Gynecology

Gynecologic lesions of the uterus & its malignancies

dra. Bautista (sshhh! Quiet!)
4th shifting (Dec 2008)
Eryka, Amyra, Rain, Allain

Benign Lesions of the Uterus

 Leiomyomas Etiology of myomas
 Endometrial Polyps • Incompletely understood
 Hematometra

Leiomyomas
• Also called myomas, fibroids, fibromyomas Pathogenesis
• th
Highest prevalence during the 5 decade of life
• Benign tumors of smooth muscle origin
• Mostly arise in any part of the body of smooth muscle origin
• Believed to be due to the degeneration of some smooth
muscles
• Majority is found in the corpus of the uterus Gross appearance
• Some women may develop myomas, some may not
• May appear singly but are most often multiple
• Varies in size from microscopic (5mm) to multinodular,
weighing more than 50 lbs.
• Small, round, firm, solid
Histologic Features
• More prone to grow & become symptomatic in nullliparous
woman
• With continued growth, the myometrium at the edge of the
tumor forms a pseudocapsule (valuable in surgical plane
myomectomy)
• Rare before menarche
• Diminish in size following menopause due to reduction of the
Fate of Myomas
significant amounts of circulating estrogen.
• Occasionally enlarge due to oral contraceptives
• Enlarges during pregnancy
Most Common Types of Myomas
Based on the relative anatomic relationship and position to the
layers of the uterus Degrees of Degeneration
a. Intramural
• within the muscle layer
• Initially, most myomas develop in the myometrium
b. Submucous
• 5-10% of myomas
• “humps & bumps” on D&C
• Most troublesome clinically
• Associated with vaginal bleeding
• Distortion of the uterine cavity → infertility or
abortion
• Rarely enlarges & becomes pedunculated → uterus
will try to expel it → prolapsed fibrous myoma
c. Subserous
• Gives the uterus a knobby contour during pelvic
exam
• Further growth may lead into the pedunculated
myoma wandering into the peritoneal cavity → may
outgrow its uterine blood supply → parasitic myoma
Broad Ligament Myoma
• Growth of myoma in a lateral direction from the uterus Symptomatology
• Difficult to differentiate from a solid ovarian tumor on pelvic
exam
• May cause hydroureter as they enlarge
• Neoplastic transformation is probably a somatic mutation of a
normal myometrium to leiomyoma that is influenced by
estrogen, progesterone and local growth factors such as
insulin-like growth factor 1 and platelet-derived growth factor
• Exact mechanism of stimulus is unclear
• Lighter color than the normal myometrium
• Cur surface: glistening, pearl white with smooth muscle
arranged in a trabeculated or whorled configuration, no
capsule, tumor rounded and well demarcated
• Tumor is rounded & well demarcated from the muscle coat of
the uterus
• No capsule
• Consist of interlacing bundles of smooth muscles & small
amounts of fibrous tissue
• Determined by a relatively poor blood supply
• Arterial supply of myoma of significantly less than that of the
similar sized area of the normal myometrium
• Growth of myoma →outgrow its blood supply → degeneration
1. Hyaline – mildest form
2. Myxomatous
3. Calcific
4. Cystic
5. Red/Carneous or infarction
• Most acute form of degeneration
• Causes severe pain and localized peritoneal
irritation
• Occurs during pregnancy, approximately 5-10%
6. Necrosis
7. Fatty
8. Malignant degeneration
• Incidence: 0.3-0.7%
• Term is ambiguous and may be incorrect
• Unknown whether myoma degenerate into sarcoma
or if sarcoma arise spontaneously in myomatous
uterus
• Incidence increases with age
• Possibility of uterine tumor being leiomyosarcoma is
10 times greater among women in their 60’s than
their 40’s
• Majority of women with intrauterine myomas are asymptomatic
• Rapid growth of uterine myoma after menopause is a
disturbing symptom and is suggestive of leiomyosarcoma

MARY YVETTE ALLAIN TINA RALPH SHERYL BART HEINRICH PIPOY KC JAM CECILLE DENESSE VINCE HOOPS CES XTIAN LAINEY RIZ KIX EZRA GOLDIE BUFF MONA AM MAAN ADI KC
PENG KARLA ALPHE AARON KYTH ANNE EISA KRING CANDY ISAY MARCO JOSHUA FARS RAIN JASSIE MIKA SHAR ERIKA MACKY VIKI JOAN PREI KATE BAM AMS HANNAH MEMAY PAU
RACHE ESTHER JOEL GLENN TONI
 Gynecology
Gynecologic lesions of the uterus & its malignancies
Page 2 of 6

