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  Table of Contents    
CASE REPORT  
Year : 2012  |  Volume : 55  |  Issue : 3  |  Page : 372-374
Huge uterine-cervical diverticulum mimicking as a cyst


1 Department of Pathology, Government Medical College, Haldwani, Nainital, India
2 Department of Obstetrics & Gynecology, Government Medical College, Haldwani, Nainital, India

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Date of Web Publication29-Sep-2012
 

   Abstract 

Here we report an incidental huge uterine-cervical diverticulum from a total abdominal hysterectomy specimen in a perimenopausal woman who presented with acute abdominal pain. The diverticulum was mimicking with various cysts present in the lateral side of the female genital tract. Histopathological examination confirmed this to be a cervical diverticulum with communication to uterine cavity through two different openings. They can attain huge size if left ignored for long duration and present a diagnostic challenge to clinicians, radiologists, as well as pathologists because of its extreme rarity. Therefore, diverticula should also be included as a differential diagnosis. Its histopathological confirmation also highlights that diverticula can present as an acute abdomen, requiring early diagnosis with appropriate timely intervention. Immunohistochemistry CD 10 has also been used to differentiate it from a mesonephric cyst.

Keywords: Cervical diverticulum, cyst, mesonephric cyst, uterine diverticulum

How to cite this article:
Chufal S, Thapliyal N, Gupta M, Pangtey N. Huge uterine-cervical diverticulum mimicking as a cyst. Indian J Pathol Microbiol 2012;55:372-4

How to cite this URL:
Chufal S, Thapliyal N, Gupta M, Pangtey N. Huge uterine-cervical diverticulum mimicking as a cyst. Indian J Pathol Microbiol [serial online] 2012 [cited 2019 Jun 18];55:372-4. Available from: http://www.ijpmonline.org/text.asp?2012/55/3/372/101748



   Introduction Top


Uterine diverticula are usually small, asymptomatic, and are commonly observed in women who had previous surgical intervention, particularly caesarean section. [1] True uterine diverticula are rare congenital mullerian anomaly, conditions associated with them include ectopic pregnancy, dysmenorrhea, abnormal uterine bleeding, and infertility. [2] Although diverticula have been well documented in the radiological literature, they have been rarely reported in the pathological literature. A new case of uterine cervical diverticulum is reported presenting with acute abdominal emergency mimicking as a huge cyst. To the best of our knowledge, such a huge diverticulum communicating with uterine cavity through two different openings and a rare clinical presentation associated with it is being reported for the first time. Various clinical and diagnostic difficulties are also discussed.


   Case Report Top


A 45-year old perimenopausal woman presented to the emergency department with complaints of severe lower abdominal pain. She was gravida 2, para 2, and last child birth was 15 years ago. Both were vaginal deliveries without any complications. She had a past history of dull aching/vague lower abdominal, pelvic pain for the last 25 years along with dysmenorrhea. She had scanty menstruation with spotting for the last 1 year. On clinical examination, blood pressure was 90/60 mm Hg and pulse was 98 per minute. There was tenderness present on per abdominal examination and a large lump was felt in left lower abdomino-pelvic area. On per vaginal examination, lump had a cystic consistency. An ultrasound was performed at a peripheral health center where a provisional diagnosis of an ovarian cyst was given. Clinically, a twisted ovarian cyst was suspected and the patient was operated. After total abdominal hysterectomy, the specimen was sent for histopathological examination.


