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Cytological Findings of Testicular Fine Needle Aspiration of Azoospermic Men


Cytological Findings of Testicular Fine Needle Aspiration of Azoospermic Men

 *Alam MA,1 Islam MS,2 Hossain N3

 The technique of fine needle aspiration (FNA) has a role as a reliable, quick and easy method of obtaining testicular cells. Recent advances in the management of male infertility or sub fertility and in particular, the finding that spermatozoa recovered from epididymis and testis can result in embryo generation after intracytoplasmic sperm injection (ICSI), question the traditional role of open testicular biopsy for the assessment of spermatogenesis. The purpose of this article was to find out the role of testicular fine needle aspiration cytology in male infertility and to provide brief information on method of needle aspiration, interpretation of testicular fine needle aspiration cytology for evaluation of spermatogenesis, its advantages, limitations and complications as compared to testicular biopsy. Adequate sample were obtained from 62 (84.93%) cases, while 11 (15.06%) cases had inadequate smears where cytological examination could not be possible. The adequate smears were categorized as maturation arrest in 25 (40.32%) cases, sertoli cell only in 21(33.87%) cases, normal spermatogenesis in 10 (16.12%) cases and hypospermatogesis in 6 (9.67%) cases. Testicular FNAC is a significant laboratory technique for the investigation of selected cases of male infertility. Compared to open biopsy, FNA has a number of advantages. Infertile male with severe spermatogenesis disorders can give birth to their own children, whereas only a few years ago the same group of men had only to choose between sperm donation and adoption.

[Journal of Histopathology and Cytopathology, 2018 Jan; 2 (1):51-55]

Key words: Cytology, Fine needle aspiration, testis, azoospermia

  1. *Dr. Md. Ashraful Alam, Associate Professor, Department of Pathology, Rangpur Medical College. drashraful09@gmail.com
  2. Md. Shahidul Islam, Associate Professor, Department of Urology, Rangpur Medical College, Rangpur.
  3. Nusrat Hossain, Junior Consultant, Gynaecology and Obestritics.Palashbari Health Complex, Gaibandha.

 *For correspondence

Introduction

Fine needle aspiration cytology (FNAC) of superficial as well as of deep seated lesions today is a well recognized diagnostic procedure for the diagnosis of neoplastic as well as non-neoplastic and inflammatory lesions. Recently, it has gained popularity for its diagnostic and therapeutic role in male infertility. Since times immemorial the wife has always been blamed for infertility especially in third world countries. Failure to find sperms in post coital test, conducted by Max Huhner in 1913, raised the possibility that husband could be responsible for infertility or sub-fertility. Approximately, 20% cases of infertility are caused entirely by male factor with additional approximately, 30% to 50% of infertile couples.1,2 Azoospermia or absent sperm in semen occurs in approximately, 5% to 10% of infertile men who are evaluated.2 Azoospermia may be obstructive azoospermia (OA) or non-obstructive azoospermia (NOA). The obstructive may have no significant effect on spermatogenesis and may be amenable to surgery, whereas, before introduction of intracytoplasmic sperm injection (ICSI), the only available option for men with NOA was adoption or sperm donor. Assessment of spermatogenesis is an important component in the diagnostic algorithm of male infertility. Traditionally, the testis biopsy has been the gold standard in this evaluation because it provides information in cases of both suspected obstruction and in failing on obstructed testes. Any technique to assess spermatogenesis must be minimally invasive and must conserve as much testicular tissue as possible. It should  not only provide qualitative but also quantitative information about spermatogenesis. In addition to answering the question whether sperm production is normal, it must also address whether sperms are present at all within the testis, as with advances in field of reproductive medicine, even a single sperm can now give men with NOA chance to enjoy biological fatherhood.3 FNAC of the testis is a simple, quick, minimally invasive and painless procedure. The sample can be obtained in outpatient department, can be more representative than biopsy as several separate punctures can be made in one sitting, and there is no local severe pain, haematoma or scarring.

The purpose of this study was to find out the role of testicular fine needle aspiration cytology in male infertility and to provide brief information on method of needle aspiration, interpretation of testicular fine needle aspiration cytology for evaluation of spermatogenesis, its advantages, limitations and complications as compared to testicular biopsy.

Methods

This is an observational study. Fine needle aspiration was performed in 73 azoospermic persons from January 2016 to June 2017 in a private diagnostic laboratory of Rangpur city, Bangladesh. Detailed history and physical examination was performed on all azoospermic people. In addition, semen analysis report was evaluated to confirm azoospermia. Hormonal evaluation including testosterone and FSH levels were obtained in the majority of cases.

