Introduction
Hysterectomy involves surgical removal of whole or the part of uterus with or without removal of its adnexal structures. It is one of the most commonly performed gynaecological procedures in the world. As all the surgical procedures carries their own advantages and risk, hysterectomy even though being a successful procedure has its own disadvantages. Sterility in women who are premenopausal is the main disadvantage of this procedure.1
The first performed hysterectomy dates back to November 1843 in Manchester, by Charles Clay. Total abdominal hysterectomy (TAH) which involves removal of entire uterus and cervix was first done in 1929 by Richardson, MD. Earlier hysterectomies had lot of dreadful complications and the patients usually died of hemorrhage, peritonitis, and exhaustion. The introduction of total abdominal hysterectomy by Richardson or Pfannesnsteil incision by Johanns Pfannenstiel or finally the performance of the first laparoscopic hysterectomy by Harry Reich in Kingston, Pennsylvania in 1988 were the instrumental historical improvements in this procedure.1
Hysterectomy is generally sorted as a last resort for many of gynaecological conditions such as uterine leiomyoma, adenomyosis, dysfunctional uterine bleeding and malignancies of uterus and its adnexal structures.1
The purpose of this study is to know the incidence of various lesions occurring in myometrium of hysterectomy specimens and to study leiomyoma and degenerative changes occurring in leiomyoma.1
Materials and Methods
The study was conducted in the department of pathology in a tertiary care hospital. It was a study of 18 months prospective type from March 2016 to September 2017. A total of 1000 cases were included in the study.
Chief complaints and clinical indications of patients undergoing hysterectomy were obtained from the histopathological requisition forms/ clinical records of the patients and were recorded in the standard proforma.
The hysterectomy specimens received from Obstetrics and Gynaecology department were assessed for gross features and were fixed in 10% buffered formalin. Subsequently the tissues were dehydrated with ascending grades of alcohol, cleared in xylene and embedded in paraffin. Thereafter, 3-5 microns thick paraffin sections were cut on a rotary microtome dewaxed and stained with Haematoxylin and Eosin.
The inclusion and exclusion criteria for specimens included in the study are as following:
Observations and Results
Table 1
Age wise distribution of leiomyoma cases
It was observed that 90.1% of leiomyoma cases presented as isolated lesion.
On gross, leiomyoma were well-circumscribed solid and white and on cut surface showed whorled appearance. Microscopically leiomyoma showed smooth muscle cells arranged in fascicular pattern. The cells were elongated and had bland cigar shaped nuclei with abundant eosinophilic cytoplasm.
Leiomyoma with adenomyosis accounted for 8.3% cases.
Grossly, adenomyosis showed trabeculations on cut surface. Microscopically, endometrial glands were seen deep within the myometrium. Multi parity or pregnant state is associated with higher chances of development of adenomyosis possibly because of the invasive nature of the trophoblast on the extension of the myometrial fibers.
Cervical leiomyoma accounted for 0.8% cases.
Leiomyoma with other benign lesion like serous cystadenoma, endometrial polyp was 0.4% each.
Table 2
Age wise distribution based on degenerative changes in leiomyoma
It was observed that 87.9% cases of leiomyoma did not show any noticeable change. Most common degenerative change encountered was hyaline degeneration and it was seen in 8.7% cases. Hyaline degeneration on gross appearance, showed a smooth whitish depressed zone alternating with bulging nodules of intact smooth appearance.
Cystic degeneration in 4 cases and myxoid in 2 cases were also noted.
In our study we found 4 cases of cystic degeneration were found. On gross, the tumor was firm and grey white in color with small cystic areas. Microscopically, the tumor is similar to usual leiomyoma with areas of cystic change.
One case of myxoid degeneration was seen. The tumor was composed of spindle cells with focal areas of myxomatous change.
Other degenerative changes like calcification and hemorrhage were seen in 0.4% cases each.
Table 3
Distribution based on variants of leiomyoma:
| Total leiomyoma cases (n=240) | Frequency | Percentage |
| Usual leiomyoma | 238 | 99.2 |
| Mitotically active leiomyoma | 01 | 0.4 |
| Cellular leiomyoma | 01 | 0.4 |
| Total | 240 | 100 |
Majority of leiomyoma cases (99.2%) were usual leiomyoma. Only 2 variants of leiomyoma, 1 case of cellular leiomyoma and other case of mitotically active leiomyoma were found.
