• Here is the gross appearance of a normal uterus with fundus, lower
uterine segment, cervix, vaginal cuff, right fallopian tube, left
fallopian tube, right ovary, and left ovary from a young woman.
A. In Singapore, 3rd most common gynaecological
cancer while in USA, endometrial carcinoma is 4 th most
common cancer in female after breast, bowel and lung.
B. 25% occur in premenopausal women.
C. 5% in younger than 40 year old.
D. 20% occur in women age 40 to 50
E. 75% presented at early stage (confined to uterus)
F. Lifetime risk of developing Ca endometrium is women
less than 75 year old is 2-3%. Average age of on set is 60
(STROMA , MYOMETRIUM)
Pathogenesis of endometrial carcinoma
1. Many endometrial carcinomas appear to arise in a background of abnormal
2. Constitutional complex of symptoms, frequently associated with women
who have endometrial carcinoma.
b. Low Parity
d. Diabetes mellitis
e. Late menopause
3. The above complex of constitutional characteristics suggest the possibility
of an underlying hormonal abnormality. Evidence suggests
hyperoestrogenism. This includes:
a. Chronic anovulation, resulting in unopposed estrogen stimulation of
the endometrium. b. Association of endometrial carcinoma with estrogen
secreting ovarian tumors, i.e. theca-granulosa cell tumors.
c. Evidence that weak androgen precursors from the adrenals and
ovarian stroma are aromatized to estrone, a weak estrogen, in body fat. This
contributes to the overall estrogen levels in the body.
d. The association of endometrial carcinoma in young women with high
dose-estrogen-containing sequential oral contraceptives. (These are no longer
available for use.)
Pathophysiology and Clinical Course
1. Presenting complaint: Abnormal vaginal bleeding (usually post menopausal)
2. Mechanisms of progression
a. Myometrial invasion
b. Ovarian metastasis
c. Regional lymph nodes
d. Distant metastases: Late occurrence with grave implications
3. Prognostic Factors
a. Tumor Grade: Relative percentage of glandular and solid areas; A solid
growth pattern is less differentiated than a glandular pattern and is therefore,
b. Depth of myometrial invasion
c. Surgical-Pathologic stage
d. New technologies are under investigation including
ENDOMETRIAL (EPITHELIAL) CARCINOMA:
Endometroid adenocarcinoma (75-80%)
Mucinous carcinoma (5%):Pattern similar with ovary and
endocervix, CEA, Good prognosis.
Serous carcinoma (<10%),
Clear cell carcinoma (4%),
Squamous carcinoma (very rare), poor prognosis
Undifferentiated carcinoma(glassy cell carcinoma), rare,
Mixed types ( if each of the component represent >10% of
A. Metastatic carcinoma (Genital source, ovary is most
B. SYNCRONOUS tumours ( Ovary-Endometrium)
ADENOCARCINOMA OF ENDOMETRIUM GRADE 1
Clinical summary: 60 year old female with vaginal bleeding
Tumor location: Endometrial cavity. Tumor size: 2.8 x 2.4 x 1.7
Tumor characteristics: Soft, pale tan, and nodula mass.
Clinical summary: 68 year old
female with postmenopausal
Tumor location: Endometrium.
Tumor protrudes into the
Tumor size: 7.5 x 5.2 x 1.5 cm.
Tumor characteristics: Soft,
fungating, polypoid, tan-red mass.
Adenocarcinoma of endometrium G3
Well differentiated adenocarcinoma has invaded through
the muscle bundles of the myometrium.
UTERINE PAPILLARY SEROUS ADENOCARCINOMA
Tumor location: Endometrium.
Tumor size: 9.5 x 8.5 x 3.0 cm.
Tumor characteristics: Soft, fungating, polypoid, pale,
tan to tan-red mass.
Aggressive tumour, intraperitoneal spread common
Resembles ovarian serous carcinoma
CLEAR CELL ADENOCA ENDOMETRIUM
Very aggressive, occur in older women
Clinical summary: 71 year old female with a history of clear cell
carcinoma of the endometrium. Tumor location: Fundus of
Tumor size: 5.0 x 3.0 x 3.0 cm.