FNA Technique

Testicular FNA was done under local anesthesia. The scrotal skin was cleaned by spirit and cotton and bilateral spermatic cord block was achieved by giving 5 to 7 ml of 2%  lignocaine. To quicken the distribution of anesthetic, spermatic cord was gently massaged after injection. After several minutes the testis was firmly palpated to ensure absence of pain. Then the testis was positioned with epididymis and vas deferens directed posteriorly, safe from injury. The scrotal skin was stretched taut over the testes by wrapping the scrotal skin behind the testes with a sponge. Testes was aspirated at three different sites, upper, middle and lower part, using 23 G needle with 10  ml disposable syringe attached to it. Precise gentle in and out movement, varying from 5-8 mm were used. After aspiration, the persons were advised for rest for at least ten minutes. Aspiration was done from both testes for evaluation of spermatogenesis. Slides were prepared from the aspirated material and fixed in 95% alcohol and stained with Papanicolaou (Pap) stain.

Contraindication for bilateral testicular sampling included the presence of local skin infection, hydrocele, orchialgia or previous biopsy.

 FNA Interpretation

All stained FNA cytological smear was interpreted for:

  1. The presence or absence of mature spermatozoa with tails.
  2. Specimen adequacy, as previously reported, an adequate, and informative, FNA specimen was defined as one that contained at least 100 clusters of 20 or more cells or at least 2000 well-dispersed testicular cells.4

 Results

FNA was performed in 73 cases of azoospermic men. The mean age of these men was 32.5 years with a range from 22 to 50 years with period of infertility more than one year. The testicular aspirates were adequate for opinion in 62 cases (Table I) out of 73 cases. The cytological diagnoses in aspirate from 73 cases are depicted in (Table II).

Table I: Adequacy of testicular smears

 

Type of sample No of smears %
Adequate 62 84.93%
Inadequate 11 15.06%

Adequate smears were categorized on cytological examination into Table II:

  1. Normal spermatogenesis in 10 (16.12%) cases.
  2. Sertoli cell only in 21 (33.87%) cases.
  3. Hypo spermatogenesis in 6 (9.67%) cases.
  4. Maturation arrest in 25(40.32%) cases.

Normal spermatogenesis of testes on FNA revealed all germ cell maturation steps from spearmatogonia till mature spermatozoa.

Maturation arrest category shows no spermatozoa, with presence of immature germ cells, including primary spermatocytes and spermatids.

Sertoli cells only on FNA of testes showing only sertoli cell.

Spermatogonia were seen as large cells with round nuclei and finely granular chromatin with a thin rim of cytoplasm 5

During our study 2 (2.73%) person complained severe pain. No one complained prolong pain or any haematoma formation.

Table II: Cytological diagnosis of 73 cases

 

Cytological diagnosis No. of cases (%)
Normal spermatogenesis 10(16.12%)
Sertoli cell only 21(33.87%)
Hypo spermatogenesis 6(9.67%)
Maturation arrest 25(40.32%)

 

 

 

 

 

 

Figure 1. Photomicrograph showing sertoli cell only (x400)

 

 

 

 

 

 

Figure 2. Photomicrograph showing hypo- spermatogenesis (x400)

Discussion

Posner and Huhner first used testicular puncture biopsies in the investigation of human infertility that examined unstained samples for spermatozoa.6  Later fine needle aspiration of the testis pioneered by Obrant and Persson (1965) was proposed as a non invasive technique.6 Characterizing the cell types was straightforward, with not much difficulty in recognizing germ cells and sertoli cells were adequate. The materials aspirated by FNAC were adequate in majority of cases (84.93%). The adequacy rate has similarity with the findings of  Ahmed.7 In our study, normal spermatogenesis was found by testicular FNAC in 16.12% of cases of azoosperic men. This finding, however, differed from the findings observed in a study done by Kuerin A et al.8 This may be  due to small number of cases in our study. In our study maturation arrest and sertoli cell only found in 40.32% and 33.87% cases respectively which were similar to the findings found by Ahmed. In our study we found 9.67% cases of hypospermatogenesis which are similar to the findings of Ahamad SU et al9 and RC Adhikari findings.10

In the present study we have done multiple aspirations of both testes under local anaesthetia by cord blocking. Some author performed aspiration by giving per rectal diclofenac sodium suppository.

Most of the authors have performed FNA under general anaesthetia or local anaesthetia. Verma A K et al performed FNA without general or local anaesthetia and found the technique is well tolerated by the most patients.11  Single aspirate may not be truly representative.12 However some studies have described sampling in one testis.10,13 The study used sampling of both testes and findings were also different in both testes. Adhikari RC observed severe pain after FNA procedure in 31.68% cases and haematoma in 2.97% person. Which was completely different observation from our observation. Rajawanshi et al.14,15 observed only complication was prolonged pain in some patients. In our study we noted only 2.73% persons complained prolong pain but no haematoma formation, that are similar observation with Ahamad MSU et al.