• Enlargement of an asymptomatic myoma to greater than 8 cm

1. Pressure symptoms from an enlarging pelvic mass in women who has not completed child bearing
• Anterior myoma → pressing the bladder → urinary
frequency & urgency Contraindications
• Posterior myoma → constipation • Pregnancy
• Urinary symptoms more common than rectal • Advanced adnexal disease
symptoms • Malignancy
• Extremely large myomas and broad ligament • Situation in which enucleation of myoma would result in a
myomas → unilateral or bilateral hydroureter severe reduction of endometrial surface so that the uterus
• Digestive disturbance would be functional
• Edema
2. Edema Myomectomy can be done through:
• Acquired dysmenorrheal: most common, frequent • Laparotomy
complaint, associated with increased myometrial • Laparoscopic technique
activity • Resection via cervical canal using hysteroscope
• Milder pelvic discomfort: pelvic heaviness, dull
Indications for Hysteroscopy
aching sensation, may be due to edematous
• Indications for myomectomy
swelling of the myoma
• Severe: vascular compromise → acute degeneration • Asymptomatic myomas when the uterine size is like 14-26
weeks of gestation
or torsion of the pedicle
3. Abnormal Uterine Bleeding • Rapid growth of myoma after menopause
• 30% of women with myoma • Consider age, future reproductive plans
• Menorrhagia – most common
Prolapsed Myoma of the Cervix
• Intermenstrual spotting or disruption of the normal
pattern Management:
• Most popular theory • Vaginal removal & ligation of the base of the myoma –
o Myomas may result in an abnormal hysteroscopic resection
microvascular growth pattern & function of • Antibiotic coverage
vessels in adjacent endometrium
o Theory that amount of menorrhagia is Medical Treatment
directly related to increased endometrial • To reduce the levels of estrogen and progesterone
surface has been disproved o GnRH agonist
o Medroxyprogesterone acetate
Diagnosis of Myoma o Danazol
1. Pelvic Exam o Antiprogesterone RU 486
• Enlarged, firm, irregular uterus
• Differential diagnosis: Advantages & Disadvantages of Pre-OP Treatment
o Pregnancy • Advantages of shrinkage of uterine fibroid
o Adenomyosis o May allow vaginal hysterectomy
o Ovarian neoplasm o May decrease intraoperative blood loss
• After excluding pregnancy, place a metal sound in o May allow Pfannenstiel incision – “bikini type cut”
the uterine cavity to help establish the clinical o May facilitate endoscopic momectomy
diagnosis • Advantages gained by induction of amenorrhea
• Sounding – hysterometer is used to measure the o May correct hypermenorrhea – menorrhagia
uterine depth associated with anemia
2. Ultrasound o May improve ability to donate blood
• Transvaginal, transabdominal
3. Hysteroscopy
o May decrease need for non-autologous blood
transfusion
• Diagnostic & therapeutic
o May atrophy endometrium, facilitating hysteroscopic
4. Hysteropsalpingography
resection
• Contrast media, xray guided, to see the outline of
the uterus Disadvantages of Pre-OP GnRH Tx
5. Hysterosonography
• Delay final tissue diagnosis
6. CT/MRI
• Degeneration of some leiomyomas necessitating piece – meal
Management enucleation at myomectomy
1. Judicious observation • Hypoestrogenic effects (eg. Trabecular bones, vasomotor
• Observe & reevaluate at 6 months interval to flushes)
determine the rate of growth • Cost
• Small asymptomatic myoma • Need to self administer or receive injection in many cases
• Myoma with AUB thorough investigation • Vaginal hemorrhage in approximately 2%
2. Medical
3. Surgical Transcatheter Uterine Artery Embolization
o Myomectomy vs. Hysterectomy • Newest modality
o Consider age, parity, future reproductive plans • Ambulatory non-surgical technique
• 4 deaths in 4000 cases
Classic Indications for Myomectomy • Large-scale randomized clinical trial is desperately needed
• Rapidly expanding pelvis mass • Promising success rate in decreasing menorrhagia
• Persistent abdominal uterine bleeding

