Fig.19.13 )thatmaydwarftheuterus.Someareembeddedwithinthemyometrium(intramural),whereasothersmaylieimmediatelybeneaththeendometrium(submucosal)ortheserosa(subserosal).Inthelatterlocation,tumorsmayextendoutonattenuatedstalksandevenbecomeattachedtosurroundingorgans,fromwhichtheymaydevelopabloodsupply(parasiticleiomyomas).Onhistologicexamination,thetumorsarecharacterizedbybundlesofsmoothmusclecellsmimickingtheappearanceofnormalmyometrium.Focioffibrosis,calcification,anddegenerativesofteningmaybepresent.
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Fig.19.13Uterineleiomyomas.(A)Theuterusisopenedtoshowmultiplesubmucosal,myometrial,andsubserosalgray-whitetumors,eachwithacharacteristicwhorledappearanceoncutsection.(B)Microscopicappearanceofleiomyomashowsbundlesofnormal-lookingsmoothmusclecells.
Leiomyomas of the uterus often are asymptomatic, being discovered incidentally on routine pelvic examination. The most frequent presenting sign is menorrhagia, with or without metrorrhagia. Leiomyomas rarely, if ever, transform into sarcomas, and the presence of multiple lesions does not increase the risk of malignancy.
Leiomyosarcomas of the uterus virtually always arise de novo from the mesenchymal cells of the myometrium. They are almost always solitary and most often occur in postmenopausal women, in contradistinction to
The most common disorder of the fallopian tubes is inflammation (salpingitis), almost invariably occurring as a component of pelvic inflammatory disease. Less common abnormalities are ectopic (tubal) pregnancy and endometriosis.
Inflammation of the fallopian tubes is almost always caused by infection. In addition to gonorrhea, nongonococcal organisms, such as Chlamydia, Mycoplasma hominis, coliforms, and (in the postpartum setting) streptococci and staphylococci are the major offenders. The morphologic changes produced by gonococci are similar to those in the male genital tract (Chapter 18). Infections with coliforms, streptococci, and staphylococci can penetrate the wall of leiomyomas, which frequently are multiple and usually arise premenopausally.
Recurrence after surgery is common with these cancers, and many metastasize, typically to the lungs, yielding a 5-year survival rate of about 40%. The outlook with anaplastic tumors is less favorable than with well-differentiated tumors.
MORPHOLOGYLeiomyosarcomastypicallytaketheformofsoft,hemorrhagic,necroticmasses.Thehistologicappearancevarieswidely,fromtumorsthatcloselyresembleleiomyomatowildlyanaplasticneoplasms.Well-differentiatedtumorsmaylieatthemorphologicinterfacebetweenleiomyomaandleiomyosarcomaandaresometimesdesignatedsmoothmuscletumorsofuncertainmalignantpotential.Thediagnosticfeaturesofleiomyosarcomaincludetumornecrosis,cytologicatypia,andmitoticactivity.Becauseincreasedmitoticactivityissometimesseeninbenignsmoothmuscletumors,particularlyinyoungwomen,anassessmentofallthreefeaturesisnecessarytomakeadiagnosisofmalignancy.
the tubes, giving rise to blood-borne infections that seed to distant sites. Tuberculous salpingitis is far less common and is almost always encountered in combination with tuberculous endometritis. All forms of salpingitis may produce fever, lower abdominal or pelvic pain, and pelvic masses, which are the result of distention of the tubes with either exudate or inflammatory debris (