 Conclusion

Testicular FNAC is a significant laboratory technique for the investigation of selected cases of male infertility. Compared to open biopsy, FNA has a number of advantages;  therefore, it is already used as a diagnostic and therapeutic method in some andrology centers. FNA combined with the introduction of ICSI (intracytoplasmic sperm injection) have revolutionized the management of male infertility in the  recent years. Infertile male with severe spermatogenesis disorders can have their own children, whereas only a few years ago the same group of men had only to choose between sperm donation and adoption.

References

  1. Sigman M, Jarow JP. Male infertility. In:Walsh PC, Retik AB, Vaughan ED, Weij AJ, Kavoussi LR, Norvick AC, et al,editors. Campbell’s urology. 8th ed. Philadelphia, WB Saunders, 2003: p.1476.
  2. Jarow JP, Espeland MA, Lipshultz LI.Evaluation of the azoospermic patients. J Urol, 1989;142:62-5.
  3. Balselv E, Francis D, Jacobsen GK. Testicular germ cell tumors, Classification based on fine needle aspiration biopsy. Acta cytol, 1990; 34:690-94.
  4. Turek PJ, Cha I, Ljung BM. Systematic fine needle aspiration of testis: correlation to biopsy and results of organ ”mapping” for mature sperm in azoospermic men. Urology, 1997; 49:743-8.
  5. Tauchmanova L, Alviggi C,Foresta C, Srtina I, Gaolla A, Colao A, et al. Cytzoospermia with normal testicular function after allogenic stem cell transplantation: a case report. Hum Reprod 2007; 22:495-9.
  6. Persson PS, Ahren C,Orbant KO. Aspiration biopsy smear of testis in azoospermia cytology versus histological examination.Scand J Urol Nephrol, 1971; 5:22.
  7. Basim Sh. A. Cytological findings of testicular fine needle aspiration in a sample of azoospermic Iraqi patients. Mustansiriya Med Journal, 2012; V11 (2):24-28.
  8. Kurien A, Mammen K,Jacob S. Role of fine needle aspiration cytology (FNAC) of testes in male infertility.Indian J Urol, 2003;19:140-4.
  9. Ahamad MSU,Islam SMJ, Chowdhury, Khanam SA,Ahmed ASMM. Teasticular FNAC in Azoospermia. Chattagram Maa-O Shishu Medical College Journal, 2014;13(1):46-8.
  10. Adhikari R C. Testicular fine needle aspiration cytology in azoospermic males. Nepal Med Col J, 2009; 11(2):88-91.
  11. Verma AK, Basu D,Jayaram G. Testicular cytology in azoospermia. Diagn Cytopathol 1993; 9:37- 42.
  12. Skakkeback NE, Hammen R, Philip H, Rebbe H. Quantitation of human seminiferous epithelium.Histological studies in 44 infertile men and controls with normal chromosomal complements. Acta Pathol Microbiol scand 1973; 81:97-111.
  13. Mahajan AD, Ali NI,Walwalker SJ, Rege JD, Pathak HR. The role of fine needle aspiration cytology of the testis in the diagnostic evaluation of infertility. Brit J Urol Intl, 1999; 84:485-8.
  14. Rajwanshi A, Indhudhara R, Goswami AK et al. Fine needle aspiration cytology in azoospermic males. Diagn Cytopathol, 1993;9:37-42.
  15. Qublan HS, Al Jader KM, Al Kaisi NS, Alghoweri AS, Abu Khait SA, Abu Qamar AA, Haddadin E. Fine needle aspiration cytology compared with open biopsy histology for diagnosis of azoospermia. J Obstet Gynaecol, 2002; 22(5):527-31.

 

 

 

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Skin Tumours Diagnosed at Department of Pathology, Sir Salimullah Medical College, Dhaka During Two Years Study Period


Skin Tumours Diagnosed at Department of  Pathology, Sir Salimullah Medical College, Dhaka During Two Years Study Period

*Hossain MD,1 Islam MN,2  Kabir E ,3  Begum S 4

Abstract

During the past century, cancer has emerged as the most challenging problems for public health systems in medium and low income countries. With a cancer load of more than one million, Bangladesh is not an exception. In this study we found that  squamous cell carcinoma was the most common malignant tumour and lipoma was the most common benign tumour of skin adnexa. The lower income generating group was the more vulnerable group for both benign and malignant tumours. It also showed that both benign and malignant tumours were more common in patients with risk behaviours as well as in patients with no risk behaviours. Tumours of the skin adnexa were the most common benign tumour found in our study

