0227743

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Présentation clinique Clinical setting

Femme de 72 ans. Metrorragies.

Biopsie endométriale. Hysterectomie

Macroscopie

72 yo. female. Metrorrhagia.

Endometrial biopsy. Hysterectomy

Gross description

L'utérus ouvert longitudinalement révèle une masse polypoïde à large base d'implantation.

Uterus opened disclose a large polypoid mass, sectioned, implanted laterally.

 

La masse présente un aspect irrégulier, necrotique, et hemorragique en surface, demarquée de l'endomètre.

The mass shows an irregular, necrotic, and hematic surface.

 

 

 

La tranche de section montre un aspect hétérogène jaunâtre, hemorrhagique, et une invasion de la paroi myomètriale.

Cut surface of the mass is heterogenous, yellowish, hemorrhagic. Invasion of the myometrium is observed.

 

Microscopie

 

 

Microscopy

 

La masse est formée de structures glandulaires de petite taille, coalescentes avec un stroma peu abondant.

The mass is formed by small sized glands, branching, with little intervening stroma.

 

Les glandes avoisinent des zones moins differeneciées compactes, moins de 50 % de la surface tumorale.

Glands are mixed with less differenciated, solid areas, less than 50 % of the tumor surface.

 

Certaines de ces zones semblent avoir une différenciation épidermoïde.

Some of these areas have squamous differenciation.

Ailleurs des flexions tubulo-papillaires sont observées,

Papillary villoglandular structures are noted,

 

ainsique des micropapilles.

and in other ares micropapillae are present.

Les glandes exhibent des formations cribriformes,

Cribriform gland arrangements, with lumens

 

contenant un matériel PAS positif.

showing a PAS positive material are noted.

Le materiel mucineux est Bleu Alcian positif.

The mucinous material is Alcyan Blue positive.

 

Par place, les cellules sont de plus grandes taille, cylindriques.

In some areas, the cells are larger, columnar.

A proximité de ces derniers, le stroma est particulier.

In their vicinity, some peculiar pattern of the stroma is noted.

 

Des bandes hyalines s'intriquent aux travées tumorales.

Hyalin bands, cheloïd-like fibers are mixed to the tumor.

Les atypies nucléaires sont modérées.

Nuclear atypia is moderate.

 

Les figures de mitoses sont rares.

Mitotic figures are rare.

Trichrome de Masson

 

Masson's trichrom

Aspect microglandulaire.

Microglandular pattern.

 

Métaplasie épidermoïde.

Squamous metaplasia.

Faible agrandissement sur la base d'implantation, invasion du 1/3 externe du myomètre.

Low power, invasion of the outer layers of the myometrium.

 

Infiltration du myomètre.

Infiltration of the myometrium.

Structures tubulo-papillaires dans le myomètre.

Villoglandular arrangements in the myometrium.

Embol tumoral lymphatique.

Lymphatic vascular emboli.

 

 

 

 

Une métastase dans le curage ilio-obturateur est observée. A lymphnode metastasis is found in the iliac region.

 

 

 

 

Diagnostic proposé:

Proposed diagnosis:
Adenocarcinome endométrioïde, variante microglandulaire, grade II (OMS). Endometrioid adenocarcinoma, microglandular variant, grade II (WHO)
Stade IIIc (FIGO) Stage IIIc (FIGO)

 

Endometrial carcinoma (Ackerman's Surgical Pathology, 8th Ed.)


General and clinical features
Carcinoma of the endometrium is the most common gynecologic malignancy in the United States, and its incidence is rising. It typically occurs in elderly patients; approximately 80% are postmenopausal at the time of diagnosis. It has been suggested that endometrial carcinoma can be divided in two distinct types on the basis of their pathogenesis: oneby far the more commonoccurring as a result of excess estrogenic stimulation and developing against a background of endometrial hyperplasia and the other developing de novo. Patients at high risk for the first category include the obese, diabetic, hypertensive, infertile; those with failure of ovulation (including the Stein-Leventhal syndrome) and dysfunctional bleeding; long-standing estrogen users; those with severe degrees of endometrial hyperplasia, andto a much lesser degree those with functioning granulosa cell tumors and thecomas.

