Myometrial tumour and also explain about stump
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I have all the information I need. Now let me compose a comprehensive answer covering leiomyoma, leiomyosarcoma (myometrial tumors), and the cervical stump.
Myometrial Tumours
The myometrium gives rise to two major smooth muscle tumours: the benign leiomyoma and the malignant leiomyosarcoma.
1. LEIOMYOMA (Fibroid / Uterine Fibroid)
Definition
A leiomyoma is a benign smooth muscle neoplasm of the myometrium. It is one of the most common tumours in women and is often called a "fibroid" (though it contains very little fibrous tissue).
Etiology & Pathogenesis
| Factor | Detail |
|---|---|
| Hormonal | Estrogen and progesterone stimulate growth; tumours shrink after menopause |
| Genetic | Rearrangements of chromosomes 6 and 12 |
| Molecular | MED12 mutations in up to 70% of cases (MED12 regulates RNA polymerase II-mediated transcription) |
| Race | More common in African-Caribbean women |
| Hereditary | Germline loss-of-function mutations in the fumarate hydratase (FH) gene cause an autosomal syndrome of multiple cutaneous + uterine leiomyomas + renal cell carcinoma |
- Robbins & Kumar Basic Pathology, Uterine Leiomyoma section
- Bailey and Love's Short Practice of Surgery 28th Ed, p.1609
Pathology - Classification by Location
Leiomyomas are typically sharply circumscribed, firm, gray-white masses with a whorled cut surface. They may be single or, more commonly, multiple.
| Type | Location | Features |
|---|---|---|
| Intramural | Embedded in myometrium | Most common; pressure symptoms, may distort cavity |
| Submucosal | Beneath endometrium | Heavy periods, infertility, recurrent pregnancy loss; if pedunculated may extrude through cervical os |
| Subserosal | Below serosa | Pressure symptoms; pedunculated forms can mimic ovarian mass ("parasitic leiomyomas" when they attach to other organs and develop independent blood supply) |
| Cervical / Broad ligament | Rare sites | Rare locations |
Histology: Bundles of smooth muscle cells resembling normal myometrium, with minimal atypia and extremely rare mitotic figures. Foci of fibrosis, calcification, and degenerative softening ("degeneration") may be present.
Degenerations of Leiomyoma
| Type | Mechanism |
|---|---|
| Hyaline | Most common; collagen replaces smooth muscle |
| Cystic | Liquefaction of hyaline areas |
| Calcific | Dystrophic calcification (seen in postmenopausal women; "womb stones") |
| Red (Carneous) | Venous thrombosis → infarction; seen in pregnancy - presents with acute pain |
| Fatty (Lipomatous) | Rare |
| Myxoid | Myxoid change |
| Sarcomatous | Malignant transformation to leiomyosarcoma - extremely rare (<1%) |
Clinical Features
- Menorrhagia (most common symptom), with or without metrorrhagia
- Pelvic pressure / pain, urinary frequency/retention, constipation
- Infertility, recurrent pregnancy loss (submucosal type)
- Acute pain from torsion of pedunculated fibroid or red degeneration in pregnancy
- Many are asymptomatic - discovered incidentally
Investigations
- Pelvic ultrasound - first line, high sensitivity and specificity
- MRI - if USS inconclusive or declined; gold standard for mapping
- LDH and its isozymes - help differentiate leiomyosarcoma from degenerated leiomyoma
- Hysteroscopy - for submucosal fibroids
Treatment
| Category | Options |
|---|---|
| Conservative | Watchful waiting if asymptomatic |
| Medical | Tranexamic acid, NSAIDs; GnRH agonists to shrink before surgery |
| Hormonal | Progesterone-releasing IUS, combined oral contraceptive |
| Surgical (uterus-sparing) | Myomectomy (open, laparoscopic, hysteroscopic) |
| Surgical (definitive) | Hysterectomy (total or subtotal) |
| Interventional | Uterine artery embolisation |
2. LEIOMYOSARCOMA
Definition
A malignant smooth muscle tumour arising from the myometrium (or endometrial stromal precursor cells). It is distinct from leiomyoma and does not arise from it in the vast majority of cases.
