Cervial Fibroid

Title:

Cervical fibroid

Patient complaint:

A 49 years old female referred to the National Maternity Hospital (NMH) from an outside institution. On presenting the patient indicated menorrhagia for 1 year but there was no dysmenorrhoea, no Intermenstrual bleeding (IMB) and no Post Coital Bleeding (PCB). The Diagnosis indicated cervical fibroid.

Treatment

The treatment choice included Hysterectomy, Myomectomy, Total Abdominal Hysterectomy (TAH) and Bilateral Salpingo-Oophorectomy (BSO). TAH/BSO is a surgery to remove of the uterus (cervix, right, left fallopian tubes, ovaries). Myomectomy is a surgical removal of the fibroid only. Total Abdominal Hysterectomy is the surgical removal of the uterus. Bilateral Salpingo-Oophorectomy is the surgical removal of the both fallopian tubes and ovaries (1). The treatment chosen was Hysterectomy (TAH, BSO) on the 22/09/2016 at 11.50am.

Histology laboratory (Gross: macroscopic examination)

On the 22/06/2016 at 2.19pm the histology laboratory received a uterus including the cervix, right left tubes and both ovaries in 10 %formalin (formalin forms cross link between protein to avoid decay and preserving the tissues and nucleic and cytoplasm for embedding and for light microscope examination) (2). The specimen was labelled with patient details uterus and cervix. The specimen opened and left to fix for 24 hours. On the 23/09/2016 the specimen was dissected. The uterus and cervix with both appendages weighed 678grams (gms). The body of the uterus was 65x60x50 millimetres (mm) and grossly unremarkable. The cervix was enlarged 55x50mm.Within the cervix a single polypoid (? fibroid) mass 90x80x80mm was seen. This was serially sectioned and sampled. The cut surface of the polypoid mass was described as firm, white whorled and well circumscribed with no focal areas of haemorrhage or necrosis seen grossly. The os was linear with a maximum diameter of 20mm.The right fallopian tube was 65mm.The fimbrial end was amputed and trisected and all embedded. The remainder of the tube was serially sectioned and sampled. The right ovary was 45x15x10mm.This was bisected and single parafimbrial cyst identified 20x10x10mm.This was bisected and all embedded. The remainder of the tube was serially sectioned and sampled. The left ovary was 40x10x10mm and grossly unremarkable. This was bisected and sampled. The myometrium was 22mm.There was a single haemorrhagic cavity 4x4x4mm,? site of ?adenomyosis. The endometrium was 3mm and fleshly. The lower uterine segment was grossly unremarkable. Specimen sectioned as follow.

Figure1: Shows the body of uterus (cervix and uterus). Notice the enlarged cervix (cervical fibroid).

block1=right fimbrial end of tube, 2=sampled right tube, 3-4=sampled right ovary. 5=left fimbrial end of tube, 6=sampled left tube, 7=left parafimbrial cyst, 8-9=sampled left ovary, 10=anterior, cervix, 11=posterior cervix, 12=left uterine segment, 13=anterior endo/myometrium, 14=15posterior end/myometrium, 16=additional sections of endometrium, 17=23=polypoid? Fibroid mass, 24=?site of adenomysis. Block1=3p, 2, 6=4p. 3, 4, 8-15, 17-24=1p.5, 7=2p, 16=3p.

Figure2: Shows the myometrium single haemorrhage cavity (site of adenomyosis?) and endometrium (fleshy).

The blocks were processed overnight using the Leica VIP tissue processor. Leica tissue processing uses alcohol for dehydration, xylene for clearing, wax for impregnation to support for sectioning. Following processing to wax the cassettes were then transported to the embedding centre using the Leica EG 1150H to embed the tissues in wax for microtome sectioning. The microtomes were used to cut the tissue into 4-5 microns section which were then placed on glass slides and stained using the routine haematoxylin and eosin (HE). HE is the most widely used stain in the histology laboratory. Haematoxylin stains nucleus and 1% acid alcohol removes the excess haematoxylin from the cytoplasm, tap water is used to blue up the nuclei to see the nuclear detail in the microscope. Eosin stains the cytoplasm (red/pink colour).

Microscopic exam result:

The microscopic exam result confirmed a benign leiomyoma in the cervix. Adenomyosis was diagnosed. Also, an area of CIN1 (cervical intraepithelial Neoplasia mild) was reported in the cervix.

Further test:

Due to the presence of CIN1 the remainder of the cervix was processed to the HE. A P16 test was also requested. P16 result was negative.

