Benign and Malignant Conditions of the Uterus and Ovary PDF

BENIGN AND MALIGNANT CONDITIONS OF THE UTERUS AND OVARY  THE UTERUS ◦ Infections ◦ Benign tumours ◦ Acute endometritis (PID) ◦ Endometrial polyp ◦ Leiomyoma ◦ Anatomical disorders ◦ Adenomyosis ◦ Class U1 ◦ Class U2...

BENIGN AND MALIGNANT CONDITIONS OF THE UTERUS AND OVARY  THE UTERUS ◦ Infections ◦ Benign tumours ◦ Acute endometritis (PID) ◦ Endometrial polyp ◦ Leiomyoma ◦ Anatomical disorders ◦ Adenomyosis ◦ Class U1 ◦ Class U2 ◦ Premalignant lesions ◦ Class U3 ◦ Endometrial hyperplasia ◦ Class U4 ◦ Class U5 ◦ Malignant lesions ◦ Class U6 ◦ Endometrial carcinoma ◦ Endometrial stromal sarcoma ◦ Leiomyosarcoma ◦ Carcinosarcoma INFECTIONS  Endometritis ◦ Non‐specific acute or chronic inflammation ◦ Often caused by bacterial or fungal Infections ◦ Associated with discharge ANATOMICAL DISORDERS Class U1: Dysmorphic uterus ANATOMICAL DISORDERS Class U2: Septate uterus ANATOMICAL DISORDERS Class U3: Bicorporeal uterus ANATOMICAL DISORDERS Class U4: Hemi uterus ANATOMICAL DISORDERS Class U5: Aplastic uterus ANATOMICAL DISORDERS ANATOMICAL DISORDERS: Complications  Menorrhagia & dysmenorrhea  Dyspareunia  Urinary tract anomalies  Infertility  Obstetric:  Sacculation of uterus  Miscarriage & preterm labour  Malpresentation  Obstructed labour BENIGN TUMOURS: Endometrial polyps  Abnormal protrusions of endometrium  Associated malignancy BENIGN TUMOURS: Adenomyosis ◦ Endometrial glands and stroma randomly in myometrium. ◦ Depth > 3mm ◦ Mean incidence 20% ◦ Enlarged and/or globular uterus ◦ Surrounding hypertrophied muscular trabeculae ◦ 30‐50% respond to progesterone BENIGN TUMOURS: Leiomyoma  Müllerian duct origin  Smooth muscle interlaced with fibrous strands  Most common neoplasm in humans  Histogenesis not established  Hormonal stimuli influences growth BENIGN TUMOURS: Leiomyoma  Round, firm tumour  Whitish  Pseudo capsule  Trabeculated appearance – whorled pattern  Relatively avascular – degenerative changes PREMALIGNANT LESIONS: Endometrial hyperplasia Morphologic architecture ◦ Simple ◦ Complex Cytologic (nuclear) characteristics ◦ Without atypia ◦ With atypia Malignant risk: ◦ Without atypia 1 – 3% ◦ With atypia 8 – 29% Associated endometrial Ca 48% ENDOMETRIAL CARCINOMA ENDOMETRIAL CARCINOMA: Risk factors Obesity: peripheral conversion of A to E Infertility ‐ anovulation, nulliparity Family history, NPCC (genetic) Early menarche, delayed menopause Unopposed exogenous E‐therapy Endogenous E – PCOS, granulosa cell tumours Tamoxifen Medical conditions– HT, DM ENDOMETRIAL CARCINOMA Histology Patterns of Spread ◦ Endometroid adenocarcinoma (G1, G2, G3) ◦ Direct infiltration ◦ Adenosquamous ◦ Lymphatic spread ◦ Villoglandular ◦ Hematogenous spread ◦ Papillary serous adenocarcinoma ◦ Clear cell carcinoma UTERINE SARCOMAS Leiomysarcoma Endometrial stromal sarcoma Carcinosarcoma  THE OVARIES ◦ Infections ◦ Tumor‐like conditions ◦ Pelvic inflammatory disease (PID) ◦ Pregnancy luteoma ◦ Massive oedema of the ovary ◦ Functional benign cysts ◦ Follicular cysts ◦ Ovarian neoplasms ◦ Corpus luteum cysts ◦ Epithelial tumours ◦ Theca lutein cysts ◦ Stromal tumours ◦ Germ cell tumours ◦ Non‐functional benign cysts ◦ Metastatic tumours ◦ PCOS & Hyperthecosis ◦ Endometriomata ◦ Paraovarian cysts ◦ Residual ovarian syndrome ◦ Ovarian remnant syndrome PID: Epidemiology 6‐20% in developing countries Protective factors: ◦ Barrier contraception Risk factors: ◦ OC ◦ Early sexual debut ◦ Tubal ligation ◦ Age < 25 years ◦ Pregnancy ◦ Sexual promiscuity ◦ Low parity ◦ Previous PID ◦ Other concomitant STD’s ◦ Low socio‐economic status PID: Defense mechanisms Vulva: apposition labia majora rich blood supply secretions fungicidal Vagina: absence of glands few entry sites lactobacilli lactic acid (low pH) vaginal flora (Döderlein bacilli) Cervix: mucus plug Uterus: endometrium regularly shed PID: Pathogenesis Lower GT infection endocervix uterine cavity endosalpinx pelvic peritoneum and ovary Transmission: sexual intercourse (haematogenous spread) (direct spread) (lymphatic spread) PID: Pathogenesis Primary infecting agents (NG, CT) (± Anaerobes (MH, UU)) Acute inflammatory response Secondary invaders (anaerobes, Gram‐) Upper genital tract Tissue destruction PID: Pathology Mild: tubes swollen, serosal surfaces hyperemic; tubes mobile; sticky seropurulent discharge at fimbrial end but still patent Moderately severe: fibrin deposits cover tube serosal surface; tubes adherent to ovaries, broad ligament or bowel Severe: pelvic peritoneum involved; tubal ostia sealed; anatomy distorted; tubal/tubo‐ovarian abscess ruptures generalized peritonitis Complete functional restitution after mild or moderate infections Other instances: Scarring and replacement of functional tissue by fibrous and collagen tissue tubes rigid Frozen pelvis CLASSIFICATION OF OVARIAN TUMORS Functional benign cysts Follicular cysts Corpus luteum cysts Theca lutein cysts CLASSIFICATION OF OVARIAN TUMORS Follicular cysts CLASSIFICATION OF OVARIAN TUMORS Theca lutein cysts CLASSIFICATION OF OVARIAN TUMORS Non‐functional benign cysts Polycystic ovaries Hyperthecosis Endometriomas Para‐ovarian cysts Residual ovarian syndrome Ovarian remnant syndrome CLASSIFICATION OF OVARIAN TUMORS Tumour‐like conditions of the ovary Pregnancy luteoma Massive oedema CLASSIFICATION OF OVARIAN TUMORS Ovarian neoplasms Epithelial tumours (benign / low grade malignant potential / malignant) Stromal tumours Germ cell tumours Metastatic tumours Epithelial Stromal Metastatic Germ cell CLASSIFICATION OF OVARIAN TUMORS Epithelial tumours Serous (75%) Mucinous (20%) Endometroid (2%) Clear cell Brenner Mixed epithelial CLASSIFICATION OF OVARIAN TUMORS Patterns of spread Trans‐celomic– peritoneum, paracolic gutters (R>L), omentum Lymphatic – pelvic & para‐aortic ‐ transdiaphragmatic – effusion Hematogenous – liver, lungs CLASSIFICATION OF OVARIAN TUMORS Germ cell tumours Dysgerminoma Teratoma (mature [e.g. BST], immature, monodermal) Endodermal sinus tumour Embryonal Ca (yolk sac tumor) Choriocarcinoma CLASSIFICATION OF OVARIAN TUMORS Stromal tumours Granulosa cell tumours (incl. tecoma/fybroma) Androblastomas Sertoli‐ Leydig cell tumours Gynandroblastoma Classification of ovarian tumours Metastatic tumours Krukenburg Gynaecologic (uterus, other ovary) G.I. tract Carcinoid Lymphoma CLASSIFICATION OF OVARIAN TUMORS Epidemiology & risk factors STIC’s CLASSIFICATION OF OVARIAN TUMORS Epidemiology & risk factors  risk: low parity, long ovulat. history  risk: multiparity Coc’s Lifestyle strategies CLASSIFICATION OF OVARIAN TUMORS Epidemiology and risk factors Hereditary syndromes 1. Site specific ovarian ca 2. Ovarian‐breast ca – BRCA1 & 2 3. Lynch II syndrome FURTHER READING ◦ CLINCAL GYNAECOLOGY FIFTH EDITION ◦ Chapter 13 Pelvic inflammatory disease ◦ Chapter 16 Leiomyomata of the uterus ◦ Chapter 19 Abnormal uterine bleeding ◦ Chapter 24 normal sexual development, congenital abnormalities of the genital tract and intersex ◦ Chapter 34 Endometriosis and adenomyosis ◦ Chapter 46 Malignancies of the uterine corpus ◦ Chapter 47 Ovarian tumours