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Eosinophilia encountered in female genital organs
Eosinophilia encountered in female genital organs DANIEL N. New
M.
A. York,
DIVACK,
JANOVSKI, New
M.D. M.D.
York
M o R E attention must be paid to tissue eosinophilia as this phenomenon has not been fully appreciated in obstetric and gynecologic pathology. Further study and correlation of the pathologic and clinical material, with particular attention to the question of allergy, seems definitely indicated. It is a known fact that tissue eosinophilia has been encountered in a number of cases of squamous carcinoma of the cervix.‘> a This has been utilized by some investigators in an attempt to arrive at criteria for prognosis in this disease.“, 4-c Thus, Lahm,4 in reporting on 156 cases of cervical carcinoma treated by radiation, cites a 40 per cent cure rate in those cases where marked cosinophilia was seen on the biopsy specimen as against a 17 per cent cure rate where it was absent. More recently Stiiper’ found significant tissue eosinophilia in 24 per cent of 1,045 cases of carcinoma of the cervix. He believed, on the basis of statistical analysis of his clinical material, that this constituted a favorable prognostic sign. Line11 and Maansson” cite a 61.9 per cent over-all incidence of eosinophilia in 291 cases of cervical carcinoma treated with radium. They could not attach to its presence in tissue any prognostic significance.
Tissue eosinophilia was noted in 25 per cent of cases of squamous carcinoma of the vulva and vagina reviewed by Stiiper. The same author was able to find only one case of eosinophilia in association with nearly 200 cases of adenocarcinoma of the different parts of the female reproductive tract. This was also noted by Goecke,3 who reported that carcinoma of the endometrium was not associated with any amount of eosinophilia. Aside from this work, however, little attention has been paid to the eosinophils in ‘the female genital tract; their appearance in such tissue is considered to be an occasional accompaniment of a nonspecific inflammation.
Methods
and
materials
The pathologic material of the Sloane Hospital for Women for the 8 month period Aug. 1, 1960, to March 31, 1961, has been reviewed. During this time some 2,542 major and minor surgical specimens have been examined. In this material a total of 25 cases presented a striking appearance of eosinophilia in association with the underlying pathologic entity. This represents an incidence of approximately 1 per cent of tissue eosinophilia encountered in unselected gynecologic and obstetric material. Our classification of eosinophilia on a histologic basis was as follows: moderate, eosinophils occasionally scattered in the connective tissue stroma of the examined organs, approximately 5 to 10 cells per high power field; marked, eosinophils scattered or forming
l:rom the Departments of Pathology and Obstetrics and Gynecology, College of Physicians und Surgeons, Columbia University, and the Obstetrical and Gynecological Division, Presbyterian Hospital (Sloane Hospital for Women), Columbia Presbyterian Medical Center.
761
762
Divack
and
Seplcnlbel
Janovski
small aggregates in the connective tissue stroma of the examined organs, approximately 20 to 50 per high power field; severe, eosinophils massively infiltrating the connective tissue stroma or being the predominant element of the inflammatory exudate of examined organs.
Table I. Preoperative with
diagnoses
in patients
tissue eosinophilia Diagnoses
No. patients
Adnexitis, acute and/chronic Leiomyomas uteri Carcinoma of the cervix Ovarian cyst Prolapse uteri Term pregnancy Ectopic tubal pregnancy Pyometra Carcinoma of the endometrium Endocervical nolv Total -
6 5 3 3 2 2 1 1 1 1 25
Table II. Site of eosinophilia, encountered
15, 1962
Am. J. Obst. & Cynrc.
-
Analysis
of
clinical
data
The clinical material has been examined with particular emphasis to age, parity, peripheral blood eosinophilia, history of allergy, history of parasitic diseases, previous surgical procedures, and clinical diagnosis. Age. There appeared to be no selectivity for any age group. The youngest patient was a 13-year-old girl