Author
Information
Jayashri Chaudhari*, Kanchan
Kothari**, Alka Gupta***, Jyotsna Dwivedi****
(* Assistant Professor, ** Associate
Professor, Department of Pathology, *** Professor, **** Second year Resident,
Department of Obstetrics and Gynecology. Seth
G.S. Medical
College and K.E.M
Hospital , Mumbai , India
Abstract
Lipoleiomyoma’s
are fatty tumors of the uterus which are not commonly seen. Cervical lipoleiomyoma’s
are even rarer then uterine lipoleiomyoma. We present an interesting case of
a large cervical leiomyoma that not only was challenging to remove surgically
but also presented a histopathological surprise when bundles of smooth muscle
were seen to be interspersed
with lobules
of mature adipocytes.
Introduction
Fatty tumours primary to the uterus are
very uncommon .The incidence varies from 0.03% to 0.2%. Lipoleiomyoma is a
benign soft tissue tumor. It is more commonnly seen at extrauterine sites either within the abdominal cavity or in the
retroperitoneum. It can also befound in the muscular fascia and the subcutis..
[1] In the uterus, lipoleiomyomas are more common in the corpus [2]
and are very rare in cervix with less than 15 cases of cervical lipoleiomyomata
reported in literature. [2, 3, 4, 5, 6, 7, 8] We present a case of cervical
lipoleiomyoma clinically mimicking malignancy.
Case Report
A 40 years old woman,
having completed her family presented with complaints of something coming out of
vagina since 6 months and hesitancy in passing urine since 2 months. Patient had
undergone surgery
for fibroid uterus 3-4 years back, and another for cervical polyp 2 years
back. Operative details were not available. There was no history of fever,
pain in
abdomen, or burning micturition or any other urinary complaints. On examination, her
abdomen was
soft. Speculum examination showed a
large, non ulcerated
mass.
The mass appeared to be a fibroid growth. On bimanual vaginal examination the
whole
anterior part of cervix was replaced with the fibroid.
Cervical rim or os could
not be felt. Decision for total abdominal hysterectomy was taken. All preoperative
serological, biochemical, radiological investigations
were within normal limits. After written, valid
consent and peri operative parenteral antibiotics patients’ abdomen was opened
by midline, infraumblical incision after administering spinal anesthesia. Intraoperatively there
was difficulty in delivering out the uterus due to large posterior cervical
fibroid growing downwards. Another small intramural fundal
fibroid was also noted. Total
size of the uterus was around 12 weeks. Bilateral adnexa were
normal.
The upper pedicles of the uterus (round ligaments, cornual pedicles)
could be divided and ligated easily. Bladder was low and not elevated by the
cervical fibroid.Anterior
fold of peritoneum could be identified and incised and the
bladder was
reflected off the isthmus of the cervix and the bladder was retracted. Bilateral uterine vascular pedicles were
divided and ligated. Supra
cervical hysterectomy done and the cervical stump was then held with long Allis forceps.
The cervix was broad, and its lower end could not be felt. The whole cervix
posteriorly, left laterally, anteriorly was replaced with the fibroid. Only a
small area in the right anterior part did not have the fibroid extension. The
cervix was debulked by bisecting it with an electrocautery and the fibroid was
reached and enucleated from within its mucosal surface. The vagina was opened
anteriorly on the right sided and a retrograde Maingot’s clamp
was applied to the left angle of the vagina and then to the left uterosacral
ligament. Both these pedicles were then divided and ligated. Fibroid
was handed over to the nurse and sent for frozen section to exclude sarcoma
changes as the gross examination of the fibroid did not show a whorled
appearance or standard degenerative changes. Right vaginal angle
was held with Allis forceps and divided and ligated. The bisected stump of the cervix
on the right side was clamped laterally with Maingot’s clamp
and divided and ligated and removed. The remaining surgery was completed by
standard method and the patient was subsequently discharged on the 5th
post operative day. Frozen section was
suggestive of degenerated cervical fibroid leiomyomatous polyp.
Figure 1: Gross photograph showing large cervical whitish
firm mass with few cystic areas.
On microscopy the mass was covered by stratified squamous
epithelium. The underlying tissue shows fascicles and bundles of smooth muscle
with interspersed lobules of mature adipocytes. Few dilated endocervical glands
were seen below the squamous epithelium and focally in the periphery amidst the
tumor. There was no proliferation of endocervical glands There was no atypia or
mitosis. The histological diagnosis was lipoleiomyoma of cervix. Sections from
the myometrium showed two small subserosal leiomyomata.
Figure 2: (HE 400X) Fascicles of smooth muscle
with intermixed mature adipocyte.
Discussion
Uterine
lipoleimyomas are rare tumors and represent less than 0.2 % of benign neoplasms
[6]. Most of them are
reported in uterine corpus . A large study of 50 uterine lipoleiomyoma revealed
that the mean
patient age was 54 and mean tumor size was 4.6 cm. Forty-three (83%)
tumors were located in the uterine corpus, and 7 (13%) were in the cervix.[8].
The
immunohistochemical findings suggest a complex histogenesis for these tumors.
They may develop either due to direct transformation of smooth muscle cells
into adipocytes by means of progressive intracellular storage of lipids or from
the immature mesenchymal cells surrounding the vessels [6 ] The
consistent finding of chromosomes 12 and 14 on different derivatives in these
tumor indicates that the t(12;14) was a primary event and immunohistochemical
studies showed that HMGI-C was aberrantly expressed in this tumor indicating
that uterine lipoleiomyomas have a pathogenetic origin similar to that of
typical leiomyomas.[9] Lipomatous component of these tumors can be
picked up by CT scan or MRI. [7] They behave like the usual
leiomyomas and no recurrence or fatality due to tumor is reported [8]
Conclusion
Lipomatous
tumors of the uterus are rare and that to cervix is very rare, only less than
15 cases of cervical lipoleiomyomas are reported. We present a rare case of
cervical lipoleiomyoma mimicking malignancy.
References
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Citation
Chaudhari J, Kothari K,
Gupta AS, Dwivedi J.
Cervical Lipoleiomyoma. JPGO 2014 Volume
1 Number 9 Available from: http://www.jpgo.org/2014/09/cervical-lipoleiomyoma.html