• Insert catheter to femoral artery, gel/foam/silicon pushed and
will obstruct uterine artery and myoma will decrease in size
Associated Rare Disease
1. Intravenous Leiomyomatosis
• Rare disease
• Benign smooth muscle fibers severely invade the
venous channels of the pelvis
• Tumor grows by direct extension
• Spaghetti tumor (gross)
2. Leiomyomatosis Peritoneal Disseminata (LPD)
• Benign disease with multiple small nodules over the
surface of the pelvic & abdominal peritoneum
• Mimics disseminated carcinoma
Histologic exam: benign appearing myomas
Associated with recent pregnancy
ENDOMETRIAL POLYPS
• Localized overgrowths of endometrial glands and stroma that
project beyond the surface of the endometrium
• Soft, palliable; single or multiple
• Few millimeters to several centimeters
• Endometrial polyps may be; sessile (broad-based) or
pedunculated (with slender pedicle)
• Prevalence: 20-25% in reproductive age group
• Unknown etiology
• Majority are asymptomatic
• If symptomatic: wide range f abdnornal uterine bleeding
patterns
• No single abnormal bleeding pattern is diagnostic of polyps
• Pedunculated endometrial polyp with long pedicle may
protrude to the external os
• Large polyps contribute to infertility
• Succulent & velvety with large central core
• Usually gray to tan, occasionally red or brown
3 histologic components of Endometrial Polyps
• Endometrial glands
• Endometrial stroma
• Central vascular channel
***malignant transformation – 0.5%***
Differential Diagnosis for Endometrial Polyps
• Submucous Leiomyomas
• Actenomyomas
• Retained products of conception
• Endometrial hyperplasia
• Carcinoma
• Uterine Ca
Management
• Removal (polypectomy) – curettage hysteroscope
• Specimen for biopsy
HEMATOMETRA
• Uterus is distended with blood & secondary to gynatresia –
partial or incomplete obstruction of any portion of the lower
genital tract
• Obstruction of the isthmus of the uterus , cervix or vagina may
be congenital or acquired
2 most common causes of Hematometra
• Imperforate hymen
• Transverse vaginal septum
Causes of acquired lower tract stenosis
Gynecology
Gynecologic lesions of the uterus & its malignancies
Page 3 of 6
• Senile atrophy of endocervical canal & endometrium
• Scarring of isthmus or synechiae (intrauterine adhesion)
• Cervical stenosis associated with surgery
• Radiation therapy
• Cryotherapy or electrocautery
• Malignant disease of the endocervical canal
• Cervical obstruction by tissue following suction curettage
Symptomatology
• Depends on the age of the patient
• Menstrual history
• Rapidity of accumulation of blood in the uterine cavity →
secondary bacterial infection → pyometra
• Early age → primary amenorrhea, cyclic lower abdominal pain
• Incomplete obstruction – spotting of dark brown blood
• Post menopausal
o Asymptomatic
o Pelvic exam – mildly tender, globular uterus
Diagnosis
• History of amenorrhea, cyclic abdominal pain
• Ultrasound
• Probing (perforate/puncture) of cervix with narrow metal dilator
– release of dark brownish discharge
Management
• Dependent on operative relief of the lower tract obstruction.
UTERINE CANCER
1. Cancer of the endometrium or endometrial cancer
2. Sarcoma of the uterus
ENDOMETRIAL CANCER
• Most common malignancy of the female genital tract
• 3rd in Philippines
• Almost all endometrial cancers are adenocarcinoma (from
glands)
• Occurs primarily in postmenstrual women and is increasing
virulent with advancing age
• Role of Estrogen – clearly understood, any factor that
increases exposure to unopposed estrogen increases the risk
of endometrial cancer
Pathognomonic Type of Endometrial Cancer
1. Estrogen dependent
• Younger perimenopausal women with history of
exposure to unopposed estrogen either endogenous
(eg Estrogen-secreting ovarian tumors) or
exogenous (eg pills)
• Tumor begins as hyperplastic endometrium and
progresses to carcinoma
• Better differentiated – more favorable prognosis
2. Estrogen independent
• Older, postmenopausal, thin women
• Less differentiated – poorer prognosis
• Not associated pathologically with endometrial
hyperplasia
• May arise even in atrophic endometrium
Risk factors in Endometrial Cancer
• Unopposed estrogen stimulus
• Unopposed menopausal estrogen-replacement therapy
• Menopause after 52 years of age -2.4x
• Obesity (21-50lbs overweight -2.3x; >50 lbs – 10x)
• Nulliparity – 2-3x
• Diabetes – 2.8x
• Feminizing ovarian tumors – secretes estrogen
 Gynecology
Gynecologic lesions of the uterus & its malignancies
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• Polycystic ovarian syndrome f. Uterine enlargement

