Uterine Malignancy

Question 1

what can cause disordered uterine bleeding?

Answer 1

endometrial polyps
endometral hyperplasia (simple/complex/atypical)

Question 2

what are the main things to look for on endometrial biopsy?

Answer 2

malignancy
inflammation
presence/absence of hyperplasia

Question 3

what can cause endometrial hyperplasia?

Answer 3

possibly persistent oestrogen stimulation

Question 4

what categories are used to describe hyperplasia?

Answer 4

distribution
component
glands
cytology

Question 5

features of simple hyperplasia?

Answer 5

general distribution
component = glands and stroma
glands = dilated, not crowded
cytology = normal

Question 6

features of complex hyperplasia?

Answer 6

focal distribution
component = glands only
glands = crowded, not round
cytology = normal

Question 7

features of atypical hyperplasia?

Answer 7

focal distribution
component = glands only
glands = more crowded, irregular in shape
cytology = atypical

Question 8

what change in glands is classed as malignancy?

Answer 8

once the glands start to fuse

Question 9

peak age for endometrial cancer?

Answer 9

50-60 yrs

uncommon under 40

Question 10

what can pedispose to endometrial carcinoma in young women?

Answer 10

PCOS

lynch syndrome

Question 11

2 main groups of endometrial carcinoma with different precursor lesions?

Answer 11

endoemtrioid carcinoma (precursor = atypical hyperplasia)
serous carcinoma (precursor = serous intra-epithelial carcinoma)

Question 12

how does endometrial carcinoma generally present?

Answer 12

abnormal bleeding

- post menopausal

Question 13

macroscopic features of endometrial carcinoma?

Answer 13

large uterus

polypoid

Question 14

microscopic features of endometrial carcinoma?

Answer 14

most are adenocarcinomas

most are well differentiated

Question 15

how might endometrial carcinoma spread?

Answer 15

directly into myometrium and cervix
lymphatic
haematogenous

Question 16

staging via direct spread?

Answer 16

into inner half of myometrium = stage 1A
into outer half of myometrium = 1B
into cervix = stage 2

Question 17

what mutation is typically present in serous (and clear cell) endometrial carcinoma?

Answer 17

P53

Question 18

type 1 endometrial carcinoma?

Answer 18

endometroid (and mucinous)
- 80% of cancers
related to unopposed oestrogen and associated with atypical hyperpalsia

Question 19

type 2 endometrial carcinomas?

Answer 19

serous (and clear cell)

- not associated with unopposed oestrogen and affect elderly post-menopausal women

Question 20

what is type 1 endometrial carcinoma associated with?

Answer 20

endometrioid and mucinous phenotypes
PTEN, KRAS and PIK3CA mutations
atypical hyperplasia as precursor lesion
microsatelite instablity (lynch syndrome)

Question 21

name a large risk factor for endometrial cancer and why?

Answer 21

obesity

associated with the endocrine and inflammatory effects of adipose tissue

Question 22

how does obesity increase risk of endometrial cancer?

Answer 22

adipocytes express aromatase that converts ovarian androgens into oestrogens which induce endometrial proliferation
sex hormone-binding globulin levels are lower in obesity therefore the level of unbound biologically active hormone is lower
lower level of insulin-binding globulins and free insulin levels are elevated (insulin and IGF exert proliferative effect on endometrium)

Question 23

does weight loss affect endometrial cancer risk?

Answer 23

yes

reduces it

Question 24

what is lynch syndrome?

Answer 24

cancer predisposition syndrome (AKA hereditary non-polyposis colorectal cancer)
causes high risk of colorectal, endometrial and ovarian cancer

Question 25

what causes lynch syndrome?

Answer 25

AD inheritance of defective DNA mismatch repair gene

Question 26

features of lynch syndrome tumours?

Answer 26

can be identified via immunohistochemistry staining of tumour for mismatch repair proteins tumours show microsatellite instability (MSI) - a characteristic of defective mismatch repair

Question 27

how do type 2 endometrial carcinomas develop?

Answer 27

precursor leison = serous endometrial intraepithelial carcinoma this spreads along fallopian tube mucosa and peritoneal surfaces so can present with extra-uterine disease

Question 28

how are type 2 endometrial carcinomas managed generally?

Answer 28

extensive surgery and adjuvant chemo/radiotherapy

Question 29

histology features of serous?

Answer 29

jaggy glands | inflammation

Question 30

histology of clear cell?

Answer 30

hobnail changes

Question 31

general prognosis of endometrial carcinoma?

Answer 31

depends on stage but generally good | serous invades peritoneal cavity early

Question 32

staging of endometrial carcinoma?

Answer 32

depends on histology and depth of invasion - 1A = none or <50% myometrial invasion - 1B = 50+% invasion of myometrium - 2 = tumour invades cervical stroma - 3 = local/regional tumour spread - 3A = tumour invades serosa of uterus and/or adnexae - 3B = vagina and/or parametrial involvement 3C = metastases to pelvic and/or para-aortic lymph nodes - 4A = invades bladder and/or bowel mucosa - 4B = distant metastases

Question 33

grading of endometrial carcinoma?

Answer 33

grade 1 = 5% or less solid growth, well differentiated grade 2 = 6-50% solid growth grade 3 = .50% solid growth, poorly differentiated (serous and clear cell generally not graded)

Question 34

what other endometrial tumours can occur?

Answer 34

endometrial stromal sarcoma (arises from endometrial stroma) carcinosarcoma (mixed with malignant epithelial and stromal elements) used to be called malignant mixed mullerian tumour

Question 35

describe endometrial stromal sarcoma?

Answer 35

can be low or high grade cells resemble endometrial stroma infiltrate myometrium and often the lymphovascular spaces typically presents with abnormal uterine bleeding but initial presentation may be as a metastases

Question 36

describe carcinosarcoma?

Answer 36

rare (<5%) high grade carcinomatous and sarcomatous elements heterologous elements commonly seen in 50% of cases (rhabdomyosarcoma, chondrosarcoma, osteosarcoma) - presence of rhabdomyosarcoma has worst prognosis generally bad outcome

Question 37

what is a leiomyoma and how does is present?

Answer 37

benign smooth muscle tumour (fibroid) | associated with menorrhagia and infertility

Question 38

what is a leiomyosarcoma?

Answer 38

malignant smooth muscle tumour commonly displaying a spindle cell morphology most common uterine sarcoma

Question 39

features of leiomyosarcoma?

Answer 39

usually in women >50 | causes vaginal bleeding, palpable pelvic mass and pelvic pain