uterus pathology

uterus

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Normal

endometrium
- stages
  - atrophic
  - inactive
  - proliferative
  - secretory
  - breakdown
    - menstrual
    - DUB
- stroma
  - decidualization
  - arias stella
  - lymphoid nodule
- hormone effects
  - gestational
  - hormones
  - IUD
- artifacts
  - intravascular menstrual endometrium
  - cervical mucus
    - lots of PMNs
  - telescoping
  - thermal artifact
    - vacuolation
  - glandular molding
    - mimicks crowding but with tearing of surrounding stroma
  - pseudopapillary endometrium
    - lots of strips of endometrium
  - histiocytes
    - can have vacuoles and look like signet ring cells
- other
  - lower uterine segment
    - inactive glands
    - mucinous endocervix glands
    - fibrous stroma
- stains
  - glands
    - positive: ER/PR, Bcl-2 (during proliferative), CK7, p63 (some basal/reserve cells)
    - negative: CK20
  - stroma
    - positive: CD10, Bcl-2
    - negative: CD34
myometrium

Non-neoplastic

endometrium
- Inflammation
  - endometritis
  - malakoplakia
  - lymphoma like lesion
  - granulomas
  - ligneous endometritis
  - radiation
- disordered proliferative
- endometrial hyperplasia
- metaplasia
  - epithelial
    - squamous metaplasia
    - mucinous
    - tubal
    - clear cell
    - hobnail
    - eosinophilic
    - papillary syncytial
    - arias stella
    - papillary proliferation
  - mesenchymal
    - smooth muscle
    - cartilagenous
    - osseous
    - glial
    - adipose
    - extramedullary hematopoiesis
- Polyps
- Adenofibroma
- Placental site nodule
myometrium
- adenomyosis
- adenomyoma

WHO neoplasms

epithelial
- endometrial carcinoma
  - endometrioid adenocarcinoma
    - villoglandular adenocarcinoma
    - secretory variant adenocarcinoma
    - ciliated cell variant adenocarcinoma
    - endometrioid adenocarcinoma with squamous differentiation
  - mucinous adenocarcinoma
  - serous adenocarcinoma
  - clear cell adenocarcinoma
  - mixed cell adenocarcinoma
  - SCC
  - transitional cell carcinoma
  - small cell carcinoma
  - undifferentiated carcinoma
  - rares
    - glassy cell
    - yolk sac
    - giant cell carcinoma
- endometrial hyperplasia
- endometrial polyp
- tamoxifen changes
mesenchymal
- endometrial stromal tumor
- smooth muscle tumor
- misc
  - mixed endometrial stromal and smooth muscle tumor
  - PEComa
  - adenomatoid tumor
mixed epithelial and mesenchymal
- carcinosarcoma
- adenosarcoma
- carcinofibroma
- adenofibroma
- adenomyoma
GTDs
misc
- sex cord like tumor
- neuroectodermal tumor
- melanotic paraganglioma
- tumors of germ cell type
lymphoma
metastasis
- neighbors
  - ovary
  - tubes
- common
  - breast
  - stomach
- less common
  - melanoma
  - lung
  - colon
  - pancreas
  - kidney

