UTERINE CORPUS

Overview of myometrial tumors

ANATOMY
• Pear shaped, smooth external surface
• Anatomic position within the pelvic cavity between the urinary
bladder (anterior) and rectum (posterior)
• Anterior portion can be identified by a higher peritoneal reflection,
due to location of the bladder in vivo
• Hysterectomy specimens are often opened in the coronal plane by
inserting a probe into the external cervical os and cutting along the
probe to reveal the endometrial cavity
• Endometrial cavity is shaped like an inverted triangle when viewed in
the coronal plane
HISTOLOGY
GROSSING
Total hysterectomy for benign conditions
• Weigh the specimen.

• Orient the specimen as to anterior and posterior.

• Examine the serosal surface for adhesions, endometriosis, tumor implants, or

inflammation and describe.

• Record the overall dimensions of the uterus (three dimensions)

• Open the uterus with scissors, along the lateral margins from the external os
to the cornu. Never use a scalpel. It is useful to use a probe within the os to
guide the scissors.

• Make transverse incisions through the entire mucosa to, but not through the
serosa.
• Do not abrade the mucosa or wash with water.

• Describe the endometrial cavity and lining including size (cornu to

cornu, fundus to endocervical canal), distortion (by leiomyomas),
color (tan, hemorrhagic), thickness, and any lesions.

• If lesions are present, describe location (anterior or posterior), size,

color, consistency, and depth of invasion into myometrium.
• Describe the myometrium including average thickness, normal
trabeculated pattern, or adenomyosis (coarse trabeculations or cystic
hemorrhagic areas). If leiomyomas are present describe number, size
(or range in size if many), location (subserosal, mural, submucosal,
anterior or posterior), color, presence of hemorrhage or necrosis or
variation in pattern.

• For high risk patients, the entire endometrial surface should be

examined, even in the absence of any gross lesion, as small and/or
grossly inconspicuous carcinomas may be present.

• Examples of high risk patients:

• repeated biopsies raising suspicion for carcinoma.
• A concurrent ovarian carcinoma.
MICROSCOPIC SECTIONS
• Lower uterine segment: One transmural section from each of the
anterior and posterior sides.
• Endometrium and myometrium: Two transmural endometrial
sections from anterior and posterior walls; if the myometrium is very
thick, include only a portion of wall.
• Sample any lesions (e.g., polyps). If leiomyomata are present, section
through each one and examine grossly. Take up to three
representative sections TOTAL. More sections are taken if there are
areas of necrosis, hemorrhage, or areas of unusual appearance.
Total hysterectomy for uterine tumors

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• Weigh the specimen and orient as above. Examine the serosal surface
for adhesions, serosal implants, or direct invasion by tumor.
• The vaginal reflection at the cervix should be examined for tumor
implants.
• Ink the parametrial surgical resection margin (disrupted areas) and
the vaginal/ cervical margin.
• The intact serosal surfaces need not be inked.
• State in the description if the specimen was received intact or was
previously opened
• Open with scissors along the lateral margins from external os to
cornu.
• Avoid cutting through areas suspicious for involvement by tumor.
• Try to make clean cuts when opening the uterus so that true surgical
margins and serosal surface will be apparent.
• Do not abrade the mucosa or wash with water.
• Make serial transverse incisions from the mucosal surface to, but not
through, the serosal surface at approximately 0.5 cm intervals.
• Leave all tissues attached in order to maintain orientation
• Describe and include any irregularities or piling up of the mucosal
surface, location of lesions (e.g., anterior vs. posterior), the portion of
the endometrial surface involved, and gross invasion (depth). Gross
invasion is appreciated as an effacement of the normal myometrial
texture but may be difficult to appreciate grossly.
• For mesenchymal tumors, describe the location (mural and/or
exophytic) including smooth vs irregular interfaces with normal
tissues, and the texture of the tumor, as well as areas of necrosis and
hemorrhage.
• Search for all parametrial lymph nodes and note their location.
Usually, nodes are not found
MICROSCOPIC SECTIONS
• Tumor: Transmural sections demonstrating depth of myometrial
invasion
• In most cases four anterior and four posterior sections are adequate.
If the tumor is in the LUS or near the cervix the entire vaginal margin
(inked) is divided into quadrants and submitted and extra slides of the
LUS and LUS/endocervical junction are also submitted.
• If no gross lesions are identified, submit the ENTIRE endometrium (all
sections do not need to be full thickness, but all should include the
endomyometrial interface to assess for invasion)
• For mesenchymal tumors (i.e., leiomyosarcomas or endometrial
stromal sarcomas), submit one section per cm of tumor. Be sure to
include the interface with the surrounding myometrium and areas of
possible necrosis.
• Cervix: Anterior and posterior cervix taken to include both exo- and
endocervix and the transformation zone.
• Lower uterine segment: Two transmural sections from the posterior
and anterior sides. See under “tumor” if the tumor is near the LUS.
• Fallopian tubes: Submit the entire tube using the SEE FIM protocol
(“Section and Extensively Examine the FIMbriated end of the fallopian
tube”) (see under “Fallopian Tube”). The cassettes containing the
fimbriae must be indicated in the cassette key.
• Ovary: Submit the entire ovaries (sections taken transverse to the
longitudinal axis) including capsule.
• Serosa: If serosa is not included in the sections of endometrium,
submit a separate section.
• Parametrium: Submit any parametrial nodules or lymph nodes.
• Other lesions: Submit sections of any other lesions (e.g., polyps,
leiomyomata)
Leiomyomas. Gross Findings
• Intramural, submucosal, or subserosal in order of frequency
• Fundus most common location
• Often multiple; wide range of sizes
• Pedunculated if subserosal.
• Sharply circumscribed and easily shells out
• Bulging white to slightly pink, firm and whorled cut surface
• Degenerative changes include ulceration, edema, cystic change,
calcification, or ossification
• Red degeneration characteristic of pregnancy, postpartum, and oral
contraceptives
Microscopic Findings
• Well circumscribed
• Intersecting fascicles of spindled cells intermixed with variable
amounts of collagen
• Abundant large blood vessels
• Abundant eosinophilic cytoplasm (when transversely cut, paranuclear
vacuole)
• Elongated “cigar”-shaped nuclei
• Nuclear palisading may be seen
• Mild to absent cytologic atypia and mitoses
• Infarct-type necrosis: “mummified” and homogeneous appearance,
area of transition between necrotic and viable tumor composed of
granulation tissue or fibrous or hyalinized tissue.