[Journal of Histopathology and Cytopathology, 2018 Jan; 2 (1):47-50]

 Key words: Skin, Tumour

  1. *Dr. Md. Delwar Hossain, Lecturer, Department of Pathology, Sir Salimullah Medical College, Dhaka. mehruddelwar@gmail.com
  2. Professor Dr. Md. Nasimul Islam, Professor and Head, Department of Pathology, Sir Salimullah Medical College, Dhaka
  3. Professor Dr. Enamul Kabir, Professor, Department of Pathology, Sir Salimullah Medical College, Dhaka
  4. Shahnaj Begum, Assistant Professor, Department of Pathology, Sir Salimullah Medical College, Dhaka

 

*For correspondence

Introduction

Cancer burden causes serious health problems both in developed and developing countries.1 Cancer has devastating effect on individual, family and society of Bangladesh. Cancer is one of the major causes of morbidity and mortality among the non-communicable diseases in our population. Appropriate prevention of cancer deserves urgent attention since the disease is expected to double in the next 20 to 25 years in most of the  countries.1 Cancer in Bangladesh is one of the major killer diseases like many other countries particularly because of ubiquitous exposure to environmental carcinogens, oncogenic viruses and microorganisms, coupled with lack of screening, awareness and poor health seeking behaviors associated with poverty, malnutrition and illiteracy. The magnitude of the problem from cancer is often unrecognized by health and general policy makers alike to other  overwhelming and more visible competitive   health problems and natural calamities.

According to Bangladesh Bureau of Statistics cancer is the sixth leading cause of death in Bangladesh.2 The number of people developing cancer is expected to increase in number mainly because of increase in life expectancy and life style factors. Each year more than 200,000 people develop cancer and 150,000 die of the disease. International Agency for Research on Cancer (IARC) has estimated death from cancer in Bangladesh was 7.5 % in 2005 and will be increased up to 13 %  in 2030.3  

IARC has projected death from 10 leading cancers in females of Bangladesh (2002) are: (1) mouth and oropharyngeal, (2) cervical, (3) breast, (4) oesophageal, (5) ovarian, (6) Lung, (7) lymphoma, (8) stomach, (9) liver and (10) colorectal cancer.3

IARC has projected death from 10 leading cancers in males of Bangladesh (2002) are: (1) mouth and oropharyngeal, (2) lung, (3) oesophagus, (4) lymphoma, (5) stomach, (6) bladder, (7) liver, (8) leukaemia, (9) colorectal and (10) prostate cancer.3

During the 2 years study period 2908 histopathological cases and 5187 cytopathological cases were diagnosed at the department of Pathology and 70 haematological malignant tumours were handled at the department of Haematology, Sir Salimullah Medical College (SSMC) and Mitford Hospital, Dhaka.4 This study was done to find out patterns of skin tumours in these cases.

Methods

This study was partial presentation of a two years tumour registry study done at the Department of Pathology, SSMC, Dhaka from 1 July, 2013 to 30 June, 2015. It was a cross-sectional observational study done on all patients diagnosed as cases of both benign and malignant tumors by cytopathology, histopathology and haematology.

 Data collection procedure

A predesigned questionnaire both in Bangla and English was developed according to MacLennan method and software was generated with the technical assistance by the University of Chicago Research Bangladesh by the cooperation of department of Pathology, Bangabandhu Seikh Mujib Medical University (BSMMU), Dhaka. Prior to the commencement of this study, approval was taken from the Ethical Review Committee of SSMC. Each patient was interviewed and relevant information was recorded systematically in a prescribed format. A written consent also attached with the questionnaire and was explained before the patient/patient’s guardian. The first part of the questionnaire was designed to record the demographic details of patients. The second part of the questionnaire was to record the pathological diagnosis of tumour with its ICD 0-3 and ICD-10 codes.  The information collected was entered into the database by software Microsoft Access 2003 and Visual Basic 6.

Recording of Data

The data were recorded according to database software. All the patients were supplied 1st part of the questionnaire (topography portion) during access to the department for submission of the specimen or for FNAC or other procedures. The data were entered case after case from the filled up questionnaire received from the patients during collection of their reports following a self-made registrar which recorded 10 items for each case likely  (1) case serial number, (2) specimen type –histopathological, cytopathological or haematological specimen (3) referred by, (4) yearly serial number i.e., accession number (5) diagnosis, (6) sites of specimen, (7) date of diagnosis and (8) Reported by.

Data were entered into the computer database software accordingly.

 Analysis of the data

Statistical analyses of the results were obtained by using Microsoft access and Window based computer software devised with Statistical Packages for Social Sciences (SPSS-15). The information was partially coded according to ICD-10 (International Classification of Diseases version-10) and ICD-3 (International Classification of Diseases – Oncology version 3).

