Gyn Path Lab

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Gyn Path Lab

• Cheri, Milica, Megan, Ronnie, and Nadeem
• January 21st, 2005

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Case presentation

• 65 yr old mildly obese postmenopausal woman
• HPI Moderate vaginal bleeding for
  approximately 1 month
• PMH Past history remarkable for breast cancer
• Medications
• Tamoxifene
• F hormonal medication

• Physical Examination
• Unremarkable

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Differential Diagnosis for post-menopausal
vaginal bleeding

• Endometrial hyperplasia
• Atrophy
• Polyps
• Endometrial response to hormone replacement
  therapy
• Endometrial adenocarcinoma
• Most post-menopausal bleeding is NOT due to
  cancer, however all such cases must be
  investigated for cancer

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Differential diagnosis for pre-menopausal woman

• lt menarche
• Precocious pseudopuberty (endocrinology active
  ovarian neoplasms)
• Hypothalamic-pituitary abnormalities

• gt menarche
• Gestational abnormalities
• Leiomyomas
• Polyps
• Anovulatory cycles
• Mid-cycle break-through bleeding

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Risk factors for endometrial carcinoma (type I)

• Hyperestrogenism
• - exogenous (HRT, Tamoxifen)
• - chronic anovulation (PCOS)
• - obesity
• - early menarche/late menopause
• Also diabetes, hypertension, DM, infertility,
  nulliparity, high fat diet, familial
  predisposition (the Lynch syndrome II HNPCC)
• Protective factors oral contraceptives, physical
  activity, smoking (?!?)
• (Type II not associated with high estrogen,
  obesity, nulliparity often in older women and
  more aggressive)

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More on risk factors
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Normal endometrium
normal proliferative
normal secretory
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An endometrial biopsy is performed
Features Over growth of glands (adenocarcinoma?) L
ess stroma myometrial invasion? cytologic atypia
(big nuclei, prominent nucleoli) hyper
cellularity in glands
adenocarcinoma likely diagnosis
Differential Dx for this slide adenocarcinoma endo
metrial hyperplasia (can resemble disordered
proliferative to well differentiated carcinoma)
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Gross (and I guess a hysterectomy afterwards)
Differential Dx for this slide Polyps (benign
overgrowths of endometrial glands and
stroma) adenocarcinoma (polypoid, necrotic,
myometrial invasion, cervical involvement) endomet
rial hyperplasia (lush sometimes polypoid)
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Diagnosis Endometrial Adenocarcinoma (but there
are two types!)Type I Estrogen-related and
associated with progressive hyperplasia-typicall
y presents as a low grade endometrioid tumor and
is associated with endometrial hyperplasia that
increases in cytologic atypia-more common and
slowly progressing-risk factors such as obesity,
nulliparity, endogenous or exogenous estrogen
excess, diabetes mellitus, and
hypertension.Type II Unrelated to estrogen and
not associated with hyperplasia-presents with
higher grade tumors or poor prognostic cell
types, such as papillary serous or clear cell
tumors-very rare but usually lethal-These
patients are often multiparous, thin rather than
obese, uterus is small and atrophic, and tend to
be older -In one series of 129 women with
uterine papillary serous cancer, 56 percent
presented with stage III or IV disease
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So we know that we have Type I what do we do
about it?

• Since 1988, it has been recommended that cancer
  be staged surgically. Therefore, once the
  diagnosis of endometrial cancer has been made,
  routine presurgical evaluation is performed to
  assess operability.
• Once preoperative evaluation, which may include a
  chest radiograph, ECG, and appropriate blood
  studies, has been performed and the results are
  found to be normal, the patient is deemed a
  surgical candidate. Then, an exploratory
  laparotomy, total abdominal hysterectomy,
  bilateral salpingo-oophorectomy, peritoneal
  cytology, and pelvic and para-aortic
  lymphadenectomy are performed.
• Obviously, if intraperitoneal disease is
  identified at the time of surgery, attempts are
  made at surgical removal.
• Staging is then determined based on surgical
  pathologic findings (see Staging). Subsequent
  therapy, if needed, is then determined, depending
  on the surgical pathological findings of the
  operative procedure.

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Stage is most important determinate of prognosis
and treatment
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Further evaluation

• More complete history sexual history,
  pregnancies, age of menarche/menopause, breast
  cancer history and other PMH, family history
• The gold standard for diagnosis is hysteroscopy
  with dilation and curettage however, office
  endometrial biopsy is used most frequently
  (simple, well tolerated, no need for anesthesia)
• Transvaginal ultrasound (double wall endometrial
  thickness lt 4-5 mm good) is an option, but is
  less reliable