Epidemiology & Pathogenesis
- Uncommon - accounts for 10-20% of soft tissue sarcomas overall
- More common in postmenopausal women (contrast to leiomyoma which occurs before menopause)
- Almost always solitary (contrast to leiomyoma which is often multiple)
- Complex, highly variable karyotypes with chromosomal deletions; defects in genomic stability
- MED12 mutations present in ~30% (vs 70% in leiomyoma)
- Robbins & Kumar Basic Pathology, Leiomyosarcoma section
Pathology
| Feature | Description |
|---|---|
| Gross | Soft, hemorrhagic, necrotic mass; typically solitary |
| Histology | Ranges from tumours resembling leiomyoma to wildly anaplastic neoplasms |
Diagnostic Triad (all three must be assessed):
- Tumor coagulative necrosis
- Cytologic atypia
- Mitotic activity (increased mitotic rate)
Note: Increased mitotic activity alone can be seen in benign smooth muscle tumours (especially in young women), so all three features together are needed to diagnose malignancy.
Immunohistochemistry: Smooth muscle proteins (smooth muscle actin, desmin, h-caldesmon) confirm smooth muscle differentiation.
Spread & Prognosis
- Local recurrence is common following surgery
-
50% eventually metastasize, primarily to the lungs
- Poor prognosis; retroperitoneal/deep tumours are particularly difficult to control
Leiomyoma vs Leiomyosarcoma - Key Differences
| Feature | Leiomyoma | Leiomyosarcoma |
|---|---|---|
| Nature | Benign | Malignant |
| Number | Multiple | Solitary |
| Age | Premenopausal | Postmenopausal |
| Gross | Firm, whorled, white | Soft, hemorrhagic, necrotic |
| Necrosis | Absent | Present (coagulative) |
| Atypia | Minimal | Marked |
| Mitoses | Very rare | Frequent |
| MED12 mutation | ~70% | ~30% |
| Transformation from leiomyoma | Extremely rare (<1%) | Mostly de novo |
THE CERVICAL STUMP
What is a Cervical Stump?
A cervical stump is the remnant cervix left behind after a subtotal (supracervical) hysterectomy - an operation in which only the uterine body (corpus) is removed while the cervix is intentionally left in place.
"A supracervical or 'subtotal' hysterectomy is the removal of the uterine corpus while leaving the cervix in situ."
- Sabiston Textbook of Surgery
Why is a Subtotal Hysterectomy Performed (Creating a Stump)?
- Technically easier and faster, especially in cases with dense adhesions or severe endometriosis where total hysterectomy is hazardous
- Historically popular; sometimes driven by patient preference (belief in preserved pelvic floor support and sexual function)
- May be performed laparoscopically via morcellation (cutting the uterine body into pieces for removal through small ports)
Surgical Procedure
- Steps identical to total hysterectomy up to the point of uterine artery ligation at the level of the internal cervical os
- The uterine body is then amputated from the cervix using scissors, electrocautery, or ultrasonic energy
- The remaining endocervix and cervical stump are cauterised
- The stump is closed with figure-of-eight sutures for hemostasis
Important Considerations After Leaving a Cervical Stump
| Issue | Detail |
|---|---|
| Cervical cancer screening | Must continue per guidelines (Pap smears / HPV testing) because the transformation zone of the cervix is still present |
| Contraindication | Subtotal hysterectomy is contraindicated if there is malignant or premalignant disease of the uterus or cervix |
| Cancer of the Cervical Stump | Cervical carcinoma can develop in the stump just as in an intact cervix |
Cancer of the Cervical Stump
This is a cervical carcinoma arising in the residual cervix after a prior subtotal hysterectomy. It is managed similarly to regular cervical carcinoma but with important differences:
- Radical trachelectomy (surgical removal of the stump) is preferred over pelvic irradiation in many cases, because intestinal adhesions to the residual cervix increase the risk of bowel complications from radiation
- Laparoscopic and robotic radical trachelectomy approaches have been reported
- "Cut-through" scenarios - e.g. if endometrial cancer is later discovered in the subtotal hysterectomy specimen, robotic radical trachelectomy of the remaining cervix may be required
- Berek & Novak's Gynecology, Cancer of the Cervical Stump
- Sabiston Textbook of Surgery, Supracervical Hysterectomy
Summary Table: Cervical Stump
| Aspect | Detail |
|---|---|
| Definition | Residual cervix after subtotal hysterectomy |
| Synonym | Supracervical / subtotal hysterectomy remnant |
| Screening required | Yes - Pap smear continues |
| Risk | Cancer of the cervical stump |
| Management of stump cancer | Radical trachelectomy (surgical) preferred over radiotherapy due to adhesion risk |
| Contraindication to leaving stump | Pre-existing cervical/uterine malignancy or premalignancy |
Morcellation and the Stump
During laparoscopic subtotal hysterectomy, the uterine body is removed by morcellation (breaking it into small pieces). A recognized risk is parasitic spread of tissue - if an occult leiomyosarcoma was present, morcellation can disseminate malignant cells throughout the peritoneal cavity. This is why the FDA has issued warnings about power morcellation, particularly in postmenopausal women where leiomyosarcoma risk is higher.
- Bailey and Love's Short Practice of Surgery 28th Ed, Morcellation section
Also add gross and microscopic feature and diagram for better understanding
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Excellent - all three images retrieved. Here is the complete expanded answer with gross features, microscopic features, and diagrams.
GROSS & MICROSCOPIC FEATURES OF MYOMETRIAL TUMOURS
1. LEIOMYOMA - Gross & Microscopic Features
Gross Pathology
FIG. 17.13 - Uterine Leiomyomas (Robbins & Kumar Basic Pathology)
(A) The opened uterus shows multiple submucosal, intramural, and subserosal tan-white tumours, each with a characteristic whorled appearance on cut section. (B) Microscopic appearance showing bundles of bland smooth muscle cells.
| Gross Feature | Description |
|---|---|
| Shape | Sharply circumscribed, rounded, well-demarcated from surrounding myometrium |
| Size | Variable - from a few mm to masses that dwarf the uterus |
| Cut surface | Characteristic whorled (trabeculated) pattern of interlacing smooth muscle bundles |
| Colour | Tan-white / gray-white |
| Consistency | Firm - due to dense smooth muscle and collagen |
| Capsule | Pseudocapsule of compressed myometrium (easy to shell out surgically) |
| Number | Often multiple; scattered throughout uterus |
| Degenerative changes | Foci of softening, cystic spaces, calcification ("womb stones"), or red discolouration (red degeneration) |
Microscopic Pathology
| Microscopic Feature | Description |
|---|---|
| Cell type | Interlacing fascicles of spindle-shaped smooth muscle cells |
| Nuclei | Elongated, blunt-ended ("cigar-shaped"), uniform, normochromatic |
| Cytoplasm | Abundant eosinophilic (pink) cytoplasm |
| Atypia | None to minimal - cells look like normal myometrium |
| Mitoses | Extremely rare |
| Necrosis | Absent (unless degenerative) |
| Stroma | Variable amounts of fibrous tissue, may show hyalinisation |
| IHC | Positive for smooth muscle actin (SMA), desmin, h-caldesmon |
Key teaching point: The cells are so bland they resemble the surrounding normal myometrium - the key diagnostic feature is the whorled architecture and circumscription, not cellular atypia.