 Results

Out of total 767 benign tumours of skin and skin adnexa lipoma was found in highest number in 91.13%, ganglioneuroma in 4.05%, nevus in 0.92%, benign fibrous histiocytoma in 0.65% and all were found more in female patients than males in both age group. On the other hand neurofibroma in 1.69% and benign mesenchymal lesion in 0.65% found more in male than female patients in both age groups (Table I)

Out of 49 malignant tumours of skin squamous cell carcinoma was found in highest number in 55.10% and 99.63% in male patients and none in female of adult age group but found only in one female of paediatric age group which was the only malignant tumour of skin of this age group. Basal cell carcinoma 22.45% and malignant melanoma 6.12% were found more in female than male and deratofibrosarcoma 10.21% and verrucous carcinoma 6.12% were found more in male than female  patients only in adult age group  (Table II).

Table I: Diagnostic distribution of benign tumours of skin / skin adnexa according to age and sex

 

Diagnosis Paediatric Adult Total (%)
Male Female Male Female
Lipoma 15 29 302 353 699 91.13
Neurilemoma/Ganglioneuroma 2 4 12 13 31 4.05
Neurofibroma 5 1 5 2 13 1.69
Nevus 0 1 1 5 7 0.92
Epithelioid mesothelioma benign 1 0 3 1 5 0.65
Benign fibrous histiocytoma 1 0 1 3 5 0.65
Fibromatosis 1 0 0 1 2 0.26
Squamous papilloma 1 0 1 0 2 0.26
Pilomatricoma 0 0 1 1 2 0.26
Cylindroma 0 0 0 1 1 0.13
Total 26 35 326 380 767 100.00

 

Table II: Diagnostic distribution of malignant tumours of skin according to age and sex:

 

Diagnosis Paediatric Adult Total (%)
Male Female Male Female
Squamous cell carcinoma 0 1 26 0 27 55.10
Basal cell carcinoma 0 0 5 6 11 22.45
Dermatofibrosarcoma 0 0 4 1 5 10.21
Verrucous carcinoma 0 0 2 1 3 6.12
Malignant melanoma 0 0 1 2 3 6.12
Total 0 1 38 10 49 100.00

 Discussion

A total of 767 benign and 49 malignant tumours of skin and skin adnexa those were diagnosed in this study found more in females than males both in paediatric and adult age group patients. Highest benign tumour of skin and skin adnexa found in this study was lipoma followed by ganglioneuroma, neurofibroma, nevus, benign mesenchymal lesion, benign fibrous histiocytoma, fibromatosis, sqamous papilloma, pilomatricoma and cylindroma. Squamous cell carcinoma was the highest malignant tumour of skin found in this study only in adult males but in no females of adult age group. Squamous cell carcinoma was found only in one female child of the paediatric age group. No other malignant tumour was found in paediatric age group either in male or female. The next malignant tumour of skin was basal cell carcinoma which was found more in adult females than in adult males. Both dermatofibrosarcoma and verrucous carcinoma were found more in male than in female. The NICRH also showed that about 60% of the male cancer patients were smokers and among them more than half (53%) had squamous cell carcinoma.5 Farhad et al. also found lipoma was the top one (35.70%) benign tumour of skin adnexa.6 Lipoma, ganglioneuroma and nevus in both age group were found more in female than in male. Neurofibroma and benign mesenchymal lesion found in both age groups were more in male than in female.

 Most of the patients were from low income generating groups and they were house wives, students, unemployed, garments or industrial workers and hawkers. The patients were mainly illiterate and a few number of the study patients were mostly up to SSC level educated. Most of the study patients were Muslim and a small number were Hindu. Most of the patients hailed from Dhaka city followed by Munshigonj, Shariatpur, Madaripur, Comilla, Manikgonj, Narayangonj, Bhola, Kishoregonj, Patuakhali, Gazipur and Narsingdi and also from other districts of Bangladesh. Out of total 64 districts of Bangladesh patients from only 7 districts were unavailable.

Conclusion

Cancer registries play a major role in providing the data to justify the establishment, implementation and monitoring of a national cancer control programme, therefore, stability in cancer registration is of pivotal importance.

This is the partial study of the two years study done (from July 1st, 2013 to June 30th, 2015) on “Establishment of Pathology Based Tumour Registry at SSMC, Dhaka.” The whole study like this one along with other institutions of the country may pave the path of a nationwide population based cancer registry in future.