Tumor characteristics: Soft, fungating and tan brown mass
SYNCRONOUS OVARIAN-ENDOMETRIAL CARCINOMA
Occur in 15-20% of endometrioid carcinoma of ovary
If disease limited to pelvis, only 16% recurs within 5 years
Metastasis to ovary is unlikely from the endometrium if :
1. Ovarian tumour is bilateral
2. Invasion is less than middle third of endometrium
3. Vessel is not involved
4.Endometrial carcinoma is well differentiated
Uterine Mesenchymal Tumour
Pure non-epithelial malignant tumour (only mesenchymal
Endometrial stromal sarcoma (formed by cells resemble endometrial stroma
during proliferative phase)
Mixed endometrial stromal and leiomyosarcoma
Soft tissue malignant tumour
Mixed epithelial-nonepithelial malignant tumour (Mesenchymal
plus epithelial component)
Adenosarcoma (epithelial component is benign, low grade malignancy and
Malignant Mixed Mullerian tumour (Carcinosarcoma, metasplastic
carcinoma and sarcoma)
Carcinofibroma (epithelial component malignant while mesenchymal
component is benign)
Undifferentiated or Unclassifiable sarcoma (poor prognosis)
UTERINE STROMAL SARCOMA
Clinical summary: 40 year old female with an enlarged uterus
Operative procedure: TAHBSO
Tumor location: Myometrium.
Tumor characteristics: Pale, tan and nodular mass. The small
nodules are leiomyomas.
Malignant smooth muscle
tumors that originate from myometrium. Peak incidence
40-60 years of age.
Bulky, fleshy tumors with a gray-tan fish flesh appearance.
Focal necrosis and hemorrhage are common.
a. May be a bulky tumor invading into the myometrium.
b. Polypoid lesion projecting into the endometrial cavity
Variable. Elongated spindle cells that variably grow in a
fascicular pattern, mimicking a benign leiomyoma. However,
the nuclei are generally pleomorphic with increased mitotic
activity (greater than 10 mitoses/10 high power fields).
Clinical Course: Variable with strong tendency to recur and
metastasize; blood borne metastases to lungs are common,
although direct extension into the peritoneal cavity also
Histology : Spindle cells.
Several mitoses are seen
• Leiomyosarcoma: Gross natural color
nicely shown large neoplasm with fish
flesh cerebriform appearance
• Second most common uterine sarcoma
Multiple small nodules are scattered throughout the lung.
These are nodules of metastatic leiomyosarcoma
• Interlacing fascicles of smooth muscle cells arranged in a
whorled pattern. Varying amounts of fibrous connective
tissue are also present.
Rare (0.2-0.7%) sarcomatous transformation in leiomyoma
Tan area at the lower edge of this tumor is softer with a fish
flesh consistency and focal necrosis. This is an area of
leiomyosarcoma in what appeared to be an ordinary
MALIGNANT MIXED MULLERIAN TUMOUR
Most common uterine sarcoma
Aggressive and early lymphatic/haematogenous spread
What is the vulva?
The vulva is the external portion of the female genital organs. It includes:
• labia majora - two large, fleshy lips, or folds of skin
• labia minora - small lips that lie inside the labia majora and surround the
openings to the urethra and vagina
• vestibule - space where the vagina opens
• prepuce - a fold of skin formed by the labia minora
• clitoris - a small protrusion sensitive to stimulation
• fourchette - area beneath the vaginal opening where the labia minora
• perineum - area between the vagina and the anus
• anus - opening at the end of the anal canal
What is vulvar cancer?
Vulvar cancer is a malignancy that can occur on any part of the external
organs, but most often affects the labia majora or labia minora. Cancer of
the vulva is a rare disease, which accounts for half of one percent of all
cancers in women, and may form slowly over many years. Nearly 90
percent of vulvar cancers are squamous cell carcinomas. Melanoma is the
second most common type of vulvar cancer, usually found in the labia
minora or clitoris. Other types of vulvar cancer include:
• Paget's disease
• verrucous carcinoma
• basal cell carcinoma
What are risk factors for vulvar cancer?
• age - of the women who develop vulvar cancer, three-fourths are over
age 50, and two-thirds are over age 70.
• infection with the human papillomavirus (HPV)
• human immunodeficiency virus (HIV) infection
• low socioeconomic status
• vulvar intraepithelial neoplasia (VIN) - there is an increased risk for
vulvar cancer in women with VIN, although most cases do not
progress to cancer.
• lichen sclerosus - can cause the vulval skin to become very itchy and
may slightly increase the possibility of vulvar cancer.
• chronic vulvar inflammation
• other genital cancers
• melanoma or atypical moles on non-vulvar skin - a family history of
melanoma and dysplastic nevi anywhere on the body may increase the
risk of vulvar cancer.
NEOPLASIA There are
macules on the vulva,
some of which have a
area. Nonpigmented red
areas are present on the
labia minora which are
also VIN. On the perineal
body, anterior to the
rectum, red and
pigmented VIN lesions
• Dysplasias may also involve the vulvar epithelium, seen here at the
right with overlying hyperkeratosis (producing an area of leukoplakia),
with more normal (but atrophic) keratinizing squamous epithelium at
the left. Most cases of vulvar intraepithelial neoplasia (VIN) do not
progress to invasive cancer. Many are multicentric, and some occur in
association with cervical or vaginal carcinoma.