| Abstract|| |
This report documents an uncommon case of choristomatous cervical polyp-containing fat tissue. The patient was a 24-year-old female who presented with irregular intermenstrual bleeding. On examination, a polypoid lesion with smooth outlines, measuring 1 cm in diameter was removed. Microscopic examination demonstrated abnormal fibrous stroma, devoid of endocervical glands, containing mature adipose tissue, and thick-walled blood vessels. The lesion was covered by a typical mature squamous cell outer lining. To the best of our knowledge, this is only the second report of an adipose tissue arising from the cervical wall. Further clinicopathologic considerations are needed to elucidate the origin of the fatty component in cervical polyps.
Keywords: Cervical choristoma, cervical polyp, heterotopic adipose tissue
|How to cite this article:|
Pecorella I, Monti M, Dei Malatesta ML, Ciardi G. Polyp of the uterine cervix with heterologous fatty tissue. Indian J Pathol Microbiol 2018;61:593-5
|How to cite this URL:|
Pecorella I, Monti M, Dei Malatesta ML, Ciardi G. Polyp of the uterine cervix with heterologous fatty tissue. Indian J Pathol Microbiol [serial online] 2018 [cited 2019 Aug 19];61:593-5. Available from: http://www.ijpmonline.org/text.asp?2018/61/4/593/242961
| Introduction|| |
Cervical polyps are common tumors on the surface of the cervical canal. They affect women who have had children and perimenopausal women. Microscopically, they show dilated endocervical mucus glands in inflamed, myxoid stroma.
Mesenchymal tumors of the uterine cervix are, on the other hand, uncommonly encountered. Among them, leiomyomas are the most common. We report a unique case of angiolipomatous polyp of the endocervix in a young female.
| Case Report|| |
A 24-year-old female presented with irregular inter-menstrual bleeding. She denied any other significant past medical history or family history. On examination, a polypoid lesion with smooth outlines, measuring 1 cm in diameter was removed and sent for histology. A choristomatous angiolipomatous lesion was found. The patient is presently well, with no signs of bleeding. The specimen was fixed in 4% formalin, processed for embedding in paraffin, and 5 μm-thick sections were stained with H and E. Further sections were subjected to immunohistochemical staining, using the streptavidin-biotin complex method.
Grossly, the polyp showed a brownish discoloration with a yellowish central area on cut section. On microscopic examination, the lesion was covered by normal squamous ectocervical epithelium and showed abnormal collagenous subepithelial stroma. Centrally, prominent mature adipose tissue containing thick-walled blood vessels and enlarged nerves was noted [Figure 1], [Figure 2]a and [Figure 2]b. There was no fatty component outside the tumor. Neither glandular structures nor mitotic figures were observed in the stroma, as well as smooth muscle fibers. Immunohistochemically, the adipose tissue showed a positive reaction with S-100 and did not react with smooth muscle actin.
|Figure 1: Endocervical choristomatous polyp. Low-power view of the cervical polyp shows the epithelial squamous lining and the underlying abundant hyalinized fibrous stroma containing mature adipose tissue in its deepest portion. (H and E, ×20)|
Click here to view
| Discussion|| |
The cervical lesion of this young female differed from the usual glandular polyps of the cervix in that no glands were present and the stroma contained fat. A thorough search of the literature revealed that the presence of mature heterotopic nonneoplastic adipose tissue in the uterine cervix, without other foreign tissue components, has been previously reported only once. The patient was a 34-year-old female presenting with discrete leukorrhea. Gynecological examination demonstrated an endocervical polypoid growth, which showed microscopically adipocytes in the stroma. A diagnosis of cervical choristoma was rendered.
Ilhan et al., also described an endocervical polyp with heterologous fatty tissue. However, their case also contained cartilage and mesonephric gland-like structures. Interestingly, abnormal thick blood vessels devoid of elastic lamina were also observed as in the present case.
However, because of these mesonephric gland-like structures, Ilhan et al. case could fall within the range of lipoadenofibromas. This entity was first described by Horie et al. as a variant of benign mixed mullerian tumor, containing a lipomatous component in addition to epithelial and mesenchymal elements. Lipoadenofibromas are exceedingly rare lesions usually originating in the endometrial cavity, composed of cystic endometrial glands, often showing epithelial endocervical-type mucinous metaplasia and abundant stromal mature adipose tissue. Broad papillary stromal fronds, covered by epithelium, project from the surface or into cystic spaces., Rare instances of adenofibromas of the uterine cervix have also been described. However, our case failed to display the biphasic nature of adenofibromas and lipoadenofibromas, as it lacked glandular structures and presented thick abnormal vessels, which are normally missing in adenofibromas.
