PART TWO
Diagnostic Cytology
Fig. 10.1 Late proliferative phase endometrium. Endometrial
biopsy, histologic section, (H&E x HP). Note the pseudostratified columnar
epithelium with elongated and variable nuclei, some with small nucleoli.
Fig. 10.2 Late secretory phase endometrium. Endometrial biopsy,
histologic section (H&E x HP). Note the extensive stromal decidual reaction
and tortuous glands containing luminal secretions.
Fig. 10.3 Menstrual phase endometrium. Endometrial biopsy, histologic
section (H&E x HP). Note the collapsing stroma (asterisk), and exhausted
secretory-type glands with degenerative vacuoles and apoptosis.
is characterized by cellular, whorls of endometrial stroma
exhibiting nuclear debris ("blue balls"), often with overlying,
draping epithelium (Fig. 10.3).
The Climacteric
This is the period in the late reproductive years characterized by
the transition from reproductive years to the nonreproductive
stage. Anovulation occurs with increasing frequency, leading to
periods of sustained estrogen production by ovarian follicles.
This environment leads to persistent endometrial prolifera-
tion without any subsequent secretory phase. Commonly, this
hyperproliferative endometrium will undergo stromal collapse
and breakdown, producing irregular and abnormal uterine
bleeding.
Post-Reproductive Years (Menopause)
With the exhaustion of ovarian follicles the reproductive years
and endometrial cycling ceases. Clinically, menopause indicates
the final menstrual period, and is considered to have occurred
when there has been no vaginal bleeding for a minimum of
six months. Endometrial proliferative activity may continue
for some months or years, but in established menopause, the
endometrium lacks both proliferative and secretory activity, and
is thin and inactive or atrophic. Such endometrium, however,
can still be the origin of malignancy.
Overview of Endometrial Carcinoma
introduction
Numerous types of benign and malignant neoplasms may
arise in the body of the uterus and some are detectable in cyto-
logic specimens1 (Table 10.1). Of these many types carcinoma
is the most common malignancy involving the endometrium,
and is the fourth or fifth most common malignancy overall
in women in developed countries. Most endometrial carcino-
mas occur in the postmenopausal woman, although a signifi-
cant proportion do present in the pre- and perimenopausal
woman.
Types i and ii Endometrial Adenocarcinoma
Endometrial carcinomas have been divided into two groups,
based upon their histopathologic appearance, immunopheno-
type, pathogenesis, and recognized precursor lesions.2-4 This
concept of two types of endometrial carcinoma almost certainly
represents an oversimplification of a complex, neoplastic pro-
cess, but has become very important in disease classification
and treatment.
The endometrioid and mucinous adenocarcinomas typify
type I carcinomas. These carcinomas are usually early stage at
presentation, and generally have a good outcome. An associ-
ated endometrial precursor lesion, complex hyperplasia with
cytologic atypia, is frequently identified. Such carcinomas fre-
quently arise in a woman with an identifiable hyperestrogenic
state. In the postmenopausal woman type I carcinomas are often
associated with obesity which produces an elevated estrogen
environment through the peripheral conversion of androgens
to estrogens within the peripheral adipose organ, or estrogen-
producing ovarian tumors.
The serous and clear cell adenocarcinomas typify type II carci-
nomas. These carcinomas are aggressive tumors that often show
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