Uterine Corpus Tumours

Uterine Corpus Tumours

1. Uterus - tumours Dr. Saumya , Dept of Pathology, SIMS www.shadan.in

2. T umours Benign tumors Endometrial polyp Malignant tumors Endometrial carcinoma Endometrial stromal sarcoma (malignant mixed mullerian tumor)

3. Endometrial polyp Exophytic masses – 0.5 to 3cms, single or multiple, sessile Pedunculated masses Asymptomatic . But may bleed when they ulcerate or undergo necrosis Stroma – cytogenetic rearrangements, hence, neoplastic. Glands - reactive, with hyperplasia or atrophy, in secretory phase. Tamoxifen Atrophic polyps – post menopausal women Adenocarcinoma arising from polyp – very rare

4. Endometrial hyperplasia Definition: A n increased proliferation of the endometrial glands relative to the stroma, resulting in an increased gland to-stroma ratio when compared with normal proliferative endometrium. The most common cause of dysfunctional uterine bleeding (DUB) & is associated with hyperestrogenemia

5. Types of hyperplasia: kurman and norris Simple hyperplasia ( cystic hyperplasia, mild hyperplasia) Cystic dilated glands , non-neoplastic, due to anovulatory cycles . Complex hyperplasia ( adenomatous hyperplasia) Overcrowded , closely opposed glands. Some of these are neoplastic contain PTEN (Phosphatase and tensin homolog mutations) & considered as EIN. PTEN- tumor suppressor gene Atypical hyperplasia ( complex / adenomatous hyperplasia with atypia) Overcrowded glands with cytological atypia. Most cases of this category are neoplastic (EIN) and many contain PTEN mutations

6. Associated conditions Obesity (peripheral conversion of androgens to estrogens ) Menopause Polycystic ovarian syndrome [PCOS] Functioning granulosa cell tumors of the ovary Excessive ovarian cortical function (cortical stromal hyperplasia ) Prolonged administration of estrogenic substances ( estrogen replacement therapy

7. Endometrial hyperplasia: It is an important cause of abnormal uterine bleeding. A subset (EIN) is considered a risk factor for endometrial carcinoma. The risk of carcinoma increases as function of the degree of atypia. Both endometrial hyperplasia and adenocarcinoma are associated with hyperestrogenism , microsatellite instability, and mutation of PTEN gene.

8. Hyperplasia without atypia Hyperplasia with atypia

9. Endometrial carcinoma 7% of all invasive carcinomas in women Incidence at present is more than cervix carcinoma as better detection mechanisms have been employed for ca cervix. RISK FACTORS : Obesity , nulliparity , early menarche & late menopause, granulosa cell tumor of the ovary, breast cancer, diabetes , hypertension, infertility& unopposed estrogen

10. Pathogenesis

11. Pathogenesis

12. Type 1

13. Type II

14. Clinical features: Post menopausal women – 55-60 yrs of age. Irregular or postmenopausal vaginal bleeding with excessive leukorrhea Uterine enlargement Diagnosis: Purely based on the biopsy sample taken or fractional curettage sample.

15. Spread:

16. Prognosis Stage I well-differentiated or moderately differentiated endometrioid carcinomas - Surgery , alone or in combination with irradiation 90 % 5-year survival in stage I (grade 1 or 2) disease Stage 2 - 75 % Stage 3 - 50% or less

17. Malignant Mixed Müllerian Tumors Malignant mixed müllerian tumors (MMMTs) ( also referred to as carcinosarcomas ) are endometrial adenocarcinomas with a malignant mesenchymal component . Uterine mesenchymal elements - stromal sarcoma, leiomyosarcoma H eterologous malignant cell types - rhabdomyosarcoma, chondrosarcoma Due to multiple combined mutations - PTEN, TP53, and PIK3CA

18. Gross :

19. Placenta:

20. Placenta:

21. Infection:

22. Gestational trophoblastic diseases: Gestational trophoblastic disease encompasses a spectrum of tumors and tumor -like conditions characterized by proliferation of placental tissue The major disorders of this type are H ydatidiform mole (complete and partial ) I nvasive mole C horiocarcinoma P lacental site trophoblastic tumor ( PSTT)

23. Hydatidiform mole: Characterized histologically by cystic swelling of the chorionic villi, accompanied by variable trophoblastic proliferation A n increased risk of persistent trophoblastic disease (invasive mole) or choriocarcinoma

24. D elicate, friable mass of thin-walled, translucent, cystic, grapelike structures consisting of swollen edematous ( hydropic ) villi Chorionic villi are enlarged, scalloped in shape with central cavitation (cisterns ), and are covered by extensive trophoblast proliferation that involves the entire circumference of the villi In contrast, in partial moles, only a fraction of the villi are enlarged and edematous .

25. Complete mole Partial mole

26. Spontaneous miscarriage or undergo curettage because of ultrasound findings of abnormal villous enlargement Greatly elevated HCG levels Curettage The patients are subsequently monitored for 6 months to a year to ensure that HCG levels decrease to non-pregnant levels 2.5% - progress to Choriocarcinoma

27. Invasive mole Invasive mole is defined as a mole that penetrates or even perforates the uterine wall. There is invasion of the myometrium by hydropic chorionic villi, accompanied by proliferation of both cytotrophoblasts and syncytiotrophoblasts . The tumor is locally destructive and may invade parametrial tissue and blood vessels. Hydropic villi may embolize to distant sites, such as lungs and brain, but do not grow in these organs as true metastases

28. Choriocarcinoma : Malignant neoplasm of trophoblastic cells derived from a previously normal or abnormal pregnancy Rapidly invasive and metastatic 50 % arise from hydatidiform moles, 25% in previous abortions, 22 % follow normal pregnancies , remainder occurring in ectopic pregnancies .

29. Choriocarcinoma is a soft, fleshy, yellow-white tumor that usually has large pale areas of necrosis and extensive hemorrhage

30. No chorionic villi Proliferation of syncytiotrophoblasts and cytotrophoblasts Large hemorrhagic areas Abnormal mitosis Highly Invasive – myometrium, blood vessels, adjacent organs

31. Clinical features: Irregular vaginal spotting of a bloody, brown fluid . This discharge may appear in the course of an apparently normal pregnancy, after a miscarriage, or after curettage . High propensity for hematogenous spread- discovered in metastatic stage The lungs (50%) and vagina (30% to 40%), followed by, brain, liver, bone and kidney Chemotherapy – Methotrexate , 100 % cure rate.

32. Placental Site Trophoblastic Tumor (PSTT ): 2% gestational trophoblastic tumours Neoplastic proliferations of extravillous trophoblasts , also called intermediate trophoblasts Uterine mass, accompanied by abnormal uterine bleeding or amenorrhea and moderately elevated HCG Histologically : Malignant trophoblastic cells diffusely infiltrating endomyometrium . It may follow a normal pregnancy ( half of the cases), spontaneous abortion, or hydatidiform mole. E xcellent prognosis, 10 % to 15% of women die of disseminated disease