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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5186_Библиотеки_им_академика_М_И_Перельмана.pdf
Figure6.45 Arias-Stellareactionoftheendometrium.Theglandularliningshowsenlarged
hobnailcells with clear cytoplasm and“smudged” nuclei, a pattern thatmaymimic clear cell
carcinoma.
HistologicGradingofEndometrioidCarcinoma
Thehistologicgradeisassignedaccordingto thepercentageofsolidepithelialgrowth
(notincludingareasofsquamousdifferentiation).
1. FIGOgrade1:Thetumorexhibitswell-formedglandsandhas5%orlessofsolid
growthpattern.
2. FIGOgrade2:Thesolidgrowthpatternoccupies6–50%ofthetumor.
3. FIGOgrade3:Thetumordisplaysmorethan50%solidepithelialgrowth.
Severenuclear atypia raises the grade by one, but the possibility of a nonendometrioid
(serousorclearcell)carcinomashouldalwaysberuledoutinthissituation.
PathologicStagingofEndometrialCarcinoma
EndocervicalInvolvement
Endocervicalstromalinvolvementisusuallydiagnosedon thehysterectomyspecimen.
Infrequently,itmay bediagnosedfromanendocervicalcurettage,butthecancerpresentin
theendocervicalcurettageisusuallyacontaminationfromtheuterinecavity.
MyometrialInvasion
The depth of myometrial invasion is expressed as a proportion of the myometrium
invadedby carcinoma.IntheFIGO stagingsystem,this isreportedasinnerorouter
half.Thepresenceoflymphaticorvascularspaceinvasionisnotusedtodeterminethedepth
of invasion. Involvement of adenomyosis by adenocarcinoma may resemble myometrial
invasion on intraoperative visual examination, but the presence of residual endometrial
stromaorbenignbasalisglandsbetweenthetumorandmyometriumisahelpfulmicroscopic
differentiatingfeature.
OvarianInvolvement
Simultaneous primary involvement should be considered before diagnosing ovarian
metastaseswithwell-differentiateduterineendometrioidcarcinoma.Inmostsuchcases,
theuterinetumorshowsminimalornomyometrialinvasion,andthereisnolymphovascular
orcervicalstromalinvasion.
MetastaticCarcinoma
The most common sites of originformetastaticcarcinomaspresentingin the uterine
corpus are breast, stomach, ovary, and colon. Most patients have a previous history of
carcinoma, and the metastasis is not the first presentation of disease. Lymphoma and
melanoma, although rare, continue to pose diagnostic problems when encountered in this
locationbecauseoftheir mimicryofundifferentiatedcarcinomaor sarcoma.Useofabasic
panelforundifferentiatedtumorsandalowthresholdforsuspectingmetastasiswillprevent
mostmisclassifications.
MesenchymalNeoplasms
Endometrialstromaltumorsandsmoothmuscletumorsaccountformostmesenchymal
neoplasmsintheuterinecorpus.Althoughmostendometrialstromalneoplasmsareeasily
separatedfromsmoothmuscleneoplasms,thereisarangeoverwhichcleardistinctionisnot
possible using conventional light microscopy and immunohistochemistry. These “mixed”
tumorsareoccasionallyreferredtoasstromomyomas.Whensuchlesionsremainambiguous
despite immunohistochemical analysis and the probability of an endometrial stromal
proliferationis high on other grounds, they should be assigned to the endometrial stromal
groupformanagementpurposes(48).
SmoothMuscleTumors
Smooth muscle tumors are the most common mesenchymal neoplasm in the uterus.
Most are composed of interlacing fascicles of spindle-shaped smooth muscle fibers (Fig.
6.46),butepithelioid(Fig.6.47)andmyxoid(Fig.6.48)variantsmaybeseen.
Leiomyoma
Leiomyomas represent the most common tumor of the uterus. They present during
reproductive years and are often multiple. The typical gross appearance is that of a wellcircumscribed, solid, white to tan myometrial nodule with a trabeculated surface on cut
sections.Degenerativechangesmayalterthisappearance,andedema,hemorrhage,fibrosis,
andhyaline(infarction-type)necrosisare commonlyseen.Occasionally,mitoticallyactive
leiomyomas containing 15 or more mitotic figures per 10 high-power fields may be
encountered,but in the absence of other atypical features (i.e., coagulative tumor cell
necrosisorsignificantcytologicatypia),theseneoplasmsareclinicallybenign(49).
CellularLeiomyoma
Leiomyomasexhibitingdensecellularitywithouttumorcellnecrosisorsignificantcytologic
atypiaaredesignated cellularleiomyomas.Theyareclinically benignbutmaybeconfused
withendometrialstromalneoplasms(Fig.6.49).Theyaredistinguishedfromstromaltumors
by the presence of diffuse expression of the smooth muscle markers desmin and hcaldesmon,withminimalorabsentexpressionofCD10(49).
LeiomyomawithBizarreNuclei(AtypicalLeiomyoma)
Leiomyomasthatexhibitdiffuseor multifocal moderate to severe cytologic atypia, but no
tumorcellnecrosisorincreasedmitoticindex(>10mitoticfiguresper10high-powerfields),
aredesignated symplastic or bizarre leiomyomas.Most of these atypical leiomyomas(Fig.