• Other findings: skeletal-like or rhabdoid cells, extramedullary

hematopoiesis, collections of lymphocytes, mast cells, eosinophils,
numerous histiocytes, acute inflammatory cells (pyomyoma)
Usual type:
interlacing fascicles of spindle cells with eosinophilic fibrillary cytoplasm and cigar shaped
nuclei lacking cytological atypia; very low mitotic count.
• Cellular:
more cellular than surrounding myometrium; thick walled
vessels and cleft-like
spaces; cells have scant cytoplasm
• Multiple foci of hemorrhage are visible on the cut surfaces
• With bizarre nuclei or atypical leiomyoma: bizarre cells in a
background of typical leiomyoma; low mitotic count . Tumor cells
have single or multiple pleomorphic nuclei with coarse, smudged
chromatin
• Fumarate hydratase deficient: staghorn vessels; alveolar type edema,
may have bizarre nuclei, large nuclei with perinuclear halos, rhabdoid
inclusions
• Mitotically active: 6-14 mitosis/10HPF; no cytological atypia
• Hydropic: Edematous stroma causing compartmentalization of the
smooth muscle cells
• Apoplectic: stellate zones of hemorrhage, zonation phenomenon,
history of progestogen treatment or pregnancy.

• Lipoleiomyoma: admixture of mature adipocytes and smooth muscle

cells.

• Epithelioid: rounded or polygonal cells with eosinophilic granular or

clear cytoplasm, no cytological atypia.
• Myxoid: circumscribed, hypocellular and myxoid tumor lacking
mitoses or cytological atypia.

• Cotylenoid dissecting: irregular nodular dissection of bland smooth

muscle cells within the myometrium.

• Diffuse leiomyomatosis: Innumerable, poorly circumscribed

hypercellular tumor nodules with no cytological atypia.
Leiomyosarcoma
• Malignant mesenchymal tumor of myometrial smooth muscle
derivation exhibiting spindle cell, epithelioid or myxoid morphology.
• Most leiomyosarcomas are intramural.
• 50–75% solitary.
• Leiomyosarcoma averages 6–9 cm in diameter.
• Soft or fleshy with poorly defined margins.
• Cut surface is gray-yellow or pink, often with areas of necrosis and
hemorrhage .
• Leiomyosarcoma tends to be larger and softer than leiomyoma; it has
a more irregular margin, and it is more likely to be hemorrhagic and
necrotic
Microscopic findings
Spindled Leiomyosarcoma
• Infiltrative growth
• Frequently hypercellular but may be hypocellular
• Long intersecting fascicles of spindled cells
• Cells with eosinophilic fibrillary cytoplasm and elongated blunt-ended nuclei
• Frequently diffuse moderate to marked nuclear atypia, including multinucleated giant
cells
• Typically ≥ 10 mitoses/10 HPFs, including atypical forms
• Frequent tumor cell necrosis; may also show infarct-type necrosis
• Diagnosis based on combination of two of the following features:
• Diffuse moderate to severe cytologic atypia
• > 10 mitoses/10 HPFs
• Tumor cell necrosis
• Vascular invasion in 20% of case
Epithelioid Leiomyosarcoma

• > 50% of the cells with an “epithelial-like” appearance

• Sheets, nests, cords, or rarely, pseudoglandular spaces

• Common hyalinization if cords and nests (plexiform growth)

• Cells with eosinophilic granular or clear cytoplasm and round or angular nucleus

• Diagnosis based on combination of ≥ 5 mitoses/10 HPFs, diffuse

moderate to severe cytologic atypia, or tumor cell necrosis
Myxoid Leiomyosarcoma

• Infiltrative growth
• Typically hypocellular with abundant extracellular myxoid matrix
• Loose or thin fascicles or no particular pattern
• Cells with stellate, spindle, or abundant cytoplasm with marked
degree of cytologic atypia
• Not infrequently cells with scant cytoplasm, minimal cytologic
atypia and rare mitoses (< 5/10 HPFs)
• Diagnosis based on finding moderate to severe cytologic atypia
or tumor cell necrosis, and in their absence finding ≥ 2 mitoses/10 HPFs