Pathology REP

Endometriosis
Definition: Prescence of endometrial glands/tissue or stroma in abnormal
sites outside the uterus (normal site in uterus)
 It is not a neoplasia nor an inflammation
 Occurs in 10% of females
 Immune or genetic factors

Sites of endometriosis:
Pelvic:
1. Adenomyosis (uterus): Endometrial glands in myometrium, non-
functioning glands
2. Ovarian endometriosis
Extra-pelvic:
1. Scars of laparotomy (Previous cesarean section)
2. Umbilicus
3. Vagina
4. Vulva
5. Cervix
Pathogenesis:
1. Regurgitation theory (Theory I): Back flow of endometrial tissue
through the fallopian tubes during menstruation. This explains Ovarian
endometriosis
2. Metaplastic theory (Theory II): Metastasis
3. Vascular/Lymphatic spread theory (Theory III): Explains the distal
sites of endometriosis

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Adenomyosis: Growth of basal layer of endometrium down into
myometrium (muscle of uterus). It is a pre-cancerous lesion

Endometriosis of the ovaries: The problem

with having endometrial tissue outside the
uterine cavity, will be under the hormonal
stimulation (estrogen & progesterone) which
will cause a menstrual cycle in any place
(cyclic bleeding in ovaries/appendix). This is
bad because the bleeding occurs in a closed
off area which causes cysts and bleeding
which is called Chocolate cyst.

Chocolate cyst is dangerous because it may cause reactive fibrosis, damage

to the ovaries, or complete destruction of the ovaries aka infertility
especially if the endometriosis is bilateral (both ovaries)

Complications of endometriosis:
1. Hemorrhage
2. Cyst formation filled with blood
3. Fitsula, cyst rupture, anemia, pyometria (uterine cavity obstruction
followed by infection) and sterility
4. Ovarian endometriosis (chocolate cyst) leads to fibrosis and sterility

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 Endometrial hyperplasia
Endometrium: Epithelial lining of the uterus
Hyperplasia: Increase in number of cells
Definition: Increase number of endometrial glands and stroma due to
prolonged estrogen stimulation

Grades of endometrial hyperplasia:

1. Mild/Simple: no cystic change
2. Moderate/Adenomatous: cystic change
3. Severe/Atypical: cystic change. Misdiagnosed as adenocarcinoma

Age affected by endometrial hyperplasia: perimenopausal; a period that

begins a few years before the last menstrual cycle. (40-44)

Microscopically:
1. Endometrial glands are variable in size and shape
2. Increase in their number; lined by one or more layers of columnar cells
3. Cystic changes with increased severity
4. Increase in number of glands and stroma due to estrogen stimulation (inc
in no. of glands only is neoplasia)
5. Swiss cheese appearance

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Differential diagnosis of atypical hyperplasia and adenocarcinoma through;
Features present in adenocarcinoma and absent in atypical/severe
hyperplasia:
1. Marked pleomorphism and loss of polarity
2. Complex branching disordered glands
3. Extensive papillary formation
4. Confluent (adherent) glandular pattern with solid or cerebriform (like
brain) appearance
5. Desmoplastic (fibrous) stroma

Clinical picture: Abnormal uterine bleeding, especially if perimenopausal

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 Tumors of the Uterus
Benign tumors:
1. Polypi
2. Leiomyoma or fibroma (submucous, intramural, or subserous)

Endometrial Polyp
Leiomyoma
Definition: Benign tumor of myometrium (smooth muscles) of uterus
 Most common benign tumor in females
 30-50% of women during active reproductive life
 Estrogen and OCP (oral contraceptive pills) stimulate its growth
 Size shrinks in post-menopausal period
 Pelvic mass may be formed
 Malignant transformation is very rare forming leiomyosarcomas

Gross picture:
1. Well circumscribed
2. Whorly appearance
3. Single or multiple, small or large
4. Some are embedded within the myometrium (intramural)
5. Some lie beneath the endometrium (submucous)
6. Some lie directly beneath the serosa (subserous)
7. Large tumors shows areas of hemorrhage and necrosis and cyst
formation. (like renal cell carcinoma??)

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Microscopic picture:
1. Whorly bundles of smooth muscles
2. Fibrosis
3. Schemic necrosis
4. Hemorrhage
5. Cystic degeneration
6. Calcification

Types of leiomyoma:
A. Submucosal: Leiomyoma projecting beneath endometrium (towards the
uterine cavity)
B. Interstitial/Intramural: Leiomyoma enclosed within myometrium
C. Subserosal: Leiomyoma projecting from the serosa

Complications in leiomyoma:
1. Infertility
2. Hemorrhage
3. Abortion
4. Degeneration
5. Malignancy, rare (Leiomyosarcoma)

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 Malignant endometrial (uterus) tumors:
1. Carcinoma of endometrium
2. Sarcoma
3. Secondary: usually from other sites in the female genital system

Endometrial carcinoma
Age: 55-65
Risk factors:
1. Obesity
2. Diabetes
3. Hypertension
4. Infertility
5. Single woman
6. Increased estrogen stimulation
7. Atypical endometrial hyperplasia (most important)
8. Breast carcinoma

Clinical picture:
1. Abnormal bleeding
2. Leucorrhea
These occur in the postmenopausal period

Two gross picture types:

1. Infiltrating: diffuse thickening in wall of uterus and narrowing of cavity
2. Exophytic: fungating cauliflower mass filling the uterine cavity
(bleeding, necrosis)