Discussion of clinical significance and the disease

The patient admitted to the NMH from an outside institution suffering from Menorrhagia for 1 year.Menorrhagia is defined as an abnormal menstrual blood loss (3). The cause is not known but is believed to be related to hormone oestrogen. Oestrogen is a hormone formed by the ovaries. It is believed that oestrogen level is low during menopause (where period stop at almost 50 years) which matches patient age. Also, the patient does not have Dysmenorrhea, Intermenstrual bleeding (IMB) and Post Coital Bleeding(PCB). Dysmenorrhea is a pain which occurs in the lower abdominal pelvis during the period. IBM is a vaginal bleeding during menstruation. PBC is a bleeding that happens after sexual intercourse (4).

The gross showed an enlarged cervix (single polypoid) and fleshy endometrium. There was a single haemorrhage cavity in the myometrium. The HE confirmed adenomyosis, leiomyoma and CIN1. In the left fallopian tube, there was a single parafimbrial cyst.

Leiomyoma (fibroid) is a benign tumour in smooth muscle caused by the abnormal growth of smooth muscle and connective tissue. It can cause a heavy bleeding (menorrhagia). Menorrhagia is a heavy bleeding in the cervix. Fibroids can sometimes cause anaemia because of heaving bleeding. Anaemia is a decrease in the quality or quantity of Red Blood Cells (RBCs). Benign tumour is not a cancer and does not spread to another tissue compared to sarcoma which is a cancer and can spread (5).

Fibroid is most widely solid pelvic tumours in women and is clinically observed in 20% to 25% of women among the reproductive years. There are 3 types of leiomyoma Subserosal (in surosal of the uterus), Intramural (within the myometrium), Submucous (in the endometrium). The patient had fibroid in the submucous. Also, Fibroid appears in woman between 35-50 years old which match patient age. The differential diagnosis of leiomyoma is Endometrial polyps, Dysfunctional uterine bleeding, Endometriosis,endometrial cancer. Chronic pelvic inflammatory disease, Tubo-ovarian abscess, Uterine sarcoma, Ovarian tumour, Pelvic masses (other causes of a pelvic mass involve, appendix abscess, tumour of the large bowel, and diverticular abscess) and pregnancy. The menorrhagia can be a sign of leiomyoma disease which match the patient symptom (6).

CIN1 was confirmed on HE. CIN1 (cervical Intraepithelial Neoplasia) where third of the cervix cells are abnormal but may not need excision and goes easily. Cervix is a part of female reproductive system found in the lower part of the uterus. Uterus is a reproductive organ in female in the pelvic between the rectum and the bladder. There are three layers in the uterus endometrium (inner layer), myometrium (middle layer) and perimetrium (outer layer) (7).

Also, adenomyosis confirmed on HE. Adenomyosis is the growth of endometrium glands (outside the endometrium) and is not a cancer. It causes pain and bleeding during period because of misplaces cells in the muscle wall. It results in formation of fibrous tissue. It is found in almost 10 % of women (8).

The doctor requested P16 which was negative. P16 is a diagnostic marker used to detect the Humanpapillomavirus (HPV) infection of the cervix using immunohistochemistry Ventana XT Benchmark automation. Ventana XT Benchmark is an automated Immunohistochemistry machine/stainer. Staining is based on detection of specific antigens using specific labelled antibodies (9). Also, the result showed no further dysplasia in the cervix. Dysplasia is the abnormal growth of the tissue in the cell. The cervix indicates squamous dysplasia which is a sign of abnormal growth of cells and is precancerous. 90-98% of dysplasia is caused by the HPV infection (10).

Conclusion

The patient has cervical fibroid, adenomyosis, CIN1 and menorrhagia for 1 year so removal of uterus is the best treatment (TAH/BSO). No further follow up was indicated for this patient.

References

(1) Leister S. Manual of Surgical Pathology. Am J Surg Path. 2014 301:423 426.

(2) Renashaw A, Pinnar M, et al. Specimen Preparation Method. PubMed 2015 202(2):136-8. https://www.ncbi.nlm.nih.gov/pmcPMC3519251656417 (Accessed on 15/01/2017).

(3) Adams G, Hesley T. Overview of Menorrhagia, Symptoms and Treatments. http://www.mayoclinic.org/diseases-conditions/menorrhagia/basics/definition/con-200219599 (accessed on 05/12/2016).

(4) Malcolm S, Ian E. Essential Obstetrics and Gynaecology. Obstet. BJOG. 2015 Oct1121(12):134-82.

(5) Cook A, Liu S. Management of Uterine Fibroid. Obstetrics and reproductive medicine. 201411(1):2031-217.

(6) Mark L. Histopathology. Gynecol 201521(7):115-135.

(7) Preutthipan O, Lawson W.Cervical pathology. Cancer T Clinic 2015 78(4):731 7.

(8) David R, John C. Histology for Pathologists. Amj Healthcare 2016:31(1)21(9):200-45.

(9) Daniel M, Leane P.Histology and Immunohistochemistry Method.J Clinical Pathology 201691(1):537-45.

(10) Yen K, Nadim V. Cervical Dysplasia. Cancer Research 201410(6)19(1):301- 309.

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