   Pathologic Finding Top


Grossly, uterus with cervix was 8.5 × 4.5 × 3.0 cm in size and the cyst was 18.0 × 16.0 × 10.0 cm, arising from the posterolateral surface around the left uterine isthmus, pushing the cervix upside laterally toward right [Figure 1]a. There were no signs of gangrene and on opening, the cyst was 0.8 to 1.5 cm thick filled with dark brown hemorrhagic fluid, internal surface of which was communicating with the endocervical canal through one opening as well as endometrial canal 3 cm above, through another opening . There was a very narrow communication of the cyst with the uterine cavity [Figure 1]b.
Figure 1: (a) Gross picture showing a huge cyst around isthmus pushing the cervix. (b) Gross picture showing communication of the cyst with uterine cavity through two narrow openings

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Hematoxylin and eosin-stained sections from the cyst near the opening through endometrial cavity showed a cyst wall lined by flattened cuboidal to columnar epithelium, whereas rest of the cyst wall was lined by metaplatic squamous epithelium giving a pseudostratified appearance to it. The subepithelial tissue was composed of fibrocollagenous and muscular tissue [Figure 2]a,b. Sections which were taken from the cyst near the opening of the endocervical canal showed endocervical glands embedded in fibrocollagenous tissue. Immunohistochemical study for CD 10 was performed. The epithelial lining of the cyst wall was negative for CD 10 ruling out its mesonephric origin; however, the stroma beneath it showed strong positivity confirming it to be cervical [Figure 2]c. Sections from the cyst near the opening of the endocervical canal showed negativity for CD 10 in the endocervical glands and the stroma surrounding it showed positivity, similar to the finding in the rest of the cyst [Figure 2]d. A diagnosis of uterine cervical diverticulum was given.
Figure 2: (a) Flattened cuboidal to columnar lined cyst wall (Hematoxylin and eosin, × 400). (b) Metaplastic squamous lined cyst wall (Hematoxylin and eosin, × 100). (c) Cyst wall showing CD 10 negativity of the lining epithelium, stroma beneath it showing positivity (IHC, × 400). (d) Sections from the cyst near the opening of endocervical canal. CD 10 is negative in the endocervical glands and the stroma showing positivity (IHC, × 400)

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   Discussion Top


The clinical differential diagnosis of a cyst in the lateral aspect of the female genital tract includes ovarian cysts, broad ligament cysts, Nabothian cyst, Bartholin's cyst and Gartner's cyst, or mesonephric cyst. [3] Uterine diverticula are rare anomalies that can also be observed at this location; however, cases of true uterine diverticula have been rarely reported which are thought to arise due to unilateral distal nonfusion of mullerian duct. [2] They can be confused with uterine sacculations which are transitory pouches with thin myometrium developing from portion of gravid uterus and regresses after the fetus is expelled. It develops mostly in uterus with previous uterine injury. [4]

The case presented here is a perimenopausal woman with previous history of normal vaginal deliveries. The incidental diverticulum is unique as it presented clinically as acute abdomen due to its huge size (18 cm in largest diameter), mimicking as a cystic mass. The diverticulum originated around the isthmus and communicated with uterine cavity through two different openings [Figure 1]b. The thick wall of the cyst and a very narrow connection through the uterine cavity as reported by Rajah et al[5] favored diverticulum over sacculation.

Uterine diverticula around isthmus have been documented in radiological literature with their doubtful mesonephric or paramesonephric (mullerian) origin; therefore, they were also considered in the differential diagnosis. [6] Unicornuate uterus with rudimentary horn is the least frequent mullerian anomaly resulting from unilateral hypoplasia of mullerian duct which may remain suspended to the uterus and may also present with acute abdomen. However, the presence of both the  Fallopian tube More Detailss and ovaries on the uterus and their absence on the superior surface of the cyst ruled out the possibility of this rare condition on gross examination. [7]

A mesonephric cyst was considered one of the major differential diagnoses as their remnants are also seen in the cervix from where there is a possibility of its origin. They can attain huge size and have a variety of epithelia both columnar and metaplastic squamous besides their usual low columnar lining. [8],[9]

The epithelial lining of mesonephric remnants as well as lesions arising from it shows luminal positivity for immunohistochemical marker CD 10. The cervical as well as endometrial lining epithelia are negative while their stroma is positive for CD 10. [10] This differential immunohistochemical staining for CD 10 was utilized to differentiate diverticula from the mesonephric cyst.