 

References

  1. Iqbal S. Cancer: A Bangladesh perspective

(http://ds.cc.yamaguchi-u.ac.jp/~applied/initiative/18-internship-houkokusyo/kiseitai/Iqbal-Mohd.Shamim.htm)

  1. Bangladesh Bureau of Statistics, 2008: Faiz et al, 2008.
  2. Wagner G (1991). History of cancer registration. In Jensen OM, Parkin DM, MacLennan R, Muir CS, and R.G. Skeet RG, editors. Cancer Registration: Principles and Methods. IARC Scientific Publications No. 95. Lyon, France. IARC.2002. p.22-28.
  3. Delwar et al. Establishment of Pathology Based Tumour Registry at Sir Salimullah Medical College, Dhaka, Bangladesh. December, 2015. P. 19 (Thesis).
  4. National Institute of Cancer Research and Hospital (NICRH), Dhaka December, 2009. Zaman MM and BakiMO (eds) (2009). 2005-2007:1-19.
  5. Farhad et al. Pathology Based Tumour Registry at BSMMU Shahbagh, Dhaka. 2013. p.57.

 

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A Study on Uterine Leiomyoma with Clinicopathological Spectrum


A Study on Uterine Leiomyoma with Clinicopathological Spectrum

 *Raza AM,1 Tazri SA,2 Ahmed M,3 Nahar S,4 Afroz D,5 Barua D6

 Abstract

Leiomyoma is the commonest benign neoplasm affecting uterus of females in the reproductive age group. They are noted clinically in 20-30% of women over 30 years of age and have a tendency to regress after the menopause. Their gross appearances are often altered by various secondary changes. Subtypes of leiomyoma are chiefly of interest as they may mimic malignancy in some cases. This study was conducted to analyze the clinicopathologic spectrum of uterine leiomyoma with regards to their clinical presentation, associated changes and variants and to compare these findings with similar studies from different parts of the world. All the hysterectomy and myomectomy specimens which were received in the department of pathology, Jahurul Islam Medical College, Kishoreganj over a period of two years with leiomyomas were included in the study. The specimens were properly labeled, fixed in formalin, examined grossly, processed, stained and examined microscopically. Age range of the patients with leiomyoma was 18-62 years. Majority of the patients were between 41-50 years (46.84% cases). Menorrhagia was the commonest symptom constituting 37.97% cases and fibroid uterus was the most common clinical diagnosis (44%). Most common location of leiomyoma was intramural (57.43%) followed by subserosal (30.69%). 56.96% leiomyoma were single and 43.04% were multiple. Degenerative changes were observed in 16.46% cases, amongst which hyaline change was the most common (6.33%). Nine types of leiomyoma variants were seen and cellular leiomyoma (6.33%) was the commonest. Adenomyosis was associated with leiomyoma in 19.23% cases.

[Journal of Histopathology and Cytopathology, 2018 Jan; 2 (1):41-46]

 Keywords: Leiomyoma, Myometrium, Hysterectomy, Myomectomy.

  1. *Dr. AKM Maruf Raza, Assistant Professor, Department of Pathology, Jahurul Islam Medical College, Kishoreganj, Bangladesh. drmarufraza@gmail.com
  2. Sumia Ahmed Tazri, Assistant Professor, Department of Gynaecology and Obstetrics, Jahurul Islam Medical College and Hospital, Kishoreganj, Bangladesh.
  3. Monira Ahmed, Professor, Department of Gynaecology and Obstetrics, Jahurul Islam Medical College and Hospital, Kishoreganj, Bangladesh.
  4. Shamsun Nahar, Assistant Professor, Department of Gynaecology and Obstetrics, Jahurul Islam Medical College and Hospital, Kishoreganj, Bangladesh.
  5. Dil Afroz, Assistant Professor (Current Charge), Department of Gynaecology and Obstetrics, Jahurul Islam Medical College and Hospital, Kishoreganj, Bangladesh.
  6. Dipi Barua, Associate Professor, Department of Gynae and Obs, Holy Family Red Crescent Medical College and Hospital, Dhaka

 *For correspondence

 Introduction

Myometrium is the thick smooth muscle coat of the uterus which encases the endometrium and is lined by the peritoneum derived serosa.1 Myometrial lesions form a diverse group of lesion in which leiomyoma (benign smooth muscle tumor) is the commonest. Leiomyoma is the commonest visceral neoplasm affecting females in reproductive age group.2 They are noted clinically in 20-30% of women over 30 years of age and are found in as many as 75% of uterus.3 They are rare prior to the menarche, common in reproductive  life, have a tendency to regress after the menopause and are associated with endometrial hyperplasia, all of which suggest their estrogen dependency.4

The importance of leiomyoma lies as they cause pain, abnormal uterine bleeding and a sensation of pressure. Large tumors produce diffuse uterine enlargement or an irregular uterine contour, which may be associated with infertility.4

 

