NUCLEI CYTOPLASMIC GRANULES

11. MENSTRUATION DISINTEGRATING FRAGMENTS OF SECRETORY ENDOMETRIUM GLANDS APOPTOSIS LINED BY DILATED & FLAT CELLS – SECRETORY EXHAUSTION CELLS LOSE COHESION THIN STRIPS STROMA FULLY PREDECIDUALISED CRUMBLED FIBRIN THROMBI

12. SUMMARY OF ENDOMETRIAL DATING

13. HORMONE INDUCED CHANGES

14. ESTROGENS PROMOTE THE GROWTH OF A NON SECRETORY ENDOMETRIUM ENDOGENOUS – CHRONIC ANOVULATION EXOGENOUS – HORMONE REPLACEMENT THERAPY PREDISPOSES TO ENDOMETRIAL HYPERPLASIA ENDOMETRIAL CARCINOMA (2-15 FOLD INCREASED RISK) – WELL DIFFERENTIATED AND SUPERFICIAL WITH GOOD PROGNOSIS

15. PROGESTATIONAL AGENTS THERAPEUTIC & CONTRACEPTIVE PURPOSES CHANGES SEEN MAINLY IN STROMA – PSEUDODECIDUAL CHANGES GLANDS SMALL WIDELY SEPARATED ATROPHIC TAKES WEEKS TO RETURN TO NORMAL PATTERN ON DISCONTINUATION ARIAS STELLA REACTION

16. ARIAS STELLA REACTION CAN BE FOCAL, EXTRA ENDOMETRIAL GLANDS HYPERSECRETORY LARGE CELLS CYTOPLASM – EOSINOPHILIC, ABUNDANT NUCLEI – IRREGULAR LARGE, SMUDGED, PLEOMORPHIC

17. SYNTHETIC PROGESTERONE RECEPTOR MODULATORS INDICATION ENDOMETRIOSIS UTERINE LEIOMYOMAS GLANDS ATROPHIC OR INACTIVE EPITHELIUM CYSTIC DILATED DYSSYNCHRONY BETWEEN GLANDS AND STROMA THICK WALLED CORDED VESSELS CLOSE TO SURFACE EPITHELIUM CILIARY METAPLASIA IS COMMON

18. TAMOXIFEN SYNTHETIC ANTI-ESTROGEN INDICATION : PROPHYLAXIS OF BREAST CARCINOMA PARADOXICAL ESTROGENIC EFFECT IN THE ABSENCE OF OVARIAN OESTROGEN CAUSES HYPERPLASIAS POLYPS MALIGNANT TUMOURS ENDOMETRIAL CARCINOMA WITH BAD PROGNOSIS

19. GESTATIONAL ENDOMETRIUM EARLY COINCIDENCE OF GLANDULAR LUMINAL SECRETION PRE DECIDUALISATION STROMAL EDEMA FULLY DEVELOPED GLANDS FLATTENED OR CUBOIDAL LINING NUCLEAR INCLUSIONS – BIOTIN ACCUMULATION SURROUNDED BY SHEETS OF DECIDUA ASSOCIATED FINDINGS – CHORIONIC VILLI, PLACENTA, FETAL PARTS ETC

20. NON NEOPLASTIC CONDITIONS

21. ACUTE ENDOMETRITIS INFLAMMATORY CELLS ARE NORMALLY PRESENT ON DAYS 26,27,28 ACUTE ENDOMETRITIS ABORTION POSTPARTUM STATE INSTRUMENTATION INFILTRATION & DESTRUCTION OF GLANDS BY PMNs

22. CHRONIC ENDOMETRITIS INFILTRATION BY LYMPHOCYTES, PLASMA CELLS & EOSINOPHILS CAUSES PREGNANCY ABORTION SUBMUCOSAL FIBROID IUD/ CERVICITIS SYMPTOMS INFERTILITY BLEEDING PV PELVIC PAIN ASYMPTOMATIC IUD FOCAL OR EXTENSIVE NECROSIS SQUAMOUS METAPLASIA

23. ACTINOMYCES CENTRAL BRANCHING FILAMENTS DIPHETHEROID FORMS DEVELOPS FOLLOWING INSERTION OF IUD HEMATOMETRA CERVICAL OCCLUSION MICROSCOPY DISAPPEARANCE OF MUCOSA LIPID CONTAINING HISTIOCYTIC CELSS – XANTHOGRANULOMATOUS ENDOMETRITIS YELLOWISH-BROWN CYTOPLASMIC PIGMENT – CEROID CONTAINING HISTIOCYTIC GRANULOMA

