patho sheet 5th of Dr faisal - Zaina Ayman

بسم الله الرحمن الرحيم

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21st of March,2011
5th of Dr. Faisal

Last lectures' revision:
There are 2 substances of Endometrial adenocarcinoma
- One of them that it depends on the estrogen and affects women in their 50s.
The risk of endometrial adenocarcinoma increases with obesity.
It has got an underlying estrogenic stimulus like any source of estrogen whether it was endogenous [previously preceded by endometrial hyperplasia or similar conditions ], or a tumor [such as granulose tumor] which secrets estrogen which might underlay the cause of endometrial carcinoma.
- The second type is serous or papillary serous. It's relatively larger and not estrogen dependent.

Here the dr. said that the grades are important as well as the prognosis, the level of differentiated whether it was well differentiated or not and number of mitosis
Stages are:
Stage 1= only in the uterus endometrium, has 90% 5 years survival rate and could be more if it was handled by good hands and treated as early as possible.
Stage 2= reached the cervix
Stage 3= extending out to the pelvis
Stage 4= extending outside the pelvis. This one here might be associated with less than 20% 5 years survival.
Endometrial carcinoma is the opposite of Cervical cancer which has certain characteristics such as its relation to blood hygiene, poverty, HIV and possibly some other microorganisms.

From the endometrial cells, different types of endometrial tumors may arise and the simplest ones are those entirely from one layer.
Stroma of the endometrium may give rise to a number of benign and malignant neoplasm. 1- A tumor that’s purely mesenchym in origin. Completely benign!
An example of a benign tumor is Adenofibroma/ Adenomyoma . This tumor is a mixture of epithelium and mesenchymal tissue arising from the same layer = stroma.
Adeno: epithelial benign tumors
Fibroma/myoma: Fibrous tissue or smooth muscles tissue.
2-Sometimes the tumor is mixed, one malignant element and the other is benign. Usually the benign is the epithelium [glandular epithelial tissue] and a mesenchyme malignancy. In this case it's called Adenosarcoma/ Squamosarcoma.
Other times you might find a mixture of 2 types of malignancy, called Carcinosarcoma or a mixed malignant mullerian tumor [MMMT]. In this case both the epithelium and the mesenchyme are malignant. It tends to happen more in older age.

Types of MMMT:
a) From a native tissue that ends up in malignancy= Homologous
b) From a dysplastic tissue - isn’t present in normal situations-origin = Heterologous.
For example, in case of carcinosarcoma, you might find malignant bone tissue, cartilage [chondrosarcoma] or squamous cell sarcoma [coming from outside the endometrium or any other type of cells that had undergone metaplastic changes that ended up in malignancy) in the uterus. It's less common than homologous because it’s the end result of lots of lines of malignancy, beginning with malignant epithelium followed by malignant mesenchyme and the mesenchyme -itself or part of it- has to metastesise from another place to result in heterologus type .

3- stromal cell nodules: A benings tumor in the form of a very small polyp in the endometrium.
Its counterpart is a pure sarcoma, example:
• Endolymphatic myosis/myoma [Sarcoma that resides in the lymphatics of the body of the endometrium]. At the beginning it resides silent for a long time but it could metastasize if left alone. Also called low grade sarcoma to differentiate it from the high grade sarcoma.
4- A small number of smooth muscle tumors may arise from the stromal endometrium. Most of them arise from the body of the uterus; they are called fibroids (ألياف الرحم)
Fibroids: smooth muscle tumors that are mixed with collagen and fibroblasts. Their scientific name is Leiomyomas.
Fibroids are the most common female genital tract tumor of all. Appears after the age of 30 in different shapes [small, irregular, smooth, ovoid ...] and sizes [begins as few mms called intramural and grows to few cm at avg. to reach the luminal aspect. It sometimes buds out more fibroids called daughter leiomyoma]. Some books say that up to 70% of women have them, but roughly speaking its 40-50% at least. After the age of 50 the incidence decreases and already present fibroids either calcificate or atrophy or become fibrosed because they are maintained by estrogen.. not caused but maintained.
 In another case, a leiomyoma with a (pedicle= neck [pedunculated]) buds out on the outer surface of the uterus towards the peritoneum. It's called Subserosal leiomyoma. Its neck sometimes moves with the peritoneum's movement and might *teshbok* on the liver and begins to take its nutrition from it… With time it might disconnect from the uterus but stays connected to the liver and then we call it Parasitic leiomyoma.
So the course is [ subserosa > pedunculated> dependent on some there organ in the peritoneal cavity for nutrition].
• Complications are adhesions and mechanical obstructions.
Few important things we should know about leiomyomas:
a) They're multiple
b) Most of them begins as intramural and grow into the lumen to be called submucosal leiomyomas. Leiomyomas could grow distorting the lumen of the uterus in a very unsightly way.
c) Complications : the surface of it could get ulcerated= bleeding, infection , abortion [in case of pregnancy] and malpresentaion (instead of delivering the baby head first, it might come out arm, leg or butt first)
d) Benign
e) Non-encapsulated
f) Well demarcated in the uterus. In the past the doctors used to remove it by their hands -since it was more condensed than the adjacent tissue- but it usually appeared again after a while. Nowadays practitioners remove it surgically.



