Multiple uterine leiomyoma with metastasis of an occult pulmonary carcinoma (a case report).CP Shroff, MM Srinivasan, KP Deodhar
A rare case of metastatic leiomyoma of the uterine corpus presenting with haemoptysis is presented.
Keywords: Autopsy, Case Report, Female, Human, Leiomyoma, pathology,Lung Neoplasms, pathology,Middle Age, Uterine Neoplasms, pathology,secondary,
Malignant matastases to the uterine corpus are extremely unusual especially from cancers originating in the extra genital sites. The extragenital tumours most often metastatizing to the uterus are from the breast, stomach, cutaneous melanoma, lung, colon, pancreas and the kidney in a descending order of frequency.,,, Metastatic involvement of the uterine leiomyoma which by itself is a benign neoplasm is even more rare. A total number of 21 cases of leiomyoma of the uterus with malignant metastasis, have been reported in the literature., Recently we came across a case of uterine leiomyomata with matastatic involvement at autopsy examination in a forty-five year old woman who was admitted for cardiorespiratory symptoms. We report this case for rarity.
A 45 year old, unmarried, obese Hindu woman was admitted to the hospital with breathlessness of 15 days duration. The patient experienced exertional dyspnoea and palpitation for the last one year. She was treated for hypertension for the last 6 months and was also treated for pulmonary Koch's in the past. She had no menstrual irregularity in the past and was menopausal for the last 3 months.
At admission, the patient's general condition was fair. She was breathless though not cyanotic. Her pulse was 100/min. B.P. 150/80 mm Hg. JVP was raised and she had sinus tachycardia. There was no lymphadenopathy. The breasts were flabby, no mass was felt on palpation. Per abdominal examination, a mass was felt on the right side of the midline extending above the umbilicus, and flushing with the pelvis below. A vaginal examination was not possible due to tight introitus. Per rectal examination, an indurated mass was felt in the anterior rectal wall, the right and left fornices extending upto the pelvic wall. The uterus could not be delineated from the mass.
Haemoglobin was 8 gm%, the total erythrocyte count was 3.8 million/cmm and E.S.R. was 63 in 5th hour. (Westergren). The total and differential leucocyte counts were within normal limits. The patient had albuminuria + +, with 15-20% puscells/hpf. Total proteins were 6.9 gm/dl, s. albumin 3.4 gm/dl. and s. globulin 3.5 gm/dl. with an albumin and globulin ratio of 1:1. Other biochemical investigations were within normal limits.
X-ray chest showed minimal patchy nonspecific subsegmental inflammatory change in the paracardiac region. The rest of the lung fields and the heart appeared normal. The patient was treated for her cardio-respiratory symptoms with injection lasix, aminophylline, digoxin, tablet adelphane, esidrex, sorbitol and mist potassium chloride.
At ultrasonography a mass with mixed echoes (6 cm size), was observed above the pubic symphysis. The urinary bladder was displaced upwards to the left. The uterus and adnexae could not be delineated. A clinical impression of a right ovarian tumour with left ventricular failure was made. On the 12th day of her hospital stay she had a bout of haemoptysis and severe cardiopulmonary distress. All efforts to resuscitate her failed. A partial abdominal autopsy was requested.
On external examination, the patient was obese with generalised pallor. There was no lymphadenopathy. The breasts were flabby, no tumour was felt on palpation. In-situ examination of the abdominal cavity revealed an irregular fibroid tumour mass arising in and obscuring the uterus, extending towards the right hypochondrium. The Fallopian tube More Detailss and the ovaries appeared normal. There was no free fluid in the peritoneal cavity. The uterus along with fibroids and adnexae together weighing 3.7 kg. was removed from the abdominal cavity. The uterus was slit open revealing a distorted endometrial cavity. Three mural fibroids were observed, one arising from the fundus 8 cm x 9 cm x 6 cm size, second from the right myometrial wall 6 cm x 7 cm x 5 cm size, the third one arising in the isthmic portion engulfing the endocervical canal 5 cm x 5 cm x 4 cm size. [Figure - 1]. Bisecting the fibroids was difficult because of multiple gritty calcific areas, their cut surfaces showed typical whorled appearance with calcific foci.