2. LEIOMYOSARCOMA - Gross & Microscopic Features
Gross Pathology
eFIG. 17.4 - Leiomyosarcoma (Robbins & Kumar Basic Pathology)
(A) A large hemorrhagic tumour distends the lower corpus, flanked by two pale leiomyomas for comparison. (B) Tumour cells are irregular in size with hyperchromatic nuclei. Numerous mitotic figures are present (arrows).
| Gross Feature | Description |
|---|---|
| Number | Almost always solitary |
| Borders | Ill-defined, infiltrative margins (contrast with leiomyoma's pseudocapsule) |
| Cut surface | Soft, fleshy - not firm/whorled like leiomyoma |
| Colour | Gray-pink to yellow-tan with areas of dark haemorrhage (red-black) |
| Necrosis | Prominent necrotic (yellow/tan) areas - coagulative tumor necrosis |
| Consistency | Soft and friable (falls apart) |
| Size | Usually large (>5 cm) at presentation |
The contrast with leiomyoma is striking: where a leiomyoma is firm, white, and whorled - a leiomyosarcoma is soft, hemorrhagic, and necrotic.
Microscopic Pathology - The Diagnostic Triad
| Microscopic Feature | Leiomyosarcoma | Leiomyoma |
|---|---|---|
| Coagulative tumor necrosis | Present - ghost cells with preserved outlines | Absent |
| Cytologic atypia | Marked - pleomorphic cells, enlarged irregular nuclei, prominent nucleoli | Minimal |
| Mitotic figures | Frequent (>10 per 10 HPF) | Very rare |
| Cell arrangement | Fascicles of spindle cells ± anaplastic/pleomorphic cells | Uniform interlacing fascicles |
| Nuclear morphology | Hyperchromatic, irregular, pleomorphic | Cigar-shaped, uniform |
| Giant cells | May be present | Absent |
| IHC | SMA+, desmin+, h-caldesmon+ | Same |
All three features (necrosis + atypia + mitoses) must be assessed together to diagnose malignancy. Mitotic activity alone in a young woman can be seen in benign "cellular leiomyoma" - do not diagnose sarcoma on this alone.
- Robbins & Kumar Basic Pathology
DIAGRAM - Leiomyoma vs Leiomyosarcoma vs Cervical Stump
QUICK VISUAL COMPARISON SUMMARY
LEIOMYOMA LEIOMYOSARCOMA
─────────────────────────────────────────────────────────
GROSS: GROSS:
• Multiple • Solitary
• Firm • Soft, friable
• Gray-white • Gray + hemorrhage + necrosis
• WHORLED cut surface • No whorling
• Sharp borders (pseudocapsule) • Ill-defined, infiltrative
MICRO: MICRO:
• Bland spindle cells • Pleomorphic cells
• Cigar-shaped nuclei • Hyperchromatic, irregular nuclei
• NO atypia • MARKED atypia
• NO mitoses • MANY mitoses (>10/10 HPF)
• NO necrosis • COAGULATIVE necrosis
• Interlacing fascicles • Fascicles ± anaplastic areas
CERVICAL STUMP - Diagrammatic Concept
NORMAL UTERUS AFTER SUBTOTAL HYSTERECTOMY
─────────────────────────────────────────────────────
┌──────────┐ [Uterine corpus removed]
│ CORPUS │
│ (uterine │ ┌──────────┐
│ body) │ ──► │ CERVICAL │ ← "STUMP"
├──────────┤ │ STUMP │ (remains)
│ CERVIX │ └────┬─────┘
└────┬─────┘ │ vagina
│ vagina
Key: Cervix left in place → must continue Pap smears
Can develop carcinoma → "Cancer of the cervical stump"
Treatment: Radical trachelectomy (preferred over radiotherapy
due to bowel adhesion risk from radiation)
Summary: Three Microscopic Criteria for Malignancy in Smooth Muscle Tumours
| Criterion | Leiomyoma | Leiomyosarcoma |
|---|---|---|
| Coagulative tumor necrosis | ❌ | ✅ |
| Cytologic atypia (moderate-severe) | ❌ | ✅ |
| Mitotic index >10/10 HPF | ❌ | ✅ |
When all three are present = Leiomyosarcoma. When borderline features exist = Smooth muscle tumour of uncertain malignant potential (STUMP) - a separate diagnostic category used when the lesion cannot be classified as definitively benign or malignant.
Source: Robbins & Kumar Basic Pathology, Ch. 17 - Female Genital System
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