24. ENDOMETRIAL TUBERCULOSIS SYMPTOMS MENSTRUAL ABNORMALITY INFERTILITY AFB IN TUBERCLES/CULTURE GRANULOMAS CONCENTRATE IN SUPERFICIAL LAYERS TAKE EM BX DURING LATE SECRETORY PHASE

25. OTHERS CHLAMYDIA – IHC OF ANTIGENS OR PCR, PLASMA CELLS VIRAL INFECTIONS – CMV, HPV – GRANULOMATOUS COCCIDIODOMYCOSIS – FROM LUNG INFECTION POSTOPERATIVE GRANULOMAS – ENDOMETRIAL ABLATION SARCOIDOSIS GRANULOMATOUS REACTION SPREADS TO MYOMETRIUM

26. HOW TO AVOID OVERDIAGNOSIS? ABNORMAL CYCLIC PATTERN FOCAL MONONUCLEAR INFILTRATE INFLAMMATORY CELLS IN THE GLANDULAR LUMINA DENSE STROMA A STELLATE STROMAL PATTERN OF PROLIFERATION FOCI OF NECROSIS OR CALCIFICATION

27. METAPLASIA - SQUAMOUS MOST COMMON – PRE MENOPAUSAL, PCOS FRANK KERATINIZATION – ICTHYOSIS UTERI NON KERATINISED SQUAMOID CELLS DIFFUSE – ADENOACANTHOSIS AGGREGATES - MORULES MORULAR METAPLASIA FUNCTIONALY INERT NO SEX HORMONE RECEPTORS LOW PROLIFERATION RATE CDX2 – INTESTINAL TRANSCRIPTION FACTOR +VE

28. METAPLASIA – CILIATED (TUBAL) SCATTERED CILIATED CELLS ARE NORMAL IN THE ENDOMETRIUM MARKEDLY INCREASED – METAPLASIA COMMON IN ATROPHIC ENDOMETRIUM NOT A SIGNIFICANT RISK FACTOR FOR ADENO CARCINOMA

29. METAPLASIA - PAPILLARY SYNCTITIAL TO PAPILLARY AGGREGATES OF EOSINOPHILIC CELLS ENDOMETRIAL BREAKDOWN

30. MUCINOUS METAPLASIA MORPHOLOGICALLY, HISTOCHEMICALLY & ULTRASTRUCTURALLY SIMILAR TO ENDOCERVICAL MUCOSA COMMON IN ENDOMETRIAL POLYPS EOSINOPHILIC METAPLASIA CELLS WITH ABUNDANT EOSINOPHILIC CYTOPLASM HOBNAIL & CLEAR CELL METAPLASIA EPITHELIUM – CLEAR, TALL CELLS WITH APICALLY LOCATED NUCLEI

31. ADENOMYOSIS PRESENCE OF ISLANDS OF ENDOMETRIAL GLANDS AND STROMA DEEP WITHIN THE MYOMETRIUM NON FUNCTIONAL – BASAL LAYER OF ENDOMETRIUM LESS PROLIFERATIVE RATE FOUND IN PROLIFERATIVE PHASE ENDOMETRIOSIS OCCURRENCE OF ENDOMETRIAL TISSUE OUTSIDE THE UTERUS FUNCTIONAL LAYERS OF THE ENDOMETRIUM MORE PROLIFERATIVE RATE PHASE CHANGES OCCORDING TO CYCLE

32. ADENOMYOSIS & ENDOMETRIOSIS THEORIES CONGENITAL MULLERIAN OR WOLFFIAN RESTS IMPLANTATION OF ENDOMETRIUM LYMPHATIC OR HEMATOGENOUS SPREAD SEROSAL METAPLASIA SYMPTOMS PELVIC PAIN – VARIES WITH THE MENSTRUAL PERIOD INFERTILITY RUPTURE AT THE TIME OF PREGNANCY

33. ADENOMYOSIS - GROSS ENLARGED & GLOBULAR UTERUS MYOMETRIAL HYPERTROPHY – ASYMMETRICAL DEPRESSED SMALL CYSTIC LESIONS NODULES - ADENOMYOMA