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Types of Endometrial carcinoma:
1. Adenocarcinoma, since the only type of epithelium present is the
glandular and squamous like cancer cervix
2. Endometrioid carcinoma: Most common type. Well differentiated
adenocarcinoma that looks like an endometrium gland with clear gland
formation.
Less differentiated tumors fail to produce glands and instead produces
solid sheets
3. Benign squamous element with malignant Endometrial carcinoma
(adenocarcinoma) is called Adenoacanthoma
4. Malignant squamous element with malignant Endometrial carcinoma
(adenocarcinoma) is called Adenosquamos carcinoma
5. Mixed Mullerian Tumor
6. Papillary serous carcinoma
7. Clear cell carcinoma

Grades of Endometrial carcinoma:

1. Grade I: Well differentiated
2. Grade II: Less differentiated
3. Grade III: Poorly differentiated

Stages of spread:
1. Stage I: Confined to uterine body
2. Stage II: Body and cervix
3. Stage III: Outside uterus, but not outside the pelvis
4. Stage IV: Lung metastasis

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Spread:
1. Direct local invasion
2. Via lymphatics
3. Blood spread

Complications:
1. Malignant fistula
2. Pyometra
3. Renal failure
4. Hemorrhage

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 Tumors of the Ovary

A. Solid/Cystic/Functioning
B. Cell of origin
1. Surface epithelium
2. Ovarian stroma
3. Germ cell

Tumors of the surface epithelium

Serous Tumors
Serous cystadenoma ovary
 Most frequent ovarian tumor
 Age: 30-40
 Solid or cystic
 60% benign
 25% malignant serous papillary cystadenoma
 15% low malignant potential (borderline)
 If benign: Serous cystadenoma
 If malignant: Serous cystadenocarcinoma
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Cut section:
1. Single cavities
2. Unilocular
3. Clear serous fluid
4. Papillary projections (more common with malignant type)

Microscopically:
1. In cystadenoma: Single layer of tall columnar epithelium and
psammoma bodies
2. In cystadenocarcinoma: Atypical lining epithelium (anaplasia) with
hyperchromasia, pleomorphism, invasion of the stroma, papillary
formation, and multiple layers of lining epithelium.

Psammoma body:
 Necrotic and apoptotic tumor cells
 Calcified
 Found on tips of papillae.
 Concentrically laminated (circular layers)
 More commonly found in serous cystadenoma than
cystadenocarcinoma

Spread:
Malignant spread to peritoneal cavity

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 Mucinous Tumors
Mucinous cystadenoma ovary
 May rupture from the peritoneum cavity and release mucin and this is
called Pseudomyxoma Peritonei
 Can happen in appendix and is called mucocele of the appendix
 Mucin-secreting cell lining
 5% of benign and 20% of malignant are bilateral
 Solid areas mean malignancy with stromal invasion
 If benign: Mucinous cystadenoma
 If malignant: Mucinous cystadenocarcinoma

Mucinous cystadenoma Serous cystadenomas

Lining epithelium Tall columnar mucin Tall columnar

secreting epithelium and
psammoma bodies
Size Larger Smaller
Cut section Multilocular Unilocular
% of malignancy 5% benign 75% 60% benign 25%
malignant 20% malignant 15%
bilateral bilateral
Psammoma bodies Not found found
Papillary formation Prominent less
 Apical vacuolation is characteristic of mucinous cystadenoma
Microscopically:
Lined by tall columnar mucin secreting of endocervical-like type and
intestinal-like type.

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 Mucinous cystadenocarcinoma
Serosal penetration points to malignancy which is called Mucinous
cystadenocarcinoma
Mucinous cystadenocarcinoma has malignant the following features:
typical lining epithelium (anaplasia) with hyperchromasia, pleomorphism,
invasion of the stroma, papillary formation, and multiple layers of lining
epithelium.

Less common tumors:

 Endometrioid tumors:
1. cystic or solid
2. Amidst chocolate blood
3. Tubular glands like those of endometrium
4. Usually malignant
 Cystadenofibroma:
1. Variant of serous cystadenoma
2. But with dense fibrous stroma
 Brenner tumor:
1. Rare, solid, unilateral, mostly benign
2. Nests of transitional epithelium (urothelium)

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 Teratomas
Definition: Totipotent (stem cells in ovary capable of giving rise to any
cell type) germ cell tumor
 15-20% of ovarian tumors
 Benign more common than malignant
 Types:
A. Benign mature cystic teratoma
B. Immature malignant teratoma
C. Specialized teratomas: struma ovarii

Benign/Mature cystic teratoma

(Dermoid cyst)
 Lined by epidermis with underlying skin adnexa of sebaceous, sweat
glands, and hair shafts. Older patients
 Lumen filled with sebaceous material, hir tufts, and teeth
 Foci of cartilage, bone bronchial epithelium, brain, gastro-intestinal
glands
 1% show malignant foci of squamous carcinoma

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 Malignant/Immature teratoma
 Early in life: around 18 years
 Solid with necrotic areas
 Immature cartilage, bone, muscle, nerve
 Foci of neuro-epithelial differentiation
 Poor prognosis: metastasis and spread

Struma ovarii
 Mature thyroid tissue in treatoma
 May be hyperfunctional/hyperthyroidism (over production of T3 & T4)
 Good finding

Metastatic ovarian tumors

krukenberg tumor
 Older age
 Bilateral
 Solid gray necrotic mass
 Metastatic signet ring adenocarcinoma cells in dense fibrous stroma
 1ry: from breast, lung and GIT

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