Patterns

Biphasic
- carcinosarcoma
- undifferentiated carcinoma
  - solid and well differentiated areas
- endometrioid adenocarcinoma with spindle elements
- atypical polypoid adenomyoma
Breakdown
- menstrual
- DUB
  - focal
  - nonsecretory
low grade endometrioid carcinoma
- low grade endometrioid carcinoma
  - back to back glands with only desmoplasia in between
- atypical hyperplasia
  - in hyperplasia, there's still normal stroma between glands
- hyperplasia with metaplasia
- atypical polypoid adenomyoma
high grade endometrioid carcinoma
- high grade endometrioid carcinoma
  - ER/PR+, p53-, lower Ki67, PTEN loss, MMR mutations
- serous carcinoma
  - can have a prominent glandular pattern
  - hobnail, ER/PR-, p53+, high Ki67, normal PTEN, normal MMR
Hobnail
- serous carcinoma
  - papillary
- clear cell carcinoma
  - tubulocystic
  - solid
  - hyaline
- hyperplasia with eosinophilic metaplasia
Hyperplastic
- Hyperplasia
  - normal stroma between glands, even if scant
- Endometrioid adenocarcinoma
  - only desmoplasia between glands
- Menstrual phase with stromal breakdown
Clear cells
- mucinous carcinoma
  - columnar mucinous cells
  - lack hobnail
  - PASD stains mucin
  - glandular
- endocervical adenocarcinoma
  - squamous predominant
  - p16 diffuse and strong
- clear cell carcinoma
  - papillary, solid, tubulocysitc
  - Polygonal glycogen cells, hobnail, high grade
  - PASD negative because it's glycogen
- endometrioid carcinoma secretory type
  - low grade
  - PASD negative because it's glycogen
- cervical microglandular hyperplasia
  - young, no cytologic atypia
- cervical mucus
  - contains PMNs
Papillary
- villoglandular
  - columnar cells
  - low grade
- serous
  - high grade
  - hobnail, nuclear atypia
- complex papillary hyperplasia
- IUD effect
  - micropapillary
  - mimicks small focus of serous
Squamous
- endometrioid carcinoma with squamous differentiation
- squamous metaplasia
  - typical and morular
- granulomas
  - can look like squamous morules
- adenosquamous carcinoma of endocervix
  - more squamous predominant
  - mucinous/signet ring cells
Tubulocystic
- clear cell carcinoma
- yolk sac tumor
Undifferentiated
- undifferentiated carcinoma
  - may have CD138, synaptophysin, chromogranin
- endometrioid carcinoma high grade
- lymphoepithelial like carcinoma
- lymphoma
- plasmacytoma
- small cell carcinoma
- rhabdomyosarcoma
Vacuoles
- endometrioid carcinoma secretory type
  - glandular
- arias stella
- clear cell carcinoma
  - rarely glandular
- endometrioid carcinoma with squamous differentiation
- atypical hyperplasia with secretory effect

Stains

p53
- overexpression
  - serous
  - clear cell
  - undifferentiated
  - endometrioid high grade
- low
  - endometrioid
PTEN
- mutated in: endometrioid (frequent)
ER/PR
- positive
  - endometrioid
    - FIGO1, 2, half of 3
  - normal endometrium
- negative
  - endocervical adenoma
    - may be limited/focal
  - serous
p16
- diffuse and strong in endocervical adenocarcinoma
- patchy in endometrioid adenocarcinoma
PAS positive
- mucinous ca
- secretory type
- clear cell
Ki-67
- high in serous
- low in endometrioid
WT1
- common diffuse nuclear expression in ovarian, tubal, primary peritoneal serous
- infrequent in endometrial serous
CD10, Bcl2, CD34
- endometrial stroma: CD10+, Bcl2+, CD34-
- cervical stroma: CD10- (may have some around glands), Bcl2-, CD34+

TNM (useful for grossing)

non-trophoblastic
- T1: confined to uterine corpus
  - T1a: endometrium confined
  - T1b: invades < 1/2 myometrium
  - T1c: invades > 1/2 myometrium
- T2: invades cervix
  - T2a: endocervical glandular involvement only
  - T2b: cervical stromal invasion
- T3: regional spread
  - T3a: involves serosa, adnexa or peritoneal fluid
  - T3b: vaginal involvement
- T4: invades bladder or bowel mucosa
- Regional nodes
  - pelvic
    - hypogastric (obturator, internal iliac)
    - common and external iliac
    - parametrial
    - sacral
  - para-aortic
trophoblastic
- T1: confined to uterus
- T2: extension to vagina, ovary, broad ligament, fallopian tube
- M1a: lung metastasis
- M1b: other distant metastasis

Staging

non-trophoblastic
- IA: T1a
- IB: T1b
- IC: T1c
- IIA: T2a
- IIB: T2b
- IIIA: T3a
- IIIB: T3b
- IIIC: N1
- IVA: T4
- IVB: M1
trophoblastic
- I: T1
- II: T2
- III: M1a
- IV: M1b
- each stage can be further divided into A and B based on a prognostic score

Sign out

endometrial biopsy
- disordered proliferative endometrium with glandular and stromal breakdown
- No hyperplasia, atypia, carcinoma, endometrial polyp, or endometritis identified
benign hysterectomy
- Cervix: Benign ectocervix and endocervix
- Endometrium: inactive endometrium, no carcinoma seen
- Myometrium: Small intramural leiomyomata, no malignancy identified
- left/right ovary: benign ovary
- left/right fallopian tube: benign fallopian tube