In the majority of patients with Stein-Leventhal syndrome, the endometrial pathology is that of hyperplasia and, as such, it will regress with medical therapy. However, a few well-documented cases of carcinoma have been reported; these have almost always been of a welldifferentiated nature, and myometrial invasion, if present at all, has been minimal. Fechner and Kaufman pointed out that the lesion may be reversible when treated by curettage followed by therapy directed toward reestablishment of ovulation and have urged a conservative approach to these patients. In support of this policy, they emphasized the fact that not a single case of well-differentiated adenocarcinoma in a patient with Stein-Leventhal syndrome has been proved to metastasize, recur locally, or cause death. The situation is quite similar regarding the relationship between endometrial pathology and functioning ovarian tumors.

Gonadal dysgenesis (Turner's syndrome) can also be associated with endometrial adenocarcinoma, usually of the well-differentiated type. McCarty et al. found thirteen reported cases; eleven patients had received replacement estrogen therapy, usually in high doses and for prolonged periods. It is not clear whether this association represents a complication of long-term estrogen exposure or a rare expression of the Turner phenotype. Interestingly, almost two thirds of the carcinomas exhibited squamous differentiation.

Some cases of endometrial carcinoma have been seen years after pelvic irradiation for some other condition, but whether these are spontaneous or radiation-induced is not clear.

Recently several reports have appeared suggesting that patients who receive tamoxifen as long-term treatment for breast carcinoma may be at an increased risk for the development of endometrial adenocarcinoma; of particular concern is the fact that in two series a significant number of these cases have been high-grade tumors associated with a poor prognosis.

Pathologic features
Grossly, carcinoma of the endometrium may form broad-based polypoid masses or infiltrate diffusely into the myometrium. In general, extensive myometrial invasion is accompanied by clinically detectable uterine enlargement. However, notable exceptions occur; sometimes deep myometrial extension is accompanied by a normal-sized uterus. At times, the tumor begins in a cornu and is missed by D&C.

Microscopically, about 80% of endometrial malignant epithelial tumors are conventional adenocarcinomas, which are usually divided into well (grade I, 50%), moderately (grade II, 35%), and poorly differentiated (grade III, 15%) tumors (Figs. 19-91 and 19-92). The FIGO grading system is primarily based on the growth pattern (relative proportion of glandular and solid areas) but it also makes provisions for nuclear atypia.

The better differentiated tumors closely recapitulate the light and electron microscopic features of the non-neoplastic endometrium, hence the term "endometrioid" that is used for them. Over a quarter of the carcinomas have papillary (villoglandular) foci, either on the surface or in the invasive areas. These tumors should be sharply separated from the much more aggressive papillary serous carcinomas.

The stroma of endometrial adenocarcinoma usually has a desmoplastic quality. It may contain collections of foamy cells, probably the result of tumor necrosis and a good marker for the presence of carcinoma. However, these cells can also be seen in hyperplasia and, exceptionally, in otherwise normal endometria. They are said to form from endometrial stroma rather than histiocytes. They are fat positive and mucin negative, in contrast to the mucin-positive macrophages sometimes seen in the stroma of benign endometrial polyps.

The non-neoplastic endometrium of a uterus harboring an adenocarcinoma is often hyperplastic, is sometimes atrophic, and only exceptionally exhibits a normal proliferative or secretory pattern; when it does, the assumption has been made that the carcinoma has arisen in a "progesterone refractory" mucosal area.

The frequency and extent of myometrial invasion by carcinoma are directly related to the microscopic grade of the tumor. Care should be exercised to distinguish true myometrial extension by carcinoma from expansion of the endometrial-myometrial junction and from atypical or malignant changes involving pre-existent foci of adenomyosis; the latter condition is recognized by the presence of endometrial stroma around the intramyometrial proliferating glandular foci. Extension of the endometrial carcinoma into the cervix occurs in over 10% of the cases, usually by direct invasion, but sometimes by implantation following D&C. This may be grossly evident or become apparent only on microscopic examination; it may involve the surface only, the fibrous stroma, or both. The presence and type of cervical extensionwhich influences the staging of the tumoris best detected by fractional curettage; care should be exercised in distinguishing bona fide cervical extension from isolated tumor fragments, or else a high false positive rate will occur.