Swathi S1, Shanthi V2, Rao NM3, B Shyam Sundar4, Grandhi B5, Boddapati A6
1Dr S Swathi, Assistant Profesor, Department of Pathology, 2Dr.Vissa Shanthi, Associate Prefessor, Department of Pathology, 3Dr. Nandam Mohan Rao, Associate Professor, Department of Pathology, 44Dr B Syam Sundar, Associate Professor, Department of Pathology, 5Dr. Bhavana Grandhi, Assistant profesor, Department of Pathology, 6Dr Amulya boddapati, Tutor, Department of Pathology. All are affiliated to Narayana Medical college, Nellore (A.P), India.
Address for correspondence: Dr S Swathi, Email: swathi191083@gmail.com
Abstract
Lipomas of the uterus are rare and cervical involvement is another rare entity. Approximately 200 cases have been reported in the literature and the incidence ranges between 0.03% to 0.2%. The lesion has lately been discussed interestingly due to its diagnostic confusion with sarcomas on radiographic examination and also due to their disputed histogenesis. We report a case of 36 years old woman presenting with non-specific lower abdominal pain and vaginal discharge who underwent hysterectomy for abnormal pap smear result and an ultrasound diagnosis of a large cyst in the posterior lip of the cervix. Histopathology revealed intramural lipofibroma of the cervix.
Keywords: Adipose Tissue, Lipofibroma, Uterine Cervix
Manuscript received: 4th Jan 2015, Reviewed: 9th Jan 2015
Author Corrected: 5th Feb 2015, Accepted for Publication: 10th Feb 2015
Introduction
Lipoma of uterus is an uncommon benign mesenchymal neoplasm. They usually develop in post-menopausal women. Pure lipomas of the uterus are very rare [5]. Most reported cases are of mixed types such as lipoleiomyoma, lipofibroma, angiomyolipoma etc [7]. The diagnosis of pure lipomas can be made by radiological examination. But mixed lipomas produce mixed echogenic presentations which lead to many differential diagnoses and make histopathological study mandatory to rule out liposarcomas.
Case Report
A 36 year old woman presented to the hospital with lower abdominal pain and vaginal discharge. On routine physical and abdominal examination no abnormality was detected. Per speculum examination reveals bulky posterior lip of cervix. Abdominal ultrasonography revealed a 41×27mm hyperechoic mass in the posterior lip of cervix and diagnosed the probability of a cyst.
Papsmear and cervix biopsy examination revealed chronic cervicitis with mild dysplasia. Abdominal hysterectomy with left salphingo ophorectomy was done.
Hysterectomy specimen showed cervical hypertrophy on external surface and on cut section a well circumscribed intramural mass with greywhite and yellow areas has been noted (fig.1). On histopathological examination of the tumor mature benign adipocytes arranged in nests and sheets admixed with fibrocollagenous stroma were noted (fig.2, 3,4). The final diagnosis was lipofibroma of uterine cervix. Uterus showed proliferative phase of endometrium and myometrium was normal, adnexae showed normal looking ovary and fallopian tube.
Discussion
Lipomas in uterus are rare. They are usually seen in the uterine corpus and are of mixed type. Uterine cervix presentation is very rare and only a few cases have been reported in the literature. The incidence of lipomas in uterus is 0.03% to 0.2% [10]. Till date less than 200 lipomas have been diagnosed in the uterus [1]. Most of them have been incidental findings and many of them were radiologically diagnosed as leiomyomas of mixed type.
Fig 1: Gross picture of lipofibroma Fig 2: H&E (4X). Microscopic picture of lipofibroma showing
of the uterine cervix mature adipocytes admixed with fibrous tissue
Fig 3: H&E (10X). Mature adipocytes Fig 4: H&E (40X). Focal areas showing mature adipocytes admixed
admixed with fibrous tissue and with dense fibrous stroma and few blood vessels
periphery showing smooth muscle cells
Though modern imaging techniques like Magnetic Resonance Imaging and Computed Tomography scan have been able to distinguish the fat content of the lipomas by using fat saturation methods, yet due to the frequent presentation of mixed lipomas, it raised the suspicion of sarcomas and teratomas which made histopathological diagnosis conclusive to rule out malignancy [2].
Uterine lipomas were first reported by Lobstein in 1816[6]. They were later subdivided into three types as pure lipomas, mixed lipomas and liposarcomas. They are seen in post-menopausal women of 50-70 years of age and clinically present with complaints similar to leiomyoma depending on the location. They present as intramural mass in uterine fundus and submucosal and subserosal presentation are very rare. The average size of the lesion varies between 5 to 10 cms and are accompanied usually with leiomyomas in uterus. Microscopically, pure lipomas are composed of mature adipocytes with smooth muscle cells confined to the periphery of the tumor. Mixed lipomas show adult type fat intermixed with smooth muscle cells arranged as fascicles or scattered myocytes or with fibrous tissue seen as delicate and dense hyalinised stroma. Occasionally, blood vessels may be prominent. Few mast cells and eosinophils may also be seen [3].
The histogenesis of uterine lipomas has been studied and debated since its discovery. Many proposed theories and advanced techniques have been used to study their origin. The proposed mechanisms are lipoblastic differentiation of misplaced embryonal nests or primitive mesenchymal tissue, pluripotent cell migration, perivascular extension of peritoneal or retroperitoneal fat, lipid metaplasia of stromal cells, metabolic disorders in estrogen deficiency states in post-menopausal women etc [8,1].
In a study done by Mignogna et al, the lipomatous tissue was reactive to S-100, vimentin, actin and desmin, but the studies of Elif ulker et al and Tereda et al show S-100 positivity and smooth muscle actin and desmin negativity[9,4]. Tereda et al, in his study found positivity for even estrogen and progesterone receptors suggesting that the lipomatous change is not degenerative type but the adipose tissue were actively proliferating and related to female genital organ specific fat tissue [11].
Derrick et al supports the viewpoint that uterine lipomas associated with leiomyomas could be hamartomas or choristomas, like renal angiomyolipomas having an association with choristomas in other organs.
Many differential diagnosis exist for lipoma of the pelvis such as benign cystic teratoma, malignant degeneration of cystic teratoma, non-teratomatous lipomatous ovarian tumor, liposarcoma, lipoblastic lymphadenopathy etc [8].
Conclusion
Uterine lipomas are a benign, mixed, mesenchymal neoplasm. Radiologically diagnosed lesion needs histopathological examination to rule out malignancy especially in the post menopausal women. The histogenesis of these tumors need a complete evaluation like that of leiomyomas. Thus by increasing awareness among pathologists many unusual morphological variants of these uterine lipomas may be discovered which may aid in understanding their histogenesis.
Funding: Nil, Conflict of interest: None initiated.
Permission from IRB: Yes
References
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How to cite this article?
Swathi S, Shanthi V, Mohan Rao N, B Shyam Sundar, Bhavana G, Amulya B. Lipofibroma of the uterine cervix: a rare benign tumor with brief review of literature. Int J Med Res Rev 2015;3(3):361-363. doi: 10.17511/ijmrr.2015.i3.065.