The liver weighed 1,700 gm, its cut surface showed multiple creamish nodules 3-5 mm in size; similar nodules were observed in the spleen which was normal in shape and weight. The stomach, small and large intestines, mesentery, pancreas and the gall bladder were normal. The lungs and the heart were removed after slitting the diaphragm. The heart showed left ventricular hypertrophy. The ascending and descending aorta showed grade I atherosclerosis. Both lungs were voluminous together weighing 1200 gm. The right lung showed irregular creamish areas 2-3 mm size scattered in the middle lobe. A single right sided hilar lymph node was enlarged 5 mm x 5 mm size.
Multiple sections were taken from various organs for histopathologic study; stained with haematoxylin and eosin, reticulin, Masson trichrome and alcian blue P.A.S. Microscopically, the three fibroids showed features of cellular leiomyoma with foci of hyalinization and calcification. A striking feature observed was the splaying of the leiomyoma cells by cords and clumps of malignant cells. The individual tumour cell displayed fair amount of eosinophilic cytoplasm; the nuclei exhibited well defined irregular nuclear membrane, coarse chromatin pattern with distinct nucleoli. [Figure - 2]. The endometrium appeared normal with glands in weak proliferative phase. The endometrial stroma was infiltrated by malignant tumour cells. The right fallopian tube showed infiltration with tumour cells in its wall. The uterine cervix, left fallopian tube and the ovaries were free of metastasis. The hepatic sinusoids were packed with malignant cells. The spleen showed multiple foci of metastases.
Sections from the middle lobe of right lung showed peribronchiolar adenocarcinoma with vascular embolization, the alveolar walls were thickened and the adjoining alveoli were lined and filled with malignant cells [Figure - 3] reminiscent of bronchioloalveolar carcinoma. Otherwise both the lungs showed features of chronic passive congestion histologically. The solitary hilar lymph node showed metastatic adenocarcinoma.
Multiple sections from the heart, pancreas, stomach, intestine, kidneys and adrenals did not show evidence of malignancy.
The following differential diagnosis on the basis of histopathologic findings were considered.
(a) myogenic tumour with unusual presentation
(b) metastatic undifferentiated adenocarcinoma
(c) metastatic histiocytic lymphoma.
Masson trichrome stain was negative, reticulin was sparse around the tumour cells and alcian blue PAS was focally positive in some of the tumour cells.
Considering the presence of pulmonary carcinoma, the cytomorphology of the malignant cells and the pattern of dissemination of malignancy in the absence of gross and histologic evidence of a primary at any other site-a final diagnosis of bronchiolo-alveolar carcinoma of the lung with metastasis to the liver, spleen, uterine corpus and uterine leiomyoma was rendered.
The uterine corpus is very rarely involved in the dissemination of extragenital cancers. The first case report of secondary involvement of the uterine cancer in the literature was that of a malignant melanoma. Kumar and Hart have reported the largest series on this subject i.e. 63 cases of metastatic involvement of the uterine corpus of which 43 were observed at autopsy histopathology. Metastases to leiomyoma were observed in 13 cases. Nine other cases of extra pelvic malignancies metastatic to leiomyoma were reported previously.,,,
The case under discussion had been treated for pulmonary tuberculosis in the past. It is possible that the patient was misdiagnosed clinically as pulmonary tuberculosis, a common ailment in our country.
No other form of cancer can disseminate so widely as lung cancer situated in close relation to low pressure pulmonary veins, Some of the released cells pass through the alveolar capillary bed into the systemic arterial circulation responsible for a crop of blood borne metastases. Pulmonary adenocarcinoma is notoriously liable to spread to distant sites at a very early stage in its development. The metastatic pattern and the pathologic characteristics of the adenocarcinoma in this case supports a diagnosis of primary local bronchiolar alveolar carcinoma. The tumour presents as greyish white single or multiple tiny foci and may even appear mucoid, resembling pneumonic consolidation or even a secondary growth. The tumour cells may secrete mucin and are observed as lining the intact often thickened alveolar walls and the surrounding patent bronchioles are capabable of transmitting air borne metastases as well. The metastatic spread to uterine leiomyoma is often haematogenous in the absence of ovarian involvement, otherwise metastases are most often caused by secondary local lymphatic spread from the ovarian metastases. In the case under discussion a haematogenous spread is responsible for the dissemination of pulmonary adenocarcinoma with the involvement of multiple leiomyoma which is a very rare occurrence. This report adds the twenty second case to the reported literature on this subject and probably the first one from India.
[Figure - 1], [Figure - 2], [Figure - 3]