Gynecology

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Patiente de 75 ans, masse végétante de la cavité utérine.

Hystérectomie

 

75 yo female with a voluminous uterine mass.

Hysterectomie

 
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Diagnostic proposé

 

 

 

 

 

 

 

Adénocarcinome endométrioïde mixte

 

Proposed diagnosis

 

 

 

 

 

 

 

Mixed endometrioid adenocarcinoma

 
  Arguments      
 
  • L'adénocarcinome mixte est une tumeur constituée d'une association du type I (carcinome endométrioïde, y compris ses variantes, ou mucineuse) et du type II(séreuse ou à cellules claires) dans laquelle la composante mineure forme au moins 10% du volume tumoral.
  • La composante adénocarcinomateuse séreuse se caractérise par son architecture papillaire. Les cellules et les noyaux sont plus fréquemment ronds que cylindrique, sans orientation perpendiculaire à la membranne basale.
  • La composante à cellules claires est formée principalement de cellules claires ou en clou de tapissier disposées en nappes solides, ou formations tubulokystiques ou papillaires. Contrairement à l'adénocarcinome endométrioïde sécrétoire, les cellules ont de grands noyaux pléomorphes.

  • Mixed adenocarcinoma is a tumour composed of an admixture of a type I (endometrioid carcinoma, including its variants, or mucinous carcinoma) and a type II carcinoma (serous or clear cell) in which the minor type must comprise at least 10% of the total volume of the tumour.
  • Serous adenocarcinoma component, characterized by a papillary architecture. The cells and nuclei are generally round rather than columnar and lack a perpendicular orientation to the basement membrane.
  • Clear cell adenocarcinoma component composed mainly of clear or hobnail cells arranged in solid, tubulocystic or papillary patterns.Unlike similarly glycogen-rich secretory endometrioid adenocarcinomas, clear cell adenocarcinoma contains large, highly pleomorphic nuclei

 

 
  Reference  

Pathology and Genetics of Tumours of the Breast and Female Genital Organs. WHO

Serous adenocarcinoma


Definition and historical annotation
A primary adenocarcinoma of endometrium characterized by a complex pattern of papillae with cellular budding and not infrequently containing psammoma bodies.
Although long recognized as a common type of adenocarcinoma of the ovary,  serous adenocarcinoma was first characterized as a common endometrial tumour in the early 1980s.


Clinical features
Serous carcinoma typifies the so-called type II endometrial carcinoma, which differs from the prototypical type endometrioid adenocarcinoma by its lack of association with exogenous or endogenous hyperoestrinism, its lack of association with endometrial hyperplasia and its aggressive behavior.


Histopathology
Serous adenocarcinoma is usually. But not always, characterized by a papillary architecture with the papillae having broad fibrovascular cores, secondary and even tertiary papillary processes and prominent sloughing of the cells. The cells and nuclei are generally round rather than columnar and lack a perpendicular orientation to the basement membrane. The nuclei are typically poorly differentiated, are often apically rather than basally situated and usually have large, brightly eosinophilic macronucleoli. Mitoses, often atypical and bizarre, and multinucleated cells are commonly present, as are solid cell nests and foci of necrosis. Psammoma bodies are found in about 30% of cases and may be numerous. When the tumour grows in a glandular pattern, the glands are generally complex and "labyrinthine.' Serous carcinoma is considered a high grade carcinoma by definition and is not graded.


Precursor lesions
A putative precursor of serous adenocarcinoma is serous endometrial intraepithelial carcinoma, which has also been also called endometrial carcinoma in situ and surface serous carcinoma.  This lesion is characterized by a noninvasive replacement of benign (most commonly atrophic) endometrial surface and glandular epithelium by highly malignant cells that resemble those of invasive serous carcinoma. Serous endometrial intraepithelial carcinoma has been proposed as the precursor or in situ phase of serous carcinoma, and in most reported studies it has co-existed with invasive serous and, occasionally, clear cell adenocarcinoma. Clinically, serous endometrial intraepithelial carcinoma has a significance very similar to that of invasive serous adenocarcinoma since it can also be associated with disseminated disease outside the uterus (usually in the peritoneal cavity) even in the absence of invasive carcinoma in the endometrium.


Prognosis and predictive factors
This tumour has a tendency to develop deep myometrial invasion and extensive lymphatic invasion, and patients commonly present with extrauterine spread at the time of diagnosis. However. even in the absence of a large or deeply invasive tumour extrauterine spread is common, as are recurrence and a fatal outcome.

 

Clear cell adenocarcinoma


Definition
An adenocarcinoma composed mainly of clear or hobnail cells arranged in solid, tubulocystic or papillary patterns or a combination of these patterns.


Epidemiology

The other major type of carcinoma of the endometrium is clear cell adenocarcinoma.
It is less common than serous carcinoma (1-5%, as opposed to 5-10% of all endometrial carcinomas) but occurs in the same, predominantly older, patient population.


Tumour spread and staging

Similar to serous adenocarcinoma, patients with clear cell adenocarcinoma are frequently diagnosed in advanced clinical stages.


Histopathology
Histologically, clear, glycogen-filled cells and hobnail cells that project individually into lumens and papillary spaces characterize the typical clear cell adenocarcinoma.
Unlike similarly glycogen-rich secretory endometrioid adenocarcinomas, clear cell adenocarcinoma contains large, highly pleomorphic nuclei, often with bizarre and multinucleated forms.
The architectural growth pattern may be tubular, papillary, tubulocystic or solid and most frequently consists of a mixture of two or more of these patterns.
Although psammoma bodies are present in approximately one-third of serous adenocarcinomas, they are rarely seen in clear cell adenocarcinomas. Occasionally,  the tumour cells have granular eosinophilic (oncocytic) cytoplasm rather than the more characteristic clear cytoplasm. This cell type may comprise the entire tumour and make it difficult to recognize as a clear cell adenocarcinoma. Endometrial clear cell adenocarcinomas are not graded.
Serous endometrial intraepithelial carcinoma may also be seen in association
with clear cell adenocarcinoma, and the associated benign endometrium is generally atrophic rather than hyperplastic.


Prognosis and predictive factors
Patients with clear cell adenocarcinoma are frequently diagnosed in advanced clinical stages, and, thus, have a poor prognosis. On the other hand, clear cell adenocarcinoma limited to the uterine corpus has a considerably better prognosis than serous adenocarcinoma of the same stage.

Mixed adenocarcinoma


Definition
Mixed adenocarcinoma is a tumour composed of an admixture of a type I (endometrioid carcinoma, including its variants, or mucinous carcinoma) and a type II carcinoma (serous or clear cell) in which the minor type must comprise at least 10% of the total volume of the tumour. The percentage of the minor component should be stated in the pathology report. It is generally accepted that 25% or more of a type II tumour implies a poor prognosis, although the significance of lesser proportions is not well understood.