6.50)areclinicallybenign,althoughlocalrecurrencemayrarelyoccur(50).
Asubsetofatypicalleiomyomasexhibitfumaratehydratasedeficiency.Someofthesemay
beassociatedwithagermlinemutationinfumaratehydratase(hereditaryleiomyomatosisand
renal cell carcinoma). Affected patients are at risk for developing aggressive renal cell
carcinomas.
Figure6.46 Uterinesmoothmuscletumor(leiomyoma),standardmorphology.Theusual
smooth muscle tumor forms a discrete intramyometrial fibrous mass. Bland spindle cell
histologyfeaturesovoid,blunt-endednucleiwithnoatypia.
Figure6.47 Uterine smooth muscle tumor (leiomyoma), epithelioid morphology. Some
smoothmuscletumorsexhibitpronouncedepithelioidhistology,mimickingepithelialprocesses.
Figure 6.48 Uterine smooth muscle tumor (leiomyoma), myxoid morphology. Rarely,
smooth muscle tumors undergo extensive myxoid change. In these cases, a myxoid
leiomyosarcomamustberuledout.
Figure6.49 Cellularleiomyoma.Leiomyomaswithmarkedcellularitymaymimicendometrial
stromaldifferentiation(seeFigs.6.53and6.54).(top,lowpower;bottom,highpower)
Leiomyosarcoma
Leiomyosarcomasareuncommonuterinetumorsbutarethemostcommonsarcomain
the uterus. They typically affect adult women in the perimenopausal years.
Leiomyosarcomas are typically solitary, fleshy, and necrotic intramural tumors. The
presence of coagulative tumor cell necrosis, moderate-to-severe cytologic atypia, and
numerous mitotic figures distinguish leiomyosarcomas from leiomyomas (Fig. 6.51).
Leiomyosarcomaisahighlymalignantneoplasmandtheprognosisispoor.
Figure6.50 Leiomyomawithbizarrenuclei(atypicalleiomyoma).Diffuse,markednuclear
atypiaintheabsenceoftumorcellnecrosisandincreasedmitoticindexisclassifiedasbizarre
orsymplasticleiomyoma(atypicalleiomyoma),whichhasaverylowriskofrecurrence.
EpithelioidLeiomyosarcomas
Theselesionsexhibitpatternsofepithelioiddifferentiationinadditiontotheusualfeaturesof
malignancy seen in the more conventional leiomyosarcomas: cytologic atypia, tumor cell
necrosis,andincreasedmitoticindex(5mitoticfiguresper10high-powerfields)(49).
MyxoidLeiomyosarcoma
This is a large, gelatinous neoplasm that usually appears to be circumscribed on gross
examination. Microscopically, the smooth muscle cells are usually widely separated by
myxoid material (Fig. 6.52). The characteristic low cellularity partly accounts for the
presence of only a few mitotic figures per 10 high-power fields in most myxoid
leiomyosarcomas. Despite the low mitotic counts, myxoid leiomyosarcoma has the same
unfavorableprognosisastypicalleiomyosarcoma(49).
SmoothMuscleTumorofUncertainMalignantPotential
Uterinesmoothmuscletumorsthatcannotbereliablydiagnosedasbenignormalignant
aredesignatedastumorsofuncertainmalignantpotential.Thisdiagnosisisusedwhen
thereisuncertaintyconcerningthetypeofnecrosis(hyalineversuscoagulative),thesubtype
of smooth muscle differentiation (standard vs. epithelioid vs. myxoid), the degree of
cytologicatypia,orthemitoticindex(49).
SmoothMuscleNeoplasmswithUnusualGrowthPatterns
Uterinesmoothmuscletumorsmaydemonstrateunusualpatternsofdistribution.Asinother
uterinesmoothmuscleneoplasms,thetumorsshowingtheseunusualpatternsofdistribution
mayexhibitstandardspindle,epithelioid,ormyxoidhistology(41).
DiffuseLeiomyomatosis
Diffuse leiomyomatosis refers to the presence of numerous, histologically benign small
smoothmusclenodulesdiffuselydistributedthroughouttheuterus.Thenodulesrangeupto3
cmindiameter,butmostarelessthan1cm.Thisconditionisbenign.
IntravenousLeiomyomatosis
This condition is characterized by the presence of cords of histologically benign smooth
musclegrowingwithinvenouschannelsbeyondtheconfinesofaleiomyoma.Extensioninto
pelvicveinsand,onoccasion,theinferiorvenacavaandrightheartmaybeseen.
MetastasizingLeiomyoma
This clinicopathologic condition consists of the presence of histologically benign smooth
muscle tumors in the lung, pelvic lymph nodes, or abdomen in association with a
histologicallybenignuterinesmoothmuscletumor.Typically,theuterinetumorisremoved
yearsbeforetheextrauterinetumorsaredetected.
Figure 6.51 Uterine leiomyosarcoma. Diagnostic criteria for uterine leiomyosarcoma are
diffuseatypia,tumor cell necrosis, and increasedmitoticindex.(top,lowpower;bottom,high
power)
DisseminatedPeritonealLeiomyomatosis
Disseminated peritoneal leiomyomatosis is a rare condition characterized by widespread