According to Doldan et al., mature adipose tissue can be identified in up to 15% of cone/loop electro excisional procedure or hysterectomy specimens and is to be considered a normal stromal constituent of the uterine cervix. In their study, fat was located in deep cervical stroma among large vessels in 79% of cases, and superficially beneath the mucosa admixed with endocervical glands in 21% of cases.
Our experience indicates that adipose tissue is not present in the normal uterine cervix. In addition, Doldan et al. acknowledged that the adipocytes were not easily discernible and only occasionally reacted with S-100 antibody, making their results questionable. It should be noted that the vehicle used in injectable lidocaine-based anesthesia can appear similar to fat on H and E, and this could explain some of Doldan et al. results.
Considering that adipose tissue is generally not regarded as a normal constituent of the uterine cervix, the present lesion is also not a hamartoma, which is an overgrowth of normal mature tissue occurring within the organ or tissue of origin.
A possible definition for the present polyp would instead be cervical lipoma. Review of the literature revealed just one case of cervical lipoma. The patient was a 30-year-old female presenting with a small soft- and well-circumscribed cervical growth. Biopsy showed a lipoma with necrosis and calcification. At some places, inflammatory reaction was present. Differently from our case, neither abnormal collagenous subepithelial stroma nor abnormal blood vessels and nerves were described.
On the other hand, it is known that müllerian stromal cells have the capacity to transform into other mesenchymal-type cells, such as chondrocytes and adipocytes, in the neoplastic process.
Alternatively, the hypothesis of a direct transformation from smooth muscle cells by means of progressive intracellular storage of lipids could be taken into consideration. This is, indeed, the origin of fat cells in lipoleiomyomas, as demonstrated by Mignogna et al. using immunohistochemical stains for vimentin, desmin, and actin. Our results, which showed positivity of lipomatous cells for S-100 and negativity for smooth muscle actin, do not support this hypothesis in the present cervical polyp. Therefore, our case could just represent a heterotopia or heterologous tissue in the cervix secondary to adipose differentiation of endocervical stromal stem cells. Hence, in agreement with de Lima et al., a proper designation could be that of cervical choristoma, i.e. an excess of normal tissue in an abnormal situation. The term “choristomatous cervical polylp” could, in general, includes a full spectrum of lesion comprising simple lipomatous polyp, angiolipomatous polyp, such as the present case, lipoadenofibroma, which is characterized by an additional epithelial glandular component, and the more complex mature teratoma of the cervix, composed of tissue of all germ layers. The young age of the patient is also in agreement with a cervical choristoma.
| Conclusion|| |
We report a rare case of cervical lipomatous heterotopia presenting as an ordinary endocervical polyp causing irregular intermenstrual bleeding. The exact origin of this condition remains unknown.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
de Lima MA, Pertence AP, de Souza MA. Heterotopic adipose tissue in the uterine cervix. Rev Hosp Clin Fac Med Sao Paulo 1998;53:149-51.
Ilhan R, Yavuz E, Iplikçi A, Tuzlali S. Hamartomatous endocervical polyp with heterologous mesenchymal tissue. Pathol Int 2001;51:305-7.
Horie Y, Ikawa S, Kadowaki K, Minagawa Y, Kigawa J, Terakawa N, et al.
Lipoadenofibroma of the uterine corpus. Report of a new variant of adenofibroma (benign müllerian mixed tumor). Arch Pathol Lab Med 1995;119:274-6.
Akbulut M, Zekioglu O, Terek MC, Ozdemir N. Lipoadenofibroma of the endometrium: A rare variant of benign mullerian mixed tumor. Arch Gynecol Obstet 2008;278:283-6.
Chu IL, Chen CL, Hsu CS. Adenofibroma of the uterine cervix coexistent with endometriosis. Taiwan J Obstet Gynecol 2012;51:285-8.
Doldan A, Otis CN, Pantanowitz L. Adipose tissue: A normal constituent of the uterine cervical stroma. Int J Gynecol Pathol 2009;28:396-400.
Hinge SA, Kher VL, Kherdekar M. Lipoma of corpus uteri and cervix uteri. Report of three cases with review of literature. J Obstetr Gynaecol India 1975:294-6. Available from: http://www.jogi.co.in/articles
Mignogna C, Di Spiezio Sardo A, Spinelli M, Sassone C, Cervasio M, Guida M, et al.
A case of pure uterine lipoma: Immunohistochemical and ultrastructural focus. Arch Gynecol Obstet 2009;280:1071-4.
Department of Radiological, Oncological and Anatomic Pathology Sciences, University of Rome “Sapienza”, Viale Regina Elena, 324 00161 Rome
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]