CD 10 negativity on the metaplastic squamous epithelial lining of the wall ruled out its mesonephric origin; however, the stroma beneath the epithelium showed strong positivity. Similar immunohistochemical results were also observed from the cyst wall near the opening of the endometrial and endocervical canal where flattened cuboidal to columnar epithelium and endocervical glands were negative for CD 10 while stroma beneath was positive [Figure 2]. Thus. immunohistochemical results combined with typical epithelial lining as observed in cervix ruled out its mesonephric origin. The cyst was thus confirmed to be a cervical diverticulum. On the other hand, if the mesonephric origin is confirmed, evaluation for other congenital urinary abnormality should be undertaken because of common embryological origin. [9] {Figure 2}

The origin of diverticula have been controversial, some consider progressive acquired myometrial weakness due to various other pathological conditions, [6] and some have suggested that they represent localized unilateral distal nonfusion of mullerian duct and named them as true uterine diverticula. [2],[6] The diverticulum in this case could be a true one as there was no other associated pathological condition and no history of instrumentation or caesarean section which could lead to myometrial weakness.

Despite their doubtful origin, diverticula if ignored for long period can attain a huge size. The divericulum initially might have been a small one which gradually increased in size due to retrograde menstruation. Its pathological confirmation alert the clinicians as well as radiologist to put diverticula in the differential diagnosis of a cystic mass in the lateral side of the female genital tract, as even huge diverticula can present with acute abdomen with fatal consequences and it is difficult to trace the origin of such a huge cyst on simple ultrasonography.

This case report also highlights the usefulness of differential staining property of CD 10 on mesonephric epithelium and mullerian stroma and the way to utilize this single immunohistochemical marker to confirm diverticula and rule out a mesonephric origin of the cyst.

 
   References Top

1.Suprapaneni K, Silberzweig JE. Caesarean section scar diverticulum: Appearance on hysterosalpingography. AJR Am J Roentgenol 2008;190:870-4.  Back to cited text no. 1
    
2.Engel G, Rushavich AM. True uterine diverticulum. A partial mullerian duct duplication? Arch Pathol Lab Med 1984;108:734-6.  Back to cited text no. 2
    
3.Arumugam A, Kumar G, Si L, Vijayananthan A. Gartner duct cyst in pregnancy presenting as a prolapsing pelvic mass. Biomed Imaging Interv J 2007;3:e46.  Back to cited text no. 3
[PUBMED]    
4.Schmidt AP, Glitz CL, Passos EP, Arbo E, Canho-Filho JS. Hysteroscopy and three dimensional ultrasonography in uterine diverticulum diagnosis: A case report. Am J Obstet Gynecol 2004;190:561-2.  Back to cited text no. 4
    
5.Rajah P, Eastwood KL, Gunn ML, Dighe M. Uterine divertculum. Obstet Gynecol 2009;113:525-7.  Back to cited text no. 5
    
6.Evan P, Kramer B. Uterine Diverticula and Accessory ducts. AJR Am J Roentgenol 2008;191:W71.  Back to cited text no. 6
[PUBMED]    
7.Atmaca R, Germen AT, Burak F, Kafkasli A. Acute abdomen in a case with non communicating rudimentary horn and unicornuate uterus. JSLS 2005;9:235-7.  Back to cited text no. 7
[PUBMED]    
8.Ferry JA, Scully RE. Mesonephric remnants, hyperplasia, and neoplasia in the uterine cervix. A study of 49 cases. Am J Surg Pathol 1990;14:1100-11.  Back to cited text no. 8
[PUBMED]    
9.Fox H, Wells M. Hainer and Taylor Obsterical and Gynecological Pathology. 5th ed. Edinburgh: Churchil and Livingstone; 2003. p. 183.  Back to cited text no. 9
    
10.Mittal K, Soslow R, McCluggage WG. Application of Immunohistochemistry to Gynecologic Pathology. Arch Pathol Lab Med 2008;132:402-23.  Back to cited text no. 10
[PUBMED]    

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Correspondence Address:
S Chufal
Department of Pathology, Govt. Medical College, Haldwani, Nainital, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.101748

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    Abstract
   Introduction
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   Pathologic Finding
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