INADEQUATE LUTEAL PHASE

This term refers to the occurrence of inadequate corpus luteum function and low progesterone output, with an irregular ovulatory cycle. The condition often manifests clinically as

infertility, with either increased bleeding or amenorrhea. Endometrial

Figure 22-27Common causes of abnormal uterine bleeding. A, The most common is dysfunctional uterine bleeding, seen here as anovulatory endometrium with stromal breakdown. Note

breakdown associated with proliferative glands. B, Chronic endometritis. C, Endometrial polyp. D, Submucosal leiomyoma (lower) with attenuation of the endometrial lining (arrow).

Figure 22-28Adenomyosis. This disorder is characterized by functional endometrial nests within the myometrium, producing foci of hemorrhagic cysts within the uterine wall.

Figure 22-29The potential origins of endometriosis.

Figure 22-30Endometriosis. A, This ovary has been sectioned to reveal a large endometriotic cyst containing necrotic brown material consisting of degenerated blood (chocolate cyst). B,

Lining of an endometriotic cyst from a pregnant patient. On the right is an endometrial gland; on the left is endometrial stroma with plump stromal cells characteristic of decidual changes.

In the center are numerous macrophages containing hemosiderin.

Figure 22-31 A, Lower-grade hyperplasias of the endometrium show principally architectural glandular changes with cystic glandular dilatation and are synonymous with anovulatory

changes. B, Atypical hyperplasias (endometrial intraepithelial neoplasia) exhibit increased gland/stroma ratio (gland crowding) and epithelial stratification (arrows). C, Loss of PTEN gene

expression in intraepithelial neoplasia, seen here as absence of staining. Compare to normal glands (arrows), which express the gene (Courtesy of Dr. George L. Mutter, Brigham and

Women's Hospital, Boston, MA.) D, Endometrial hyperplasia with squamous metaplasia.

Figure 22-32 A, Endometrial adenocarcinoma presenting as a fungating mass in the fundus of the uterus. B, Well-differentiated endometrial adenocarcinoma. Glandular architecture is

preserved but the tissue is confluent without intervening stroma, which distinguishes carcinoma from hyperplasia. C, Papillary serous carcinoma of the endometrium, with accumulation of

nuclear p53 protein as seen by immunohistochemistry (inset upper left).

Stage II.Carcinoma has involved the corpus and the cervix.

Stage III.Carcinoma has extended outside the uterus but not outside the true pelvis.

Stage IV.Carcinoma has extended outside the true pelvis or has obviously involved the mucosa of the bladder or the rectum.

Cases in various stages can also be subgrouped with reference to the three grades described above:

G1.Well-differentiated adenocarcinoma

G2.Differentiated adenocarcinoma with partly solid (less than 50%) areas

G3.Predominantly solid or entirely undifferentiated carcinoma. Serous and clear cell carcinomas are automatically classified as grade 3.

Clinical Course.

Carcinoma of the endometrium may be asymptomatic for periods of time but usually produces irregular vaginal bleeding with excessive leukorrhea. Uterine enlargement in the early stages

may be deceptively absent. Cytologic detection on Papanicolaou smears is variable and most likely associated with serous carcinomas, which produce easily detached clusters of cells that

are sampled in pap smears. Exclusion of a cervical adenocarcinoma can usually be based on cervix exam and the fact that older age groups are much more susceptible to primary

endometrial (versus cervical) cancer. However, upper genital tract carcinomas (fallopian tube and ovary) may be associated with abnormal cytology. The diagnosis of endometrial cancer

must ultimately be established by curettage and histologic examination of the tissue.

As would be anticipated, the prognosis depends heavily on the clinical stage of the disease when it is discovered, and its histologic grade and type. In the United States, most women (about

80%) have stage I disease clinically and have well-differentiated or moderately well-differentiated endometrioid carcinomas. Surgery, alone or in combination with irradiation, gives about

90% 5-year survival in stage I (grade 1 or 2) disease. This rate drops to approximately 75% for grade 3/stage I and to 50% or less for stage II and III endometrial carcinomas.

As mentioned, uterine papillary serous and clear cell carcinomas have a propensity for extrauterine (lymphatic or transtubal) spread, even when confined to the endometrium or its surface

epithelium. Overall, fewer than 50% of patients with these tumors are alive 3 years after diagnosis and 35% after 5 years. If peritoneal cytology and adnexal histologic exam are negative,

the five year survival of stage I disease is approximately 80% to 85%.[82] The additional advantage of prophylactic radiation or chemotherapy in early-stage disease is unclear.[83] [84]

Date: 2016-04-22; view: 805