Grossly, they are well-circumscribed, firm, gray-white bulging masses (varying in size from barely visible nodules to large tumors that fill the pelvis) and have a whorled appearance on cut surface with cells arranged in fascicles on microscopy. The gross appearances are often altered by secondary or degenerative changes, which are commonly seen.5,6 Hyaline degeneration/necrosis is present in more than 60% cases, particularly in postmenopausal women, and cystic degeneration, myxoid change, fatty degeneration and calcification each occur in about 4% cases. After menopause or delivery leiomyomas can undergo atrophy with significant shrinkage and fibrosis. Red degeneration is associated with pregnancy and contraceptive use and is due to thrombosis in tumour.5

Most subtypes of leiomyoma are chiefly of interest in that they mimic malignancy in one or more respects. These subtypes are mitotically active leiomyoma, cellular leiomyoma, haemorrhagic cellular leiomyoma, leiomyoma with bizarre  nuclei, epithelioid  leiomyoma, and myxoid leiomyoma.7-9

 In the histopathology laboratory of Department of Pathology, Jahurul Islam Medical College we examined a good number of specimen of leiomyoma. This study was conducted to analyze the clinicopathologic spectrum of uterine leiomyoma with regards to their clinical presentation, associated changes and variants and to compare these findings with similar studies from different parts of the world.

 Methods

The study included all the hysterectomy and myomectomy specimens received in the department of Pathology, Jahurul Islam Medical College, Bajitpur, Kishoreganj over a period of two years from September 2015 to July 2017.  A total of 79 cases diagnosed with leiomyoma were included in the study. The clinical information and the relevant investigations of the patients were obtained from the histopathological requisition forms and clinical record files. The specimens received in the department of pathology were properly labeled, numbered and fixed in 10% buffered formalin. After a detailed gross examination of the specimens, multiple sections were taken from representative sites, processed and paraffin blocks were made. The blocks were sectioned and stained routinely with haematoxylin and eosin. Special stains were used wherever required.

 Results

Age of the patients with leiomyoma ranged from 18 to 62 years. Majority of the patients were between 41-50 years accounting for 46.84% cases (Table I).

 Table I: Age wise distribution of patients with leiomyoma (n=79)

 

Age range (in years) No. of cases Percentage(%)
Below 20 01 1.27%
21-30 40 5.06%
31-40 16 20.25%
41-50 37 46.84%
51-60 19 24.05%
Above 60 02 2.53%
Total 79 100%

Menorrhagia was the commonest symptom constituting 37.97% cases, followed by pain in abdomen in 18.99% cases and dysmenorrhea in 17.72 cases (Table II).

 Table II: Chief complaints of patients with uterine leiomyoma (n=79)

 

Chief complaint No. of cases Percentage(%)
Menorrhagia 30 37.97%
Pain in abdomen 15 18.99%
Dysmenorrhea 14 17.72%
Mass per vaginum 13 16.46%
Post-menopausal bleeding 04 5.06%
Leucorrhoea 02 2.53%
Infertility 01 1.27%
Total 79 100%

Clinical diagnoses  were fibroid uterus in 44% cases, utero-vaginal prolapse in 20% cases, dysfunctional uterine bleeding in 19% cases and pelvic inflammatory disease in 17% cases. Most common site of leiomyomas was intramural (57.43%) followed by subserosal (30.69%), submucosal 8.91% cases while broad ligament leiomyomas constituted 2.97% cases.

In the present study, out of 79 cases of leiomyomas, 45(56.96%) were single and 34 (43.04%) were multiple. Number of leiomyomas observed in the present study varied from 1 to 10. Sub-serosal leiomyomas varied from few mm to 6 x 5 x 4 cm in size. Intramural leiomyomas varied from few mm to 12 x 10 x 8 mm in diameter. Sub-mucosal leiomyomas varied from few mm to 3.5 cm in diameter.

In this study, majority of leiomyomas were diagnosed in multiparous women. Out of 79 patients with leiomyomas, 78 (98.73%) were parous, which includes 10 cases of uniparous patients and only 1 was nulliparous (1.28%). We observed 42 cases of typical leiomyomas (53.16%), followed by leiomyoma variants in 24 cases (30.38%) and degenerative changes in 13 cases (16.46%) (Figure 1).