34. ENDOMETRIOSIS GROSS BLUISH CYSTIC NODULES SURROUNDED BY FIBROSIS MULTIPLE POLYPOIDAL MASSES – ENDOMETRIOTIC POLYPOSIS

35. MICROSCOPY - ADENOMYOSIS ENDOMETRIAL GLANDS & STROMA ARE SEEN IN THE MYOMETRIUM AT A DISTANCE OF AT LEAST OF 1 LOW POWER (10X) FIELD FROM THE EM-MM JUNCTION ALWAYS IN PROLIFERATIVE PHASE STROMA PREDOMINANT – STROMAL ADENOMYOSIS

36. MICROSCOPY - ENDOMETRIOSIS ENDOMETRIAL GLANDS AND STROMA IN DENSE FIBROUS MASS WITH FRESH AND OLD HEMORRHAGE STROMAL COMPONENT – SMOOTH MUSCLE METAPLASIA

37. ENDOMETRIAL ATROPHY MITOTICALLY INACTIVE CYSTIC ATROPHY CYSTICALLY DILATED GLANDS CUBOIDAL OR FLATTENED LINING

38. WEAKLY PROLIFERATIVE ENDOMETRIUM TUBULAR GLANDS – CELLS WITH PSEUDOSTRATIFIED NUCLEI MITOTIC FIGURES – ABSENT COMMON & NORMAL PATTERN PERIMENOPAUSAL POSTMENOPAUSAL

39. DISORDERLY PROLIFERATIVE ENDOMETRIUM ABSENCE OF UNIFORM GLANDULAR DEVELOPMENT DYSSYNCHRONOUS GROWTH OF THE FUNCTIONALIS NORMAL G:S RATIO IDENTICAL TO LATE PROLIFERATIVE PHASE NORMAL IN PERIMENARCHAL AND PERIMENOPAUSAL AGE GROUP ANOVULATORY CYCLES EXOGENOUS ESTROGEN THERAPY

40. ENDOMETRIAL HYPERPLASIA PROLIFERATING ENDOMETRIUM – GLANDULAR CROWDING INCREASED GLAND STROMAL RATIO = 2:1 OR 3:1 CLASSIFICATION (WHO 2014) ENDOMETRIAL HYPERPLASIA WITHOUT ATYPIA ATYPICAL HYPERPLASIA

41. HYPERPLASIA WITHOUT ATYPIA GLANDS CYSTIC DILATION MINIMAL BUDDING LINING EPITHELIUM – NORMAL LP NO CYTOLOGICAL ATYPIA STROMA COMPRESSED

42. HYPERPLASIA WITHOUT ATYPIA GLANDS MORE BUDDING NO CYTOLOGICAL ATYPIA STROMA VERY MINIMAL

43. ATYPICAL HYPERPLASIA GLANDS BUDDING CYTOLOGICAL ATYPIA CRITERIA FOR ATYPIA NUCLEAR ENLARGEMENT NUCLEAR PLEOMORPHISM LOSS OF NUCLEAR POLARITY INCREASED N:C RATIO EXTENSIVE NUCLEAR STRATIFICATION MITOTIC FIGURES + STROMA VERY MINIMAL

44. ENDOMETRIAL POLYP GROSS : PEDUNCULATED LESION MICROSCOPY GLANDS CYSTICALLY DILATED CROWDED LINING – ATROPHIC/WEAKLY PROLIFERATIVE GLANDS STROMA COLLAGENATED FIBROUS TISSUE, NUCLEAR ATYPIA, INCREASED MITOTIC ACTIVITY HYPERPLASIA, CARCINOMA – FOCAL CENTRAL – LARGE, THICK WALLED BLOOD VESSELS

45. FUNCTIONAL POLYP – CYCLING ENDOMETRIUM ADENOMYOMA – SMOOTH MUSCLE STROMA ATYPICAL POLYPOID ADENOMYOMA – SMOOTH MUSCLE STROMA + ATYPICAL ENDOMETRIAL GLANDS

46. REFERENCES ROBBINS AND COTRAN PATHOLOGIC BASIS OF DISEASE DIFIORE’S ATLAS OF HISTOLOGY WITH FUNCTIONAL CORRELATION STERNBERG’S DIAGNOSITIC SURGICAL PATHOLOGY ROSAI AND ACKERMAN’S SURGICAL PATHOLOGY

47. THANK YOU