Leiomyosarcomas:
 They're much less common than leiomyomas.
 Very unlikely to result from a leiomyoma!
Most of times leiomyosarcomas are misdiagnosed for leiomyomas and after few months the characteristics of the sarcoma appears and dr.s think that it's been transformed from a leiomyoma to a sarcoma. So again, leiomyosarcomas don’t arise from leiomyomas.
 There's about a minimum of one decade older on the avg. peak incidence of leiomyomas. [45-50 years.]
 When they first manifests, they're usually bigger in size [10-12-14cm] than leimyomas [mm to few cm].

If more than 10 mitotic figures per 10 high power fields are present then mostly the behavior of this smooth muscle tumor is malignant.
If less than 5 mitotic figures per 10 high power fields are present then mostly the behavior is benign.
Other parameters to determine the behavior of the tumors are cellular, nuclear and the destruction of the tissues.

Adenomyosis.
Is thickening of the uterine wall giving its cavity a slit like appearance.
It usually refers to ectopic endometrial tissue within the myometrium. Adenomyosis may give rise to adenomyoma. [28s-29.4]
• Features of adenomyosis are: glands, hemorrhage, focus, endometrial stroma.

Fallopian tubes.
Their problems are categorized into few categorize:
 Inflammation: acute or chronic tuberculus/ chronic granulomatous.
a) Might result from ascending inflammation caused by Gonococcus [that cause vaginits and serricitis] or Chlamydia from the vagina, and once it reached the fallopian tube it could cause abscesses.
b) Starts as acute then becomes chronic. Other microorganisms dip deeply into the lymphatics or the blood stream and reach the ovaries and tubes, this is how the deeper tissues are involved!
c) They cause a series of events [changes in the tubes] to cause deputy of the fallopian tubes that might be adherent, purulent and might cause adhesion to the ovary or pelvic organs like intestines. They might pour puss into the peritoneum and disseminate and spread to somewhere else.
 TB in the endometrium
There is no well-formed granuloma because the endometrium is shed every month in menstruation, but the endometrium might have secondary TB [tubal TB= TB salpingitis]. Its usually secondary to pulmonary TB but can be secondary to intestinal TB.

Ectopic pregnancy:
Implantation, not in the uterus, but elsewhere. Roughly speaking, most of ectopic pregnancies occur in the fallopian tube.
Causes:
1. PID.. pelvic inflammatory disease.. its no.1 cause due to inflammation caused by ascending infection and scarring that can block or twist the tube. Scarring (adhesions) may prevent a fertilized egg from moving down the fallopian tube to the uterus or change the direction which sperms normally go to reach the ovum.
2. Endometriosis
3. Appendicitis
4. Adhesions due to any cause.

Most complication feared is that about the 6th week of ectopic pregnancy the tube ruptures, and this is an emergency that might kill the patient.

• Ectopic pregnancy could happen next to the ovary or peritoneum.
Tumors of the fallopian tube.
The incidence isn’t very high but there's a wide range between benign and malignant. Example: female adnexal tumor of wolffian origin

Ovaries

Diseases: arise if the egg fails to release from the follicle in the ovary and an ovarian cyst is then formed.
Types:
 Inflammation:
Ovarian inflammation is very close related to the fallopian tubes ascending infections.
 Non-neoplastic lesions: most important are cysts
 Neoplastic lesions:
Are numerous in number with groups, types and subtypes. The tumor itself might act each time in a different way.
• All of them are malignant
• By the time they're diagnosed, they're far in an advanced stage where it had probably spread not only to the other ovary but to other tissues developed in the mullerian duct like the uterus.
• The incidence is not high but the death rate is.

• GROUP 1
1- Originated from the surface epithelium they are non-neoplastic cysts.
Forms by of the dipping of the surface epithelium or mesothelium -that’s normally covering the surface of the ovary- into the cortex of the ovary. Some of the foci might disconnect with the surface and might form a focus made of cells originated from the surface epithelium.
Their behavior is frequently benign, cyst forming and that’s why they're called epithelium inclusion cysts/ serous inclusion/ ovarian inclusion cysts.
• Their counterpart might become neoplastic and that’s the biggest family of ovarian tumors [surface epithelium neoplasms].
2-Paratubal / paraovarian cysts are named according to the site which they're closer to [fallopian tubes or ovary]. They're completely benign particullarly if they were few mm and translucent. They're found hanging like bells from the ovary and tubes on the suspensory ligament .

3- There are cysts attached to the fimbria of the fallopian tube
Hydatid cysts of morgagni : one of the small pedunculated structures attached to the uterine tubes near their fimbriated end. They're very common, totally benign and doesn’t transform into malignant tumor.

 GROUP 2 = non-neoplastic cysts.
1-Before ovulation, the ovum grows inside of the primordial follicle and layers, spaces and secretions grow around the ovum. When the ovum fails to be extruded from the ovary it'll be trapped and sealed within the ovary to form a cyst…
• Their sizes decide their names [follicular cyst or cystic follicle.] they're the same but one is larger than the other. Their sizes range from 3cm till 10 cm.
• They're totally benign.
• Might contain and secret estrogen, one of the sources that produce estrogen in endometrial hyperplasia other than the ovary proper.
2-Aother side of the story is when ovulation happens, the place where the ovum was extruded becomes under certain effect of the pituitary gland! It's then transformed into corpus luteum that secrets progesterone. Cystic corpus luteum.
• Benign.
• Their S&S are appear on females aged between [18-19-25-30-…]:
a) Irregularity in the menses
b) Pain
c) Protruded masses
AS A RULE
Any follicle cyst ,that doesn’t disappear within 2 months, should be considered as malignant or neoplastic like tumors of the ovary. We have to discover them as soon as possible coz they're extremely dangerous

Best wishes,
Zaina Ayman