Figure 1. Various pathological changes seen in uterine leiomyomas (n=79)

 

Degenerative changes were observed in 13 leiomyomas (16.46%). Among these, 5 leiomyomas (6.33%) showed hyaline change which constituted the most common degenerative change observed in this study, 3 leiomyomas (3.8%) showed myxoid change, 3 cases (3.8%) showed calcification, 3 cases (3.8%) showed cystic and 2 cases (2.53%) demonstrated carneous (red) degeneration. We observed 9 types of variants of leiomyoma in the present study among the total 79 leiomyomas (Figure 2), which included cellular leiomyoma (6.33%), diffuse leiomyomatosis (5.05%), apoplectic leiomyoma (3.8%), cotyledonoid leiomyoma (3.8%), palisaded leiomyoma (2.53%), vascular leiomyoma (3.8%), intravascular leiomyoma (2.53%), mitotically active leiomyoma (1.27%) and atypical leiomyoma (1.27%). Adenomyosis was found associated with leiomyoma in 15 cases (19.23%).

Figure 2. Variants of uterine leiomyoma observed in the present study (n=79)

 Discussion

Leiomyomas continue to be a major cause of morbidity in perimenopausal women. Limited data is available from our community regarding clinicopathologic patterns of uterine leiomyomas. This study was conducted to analyze the clinicopathologic spectrum of uterine leiomyomas with regards to their presentation, location, associated changes and variants and to compare our findings with those of other similar studies from different parts of the world.

The ages of the patients ranged from 18-62 years. The average age of patients was 45.82 years. Highest numbers of patients included in this study were between 41-50 years (46.82%). These findings were similar to that observed by Gupta et al (51.40%), Rather et al (47.27%), Vaidya et al (45.63%) and Rizvi et al (44.56%).10-13 In this study, menorrhagia was the commonest presenting symptom seen in 37.97% cases, followed by dysmenorrhea in 18.99% cases. Menorrhagia was also the presenting complaint in studies by Sarfraz (68%), Karthikeyan (62.5%), Rather (35.43%), Gowri (49.03%) and Manjula K (35.4%).11, 14-17

The most common preoperative diagnosis was fibroid uterus in 44% cases followed by utero-vaginal prolapse in 20 % cases, dysfunctional uterine bleeding in 19% cases and pelvic inflammatory disease in 17 % cases. These findings are consistent with the data reported by Vaidya et al (42.96% and 18.95%), Siwatch et al (39% and 22.6%), utero-vaginal prolapse was the commonest indication in a study by Jha et al (37.1%), Gupta et al (40.0%).10,12,18,19 In the present study, out of 79 cases of leiomyomas, 45 (56.96%) were single and 34 (43.04%) were multiple. In a study by Sarfraz et al (2010) multiple leiomyomas were seen in 60.87% cases.16

The most common site of leiomyomas in our study was intramural (57.43%) followed by subserosal leiomyomas (30.69%), submucosal leiomyomas (8.91%) and broad ligament leiomyomas (2.97%). Jung et al observed intramural fibroids in 55.7% cases, subserous fibroids in 16.3% cases, 15.6%, and submucosal fibroids in 12.4% cases respectively.20 Intramural leiomyomas were also the commonest types in studies by Gowri et al (48%) and Rosario et al (52%).15,21

In the present study, degenerative changes were observed in 13 leiomyomas (16.46%). Among these, 6.33% showed hyaline change which constituted the most common degenerative change observed in this study, 6.33% showed myxoid change, 3.8% showed calcification, 3.8% showed cystic and 2.53% demonstrated red (carneous) degeneration. Jung at al found secondary (degenerative) changes in 9.2% cases and the most common change was hyaline degeneration (5.7%).20 Abraham and Saldanha observed secondary changes in 22.2% cases; among these 49% showed hyaline change, 4.9% showed myxoid change, 4.9% showed calcification, 3.35 showed red degeneration and 4.9% showed hydropic change.21

In the present study, 9 variants of leiomyoma were seen in 24 cases out (30.38%) of the total 79 leiomyomas, which included following types of variants-cellular leiomyoma (6.33%), apoplectic leiomyoma (3.8%), diffuse leiomyomatosis (5.05%), cotyledonoid leiomyoma (3.8%), palisaded leiomyoma (2.53%), vascular leiomyoma (3.8%), intravascular leiomyoma (2.53%), mitotically active leiomyoma (1.27%) and atypical leiomyoma (1.27%). Abraham and Saldanha in their study encountered leiomyoma variants in 7.5% cases, of which 78% were cellular leiomyomas, 9.5% were lipoleiomyoma and 4.7% were bizarre (symplastic) leiomyomas and 2.3% were epithelioid leiomyomas.21

 Conclusion

From our study we can conclude that leiomyoma is the most common benign tumor of the uterus in our community. They are commonly seen in perimenopausal females and present with menorrhagia, pain in abdomen or dysmenorrhea. Intramural site was the most common location, hyaline change was the most common degeneration and cellular variant was the most common subtype seen. The pathologist needs to be cautious while diagnosing cases of atypical, mitotically active or bizarre leiomyoma due to their morphologic homogeneity with leiomyosarcoma.

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