Uterine Malignancy

Question 1

Define hyperplasia

Answer 1

Increase in cell number

Question 2

What causes endometrial hyperplasia?

Answer 2

Unknown - persistent oestrogen stimulation?

Question 3

How will endometrial hyperplasia present?

Answer 3

Abnormal bleeding

Question 4

Describe simple hyperplasia

Answer 4

General distribution with dilated glands and stroma, with normal cytology

Question 5

Describe complex hyperplasia

Answer 5

Focal distribution with crowded glands but normal cytology

Question 6

Describe atypical hyperplasia

Answer 6

Focal distribution with crowded glands and atypical cytology - abnormal nuclei

Question 7

What is the peak incidence of endometrial carcinoma?

Answer 7

50-60 years old

Question 8

Name the two precursors to endometrial carcinoma

Answer 8

Atypical hyperplasia

Serous intraepithelial carcinoma

Question 9

How does endometrial carcinoma present?

Answer 9

Abnormal bleeding - post menopausal

Question 10

Where will endometrial carcinoma spread?

Answer 10

Directly to myometrium and cervix
Lymphatic
Haematogenous

Question 11

Name the two types of endometrial carcinoma

Answer 11

• serous and clear cell

- endometriod and mucinous

Question 12

What grade is serous carcinoma?

Answer 12

Always high grade

Question 13

Describe serous carcinoma

Answer 13

Almost always have a p53 mutation, complex papillary/glandular appearance with marked pleomorphism and inflammation

Question 14

Describe clear cell carcinoma

Answer 14

Tubulocystic with no mutations

Question 15

How does endometrioid carcinoma arise?

Answer 15

Unopposed oestrogen - no progesterone to inhibit growth

Question 16

What mutations can be present in an endometrioid carcinoma?

Answer 16

PTEN, KRAS, PIK3CA

Question 17

What does endometrioid carcinoma look like?

Answer 17

Closely packed back to back glands with an irregular saw tooth lumena

Question 18

State two key risk factors for endometrial carcinoma

Answer 18

Obesity

Lynch Syndrome

Question 19

Why is obesity a risk factor for endometrial carcinoma?

Answer 19

Adipocytes express aromatase which converts androgens to oestrogen and induces proliferation
SHBG is lower and therefore unbound hormone is higher

Question 20

Why is lynch syndrome a risk factor for endometrial carcinoma?

Answer 20

Inheritance of DNA mismatch repair gene by autosomal dominant inheritance characterised by micro satellite instability

Question 21

What has a worse prognosis endometrioid or serous?

Answer 21

Serous is more likely to spread into the peritoneal cavity

Question 22

Describe the staging of endometrial carcinoma

Answer 22

IA - no or <50% myometrial invasion
IB - >50% myometrial invasion
II - tumour invade cervical stroma
IIIA - tumour invades serosa of uterus
IIIB - vaginal invasion +/- parametrial involvement
IIIC - metastases to pelvis +/- para-aortic nodes
IV - invades bladder, bowel or distant mets

Question 23

Describe the grading of endometrial carcinoma

Answer 23

1 <5% solid growth
2 6-50% solid growth
3 >50% solid growth

Question 24

Other than endometrial carcinoma what other malignant tumours can arise from the uterus?

Answer 24

Endometrial stromal sarcoma
Carcinosarcoma
Leiomyosarcoma

Question 25

Describe a low grade endometrial stromal sarcoma

Answer 25

Similar appearance to normal stroma but can recur outside of the uterus

Question 26

Describe a high grade endometrial stromal sarcoma

Answer 26

Increased atypia, pleomorphism and proliferation

Question 27

How do endometrial stromal sarcomas present?

Answer 27

Abnormal uterine bleeding but initial presentation may be as metastases (lungs/ovary)

Question 28

What is carcinosarcoma?

Answer 28

Grade 3 endometrioid, serous, clear cell with elements of sarcoma

Question 29

What is meant by heterologous elements?

Answer 29

Don't belong in the uterus

Question 30

What are the common heterologous elements?

Answer 30

- rhabdomyosarcoma - chondrosarcoma - osteosarcoma

Question 31

What is the pathological name for a fibroid?

Answer 31

Leiomyoma

Question 32

How can fibroids present?

Answer 32

Menorrhagia Infertility Pressure symptoms

Question 33

Name six types of fibroid

Answer 33

``` Subserous - poke outwards Intramural - within the wall (most common) Submucous - push into the cavity Pedunculated - grow on a stalk Seedling - baby ones Cervical ```

Question 34

What is the malignant transformation of leiomyoma?

Answer 34

Leiomyosarcoma

Question 35

What is a leiomyosarcoma?

Answer 35

Malignant smooth muscle tumour commonly displaying haemorrhage and spindle cell morphology or necrosis

Question 36

What are the symptoms of leiomyosarcoma?

Answer 36

Abnormal vaginal bleeding Palpable pelvic mass Pelvic pain

Question 37

What investigations are done in suspected uterine malignancy?

Answer 37

Transvaginal ultrasound Endometrial biopsy Dilatation and curettage Hysteroscopy

Question 38

How are uterine malignancies treated?

Answer 38

surgery radiotherapy high dose progesterone chemotherapy

Question 39

What surgical treatments can be done in uterine malignancy?

Answer 39

Hysterectomy and bilateral sapling-oophrectomy | Lymphadenectomy

Question 40

Where do uterine malignancies tend to recur?

Answer 40

Vaginal vault

Question 41

If a patient is unsuitable for surgery what treatment is available?

Answer 41

Radiotherapy or high dose progesterone

Question 42

If a uterine malignancy is widespread what treatment is available?

Answer 42

Chemotherapy