The gross appearance of cellular leiomyoma and mitotically active leiomyoma was similar to usual leiomyoma.
Cellular leiomyoma on microscopy showed high cellularity with increased smooth muscle proliferation. Large thick walled blood vessels seen. No atypia and no mitotic figures were noted.
Mitotically active leiomyoma microscopically shows smooth muscle cells arranged in fascicular pattern. 5 mitotic figures /10 HPF were noted. No necrosis or atypia was seen.
Figure 1
Multiple Uterine fibroid (a): The cut surface of uterus shows multiple fibroids. Largest fibroid measuring 4x3 cm is intramural in location and smallest fibroid is subserosal in location measuring 2x1 cm. The fibroid are well circumscribed, grey white in color and has characteristic whorl appearance. (b): The low power view shows smooth muscle cells arranged in fasicular pattern separated by connective tissue stroma; (c): The tumor cells are elongated with cigar shaped nuclei and eosinophilic cytoplasm
Figure 2
Leiomyoma with hyaline change (a); On cut surface well circumscribed tumor with whorl appearance and smooth glistening surface suggestive of hyaline change; (b) & (c): Tumor cells arranged in whorl pattern and separated by pink eosinophilic hyaline material
Figure 3
Cystic change in leiomyoma (a): On cut surface one intramural fibroid identified measuring 3x2 cm, grey white in color with whorl appearance and areas of cystic changes; (b): Tumor composed of smooth muscle cells arranged in whorl pattern seen. The spindle cells are separated by large areas of cystic spaces
Figure 4
Myxoid change in leiomyoma; (a) & (b): Shows whorl arrangement of uniform spindle cells and surrounded by pool of myxoid edematous stroma
Discussion
In present study degenerative changes showed hyaline degeneration being the commonest accounting 8.7% cases. Similar findings were seen in study by Prem et al2 which showed that hyaline degeneration as commonest degenerative change in 5% cases.
In our study we found 99.2% leiomyoma of usual type. Two variants of leiomyoma. One was cellular leiomyoma and other was mitotically active leiomyoma accounting for 0.4% each.
Kokila K et al3 did a retrospective study over a period of one year and studied 1879 hysterectomy specimens and 664 specimens were found to have fibroid. Usual leiomyoma were found in 88.6% cases and other variants like mitotically active leiomyoma, symplastic leiomyoma, and cellular leiomyoma, neurilemmoma like variant, fatty degeneration, hyaline degeneration, calcification and hydropic degeneration constituted 11.4%. Out of that mitotically active leiomyoma and cellular leiomyoma accounted for 0.43% each. These findings were similar to our study.
Table 4
Comparison of degenerative changes and variants of leiomyoma in various studies
In present study adenomyosis was second commonest lesion found and seen in 32.5% cases. Other studies like Jha et al4 and Ranabhat et al5 Parveen et al6 also found adenomyosis as second commonest lesion in 17.2%, 28% and 24% respectively.
In majority of cases it presents with menorrhagia and diagnosed as incidental finding.
In this study the most common co-existing lesion with leiomyoma was adenomyosis found in 8.3% cases. A study done by Karthikeyan et al7 among rural population in India also showed that most common co-existing lesion with leiomyoma was adenomyosis in 8.8% cases. The reason for this coexistence might be the same set of risk factor and pathogenic mechanism operating for both the lesions.8, 9
Other co-existing lesion found with leiomyoma was serous cystadenoma and endometrial polyp but they had very low incidence of 0.4% each.
Table 5
Comparison of myometrial lesion in various studies
Conclusion
Leiomyoma was the most common pathology found in hysterectomy specimens in our study which is also true for other countries.
Adenomyosis identified on histopathological examination was seen to be an important lesion in cases presenting with DUB. Hence, cases presenting with DUB should be thoroughly evaluated to rule out any underlying pathology.
Histopathological examination helps in identifying rare and unusual malignancies, thus it is important for confirming diagnosis and safeguarding the line of treatment in malignant disease. Moreover, it helps in identifying those lesions which occurs more frequently as well as pure incidental findings in hysterectomy specimens.
Thus, it is mandatory to examine all hysterectomy specimens and their detail histopathological examination even of those specimens which grossly appears normal for better management of the patients post-operatively.
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