57. Diseases of the uterus and fallopian tubes
Endometrial carcinoma
Endometrial carcinoma is the most common cancer of the female genital tract in the western world. The peak incidence is between 50 and 70 years old. It is rare before the age of 40.
We divide endometrial carcinoma into two histological subtypes, endometrioid type (type I) and non-endometrioid type (type II). These types are histologically and pathogenetically distinct.
Endometrioid endometrial carcinoma gets its name as they are histologically similar to normal endometrial glands. It develops in association with oestrogen excess and endometrial hyperplasia and is the most common subtype as it accounts for 80% of endometrial cancers. It develops in perimenopausal women (around 50). This type has better prognosis than the other type. Mutations in PTEN are characteristic.
The most important risk factors for endometrioid endometrial carcinoma are:
- Obesity
- Diabetes
- Hypertension
- Infertility
- Increased exposure to oestrogen
Non-endometrioid endometrial carcinoma can be of serous (most common), mucinous, clear cell or other subtypes. They have no association with oestrogen excess and instead develop from atrophic endometrium. It is therefore characteristic in older, postmenopausal women. Mutations in p53 are characteristic.
| Endometrioid endometrial carcinoma | Non-endometrioid endometrial carcinoma | |
|---|---|---|
| Relative incidence | 80% | 20% |
| Peak incidence | Perimenopause | Postmenopause |
| Association with oestrogen | Associated with high oestrogen | No association |
| Develops from | Endometrial hyperplasia | Atrophic endometrium |
| Associated gene mutation | PTEN | p53 |
| Prognosis | Better | Worse |
Prognosis: In both types, the stage of the cancer at the time of diagnosis is essential for the prognosis. Early-stage carcinomas have high 5-year survival rate, but the mortality increases in higher-stage tumors.
Symptoms: Patients usually present with postmenopausal bleeding. The peak incidence is in postmenopausal women, who normally don’t bleed.
Diagnosis: Endometrial biopsy or curettage may be used. It’s important to distinguish between endometrial hyperplasia and endometrial carcinoma on curettage: If there is stroma in the sample, it is hyperplasia. If there are only glands and no stroma, it is cancer.
Treatment: Hysterectomy. Radiotherapy and/or chemotherapy if there are metastases.
Endometrial polyp
Endometrial polyps are focal overgrowths of endometrial tissue. They can be sessile or pedunculated. Their histology is similar to the basal endometrium. The stromal cells are monoclonal, often with rearrangement of chromosomal region 6p21, and thus constitute the neoplastic part of the tumor. These polyps are more common around the time of menopause.
These polyps are usually asymptomatic but they may cause abnormal uterine bleeding. They may progress into cancer.
Leiomyoma
Leiomyomas in the uterus are smooth muscle tumor cells that originate from the myometrium. These tumors are also very firm, which is why they’re also often called fibrinoids.
Epidemiology: Uterine leiomyomas are very common, affecting 30 – 50% of women in reproductive age. It’s more frequent in nulliparous, obese or black women. Oestrogen is important for their growth, which is why they shrink after menopause.
Morphology: As already mentioned these tumor are very firm. They’re well-circumscribed, homogenous grey-white masses. Most frequently multiple rather than a single tumor are found. They have a characteristic “whorly” (they form whorls) appearance on the cut surface. On histology the tumor consists of bundles of smooth cells that resemble normal myometrium.
Classification: They are classified based on their location:
- Intramural leiomyoma – inside the myometrial wall – most common
- Subserosal leiomyoma –in the outer uterine wall, just beneath the serosa
- Submucosal leiomyoma – in the inner uterine wall, just beneath the mucosa
Subserosal leiomyomas may attach to surrounding organs, in which case they’re called parasitic leiomyomas.
Symptoms: They’re most commonly asymptomatic. The symptoms depend on the location and size of the tumors. Potential symptoms include:
- Abnormal uterine bleeding
- Pelvic pain/discomfort
- Urinary tract symptoms
- Urinary retention
- Bowel symptoms
- Constipation
- Infertility
- Pain during sex
The uterus will be irregularly enlarged.
Treatment: Only symptomatic leiomyomas will be treated. These can be treated medically or surgically, depending on the severity of the symptoms.
Leiomyosarcoma
Uterine leiomyosarcoma do not arise from leiomyomas but arise de novo from mesenchymal cells in the myometrium. Unlike leiomyomas these tumors are soft and solitary (single rather than multiple) and occur in postmenopausal women.
Morphology: Uterine leiomyosarcoma are solitary, soft, haemorrhagic and necrotic masses. The histological criteria for uterine leiomyosarcoma are necrosis, atypia and mitotic activity.
Prognosis: These tumors often recur and metastasize, giving them a poor prognosis.
| Leiomyoma | Leiomyosarcoma | |
|---|---|---|
| Gross morphology | Well-circumscribed, firm, whorly grey-white masses | Soft, haemorrhagic and necrotic masses |
| Single or multiple? | Most frequently multiple | Most frequently single |
| Peak age incidence | Premenopause | Postmenopause |
Inflammation of the fallopian tubes
Inflammation of the fallopian tubes is called salpingitis and is a component of pelvic inflammatory disease. As with any pelvic inflammatory disease the most common causes are STIs like chlamydia and gonorrhoea. In postpartum women, streptococci and staphylococci may be the cause.
Symptoms: Salpingitis can cause typical genital tract symptoms like chronic pain, pain during menstruation or pain during sex.
The potential adverse effect of salpingitis is scarring and adherence of the tube(s) to the ovary. This can cause a tubo-ovarian abscess. Adhesion or obstruction of the tube(s) may cause tubal ectopic pregnancies or sterility.
Tumours of the fallopian tubes
Primary adenocarcinoma may occur in the fallopian tube. These cancers are rare, accounting for less than 2% of all gynaecological cancers. These cancers are more frequent in women with germ-line mutations in the BRCA gene.
As the fallopian tube opens to the peritoneal cavity these tumors frequently spread to the peritoneum.
Tumors of the fallopian tubes may be mistaken for ovarian tumors due to the proximity.