• Tamoxifen therapy for breast CA (>2 years)
Endometrial Cancer Diagnosis
Diminished Risk 1. Office endometrial biopsy – out-patient small volume tissue
• Ovulation obtained
• Progestin therapy 2. Hysteroscopy D&C – get sample from the endocervix
• Combination of oral contraceptive
• Menopause prior to 49 year old a. Fractional D&C – endocervical
• Normal weight → endometrium
• Diagnostic procedure of choice ( gold
• Multiparity
standard)
ENDOMETRIAL HYPERPLASIA b. Hysteroscopy – direct visualization of endometrial
• Precancerous surface
• Predominant form: usually present with vaginal bleeding 3. TVS ( transvaginal ultrasound)
• Endometrial thickness > 5mm
Classification of endometrial hyperplasia • Polypid endometrial mass
1. Simple hyperplasia
• Collection of fluid
• Endometrium with dilated glands that may contain
some outpouching and abundant endometrial
Management
stroma
• Ovulation induction
• Cystic hyperplasia
• Cyclic progestin therapy – MPA 10-20 mg
• “Swiss Cheese” hyperplasia
• Continuous progestin tx
• Occurs in hyperplastic endometrium in menopausal
• Periodic endometrial biopsy
or pause menopausal women
• Weakly malignant
• No atypia
2. Complete hyperplasia
• Glands are crowded with very little endometrial
stroma and a very complex gland pattern and
outpouching formations ENDOMETRIAL CANCER PATHOLOGY
• Traditional terminology – variant of adenomatous
hyperplasia with moderate to severe degree of 1. Endometriod cancer
architectural atypia but no cytological atypia • 80%
• Low pre-maliganant potential • Criteria: presence of invasion
• Architecturally complex (budding & infolding) • Desmoplastic stroma
crowded glands with less intervening stroma, no • Glands back to back without intervening stroma
atypia • Extensive papillary pattern
3. Atypical Hyperplasia
• Contain glands with cytologic atypia (criteria: large
• Squamous epithelial differentiation
nuclei, variation of size & shape, lost of polarization) • Adenocanthomas – benign squamous differentiation
• Degree of cytologic atypia is the major determinant
of pre-malignant potential • Adenosquamous cancer – malignant looking squamous
• Increase N:C ratio with irregularity in size and shape element, endometrial cancer with squamous differentiation
of the nuclei
a. Atypical simple hyperplasia Grading
b. Atypical complex hyperplasia Grade 1 Well-differentiated
• Greatest pre malignant potential Grade 2 Moderately differentiated
Grade 3 Poorly differentiated
Endometrial hyperplasia classification
TYPE PROGRESSION TO CA 2. Clear cell cancer
Simple hyperplasia 1% • Less common
Complex hyperplasia 3% • Resembles clear cell carcinoma of the ovary, cervix,
Atypical simple 8% vagina
Atypical complex 29% • Tends to develop on postmenopausal women
• Prognosis much worse than typical endometrial
Diagnosis adenocarcinoma
a. Screening
a. Endometrial sampling, fractional D&C, hysteroscopy
• Cells have hobne configuration arranged in papilla
b. Transavaginal sonography with hyalinized stalk
• Endometrial thickness (>4mm- 3. Serous cancer
hyperplasia) • Uterine papillary serous cancer
c. Progestin challenge • Highly virulent and uncommon
d. Pap smear – 30-70% of endometrial hyperplasia • Histology: epithelial anaplasia & papillary growth
b. Symptoms • Resembles papillary serous of the ovary
a. Vaginal bleeding (peri- or postmenopausal) – classic 4. Secretory cancer
b. Watery pus like discharge • Extremely rare
c. Pain (pelvic pressure or discomfort) – late • Occurs primarily in perimenopausal women
d. Hematometria or pyometria – on postmenopausal
• Diagnosed in the presence of progestational
e. Parametrial induration – late findings
stimulation
 Gynecology
Gynecologic lesions of the uterus & its malignancies
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• Good prognosis • Extra uterine diseases

5. Mucinous cancer
• Extremely rare
Treatment
1. Surgery
• Occurs primarily in postmenopausal women • TAHBSO (total abdominal hysterectomy with
• Can be confused with primary mucinous cancer of bilateral salpinghoopherectomy) + BLND (bilateral
the ovary cervix or bowel lymph node dissection
6. Squamous cell cancer
• Occurs in postmenopausal women • Inspect diaphragm, liver, omentum, pelvic
& aortic lymph node, peritoneal washing,
1988 FIGO STAGING FOR ENDOMETRIAL CANCER omental biopsy/partial omentectomy
Stage 1 IA Tumor limited to endometrium (lining) • Radical hysterectomy with BLND
IB Invasion <1/2 of myometirium • Hysterectomy – remove the uterus & may also
IC Invasion >1/2 of myometrium remove the cervix (total) and vaginal (radical)
Stage 2 2A Endocervical glandular involvement only 2. Radiotherapy – in the early stages of endometrial cancer or in
2B Cervical stroma invasion patients with inoperable cancer
Stage 3 3A Tumor invades serosa &/or adnexa (&/or peritoneum) 3. Chemotherapy – Doxorubicin, Platinum compounds, cisplatin
&/or positive cytology & carboplatin
3B Vaginal metastasis 4. Hormone therapy – progestational agents in the tx of
metastatic ca
3C Metastasis to pelvic &/or para-aortic lymph node
Stage 4 4A Invasion of bladder &/or bowel mucosa
Sarcoma of the uterus
4B Distant metastasis including intraabdominal &/or
inguinal lymph nodes
Uterine sarcoma
• Less than 5% of uterine malignancy
Prognostic factors
1. Clinical factors • Classification is based on determination of resemblance of
• Patient’s age at diagnosis sarcomatous elements in mesenchymal tissue normally found
in the uterus (homologous sarcoma) and from tissues foreign
• Race – white Pxs have higher survival rates than
to the uterus (heterologous sarcoma)
blacks
• Clinical tumor stage: when recognized prognostic Modified classification of uterine sarcoma
factor for endometrial Ca
2. Pathologic factors 1. Pure sarcoma
• Tumor stage a. Homologous (normal/same tissue)
• Histologic type i. Smooth muscle tumors
• Leiomyosarcoma
• Uterine size
• Leiomyoblastoma
• Death of myometrial invasion
• Metastasizing tumors with
• Microscopic involvement of vascular spaces in the
benign histologic appearance
uterus by tumor
o Intravenous
• Spread of lymph nodes, peritoneal cavity, or uterine
leiomyomatosis
adnexa
(spaghetti tumor)
o Metastasizing uterine
Histologic grade
leiomyoma
G1 Mildly differentiated
o Leiomyomatosis
G2 Moderately differentiated
Peritonealis Myosis
G3 Poorly differentiated ii. Endometrial stroma sarcoma
b. Heterologous (foreign tissue)
Best prognosis Poor prognosis i. Rhabdomyosarcoma
Typical adenocarcinoma Papillary serous carcinoma ii. Chondrosarcoma
Better differentiated tumors with or Clear cell carcinoma iii. Osteosarcoma
w/o sqaumous element iv. Liposarcoma
Poorly differentiated w/ or w/o c. Other sarcoma
squamous element 2. Carcinoma
a. Homologous carcinoma (carcinoma + homologous
Pattern of spread sarcoma)
• By lymphatics b. Heterologous carcinoma (carcinoma + heterologous
sarcoma)
Pretreatment evaluation 3. Mullerian
1. History 4. Lymphoma
2. PE
3. Chest Xray, ECG, CBC, Platelet count, blood chemistry Leiomyosarcoma
4. Ultrasound, MRI, CT scan o Most common
5. Cytoscopy, proctosigmoidoscopy, IVP, barium enema
6. Serum CA 125 Determination of malignancy
o # of mitosis/10HPO field
Indications for selective pelvic & para aortic lymph node dissection o Cytologic atypia, abnormal mitotic figures
• Tumor histology – clear cell, serous, sqamous, or grade 3 o nuclear polymorphism
endometriod o 4 mitosis per 10 HPO field – benign clinical stage
• Endometrial invasion, >1/2
• Isthmus – cervical invasion o >5 mitosis per 10 HPO field with cytological
• Tumor size >2cm atypia – diagnosis of leiomyosarcoma
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Gynecologic lesions of the uterus & its malignancies
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o >10 mitosis per 10 HPO field - worst prognosis

o Occur in age 50, occasionally with conjunction of leiomyoma
o Development of leiomyosarcoma from leomyoma (sumera???)
is rare

Signs & symptoms

o Rapid uterine enlargement in peri & post menopausal age
group
o Enlarge pelvic mass, pain, vaginal bleeding

Treatment
o Surgery - TAHBSO
o Exploration laparotomy – special attention to pelvic
& para aortic lymph node
o Radiotherapy – pre & post operative radiotherapy decreases
recurrences
o Chemotherapy
o Doxorubicin – most active single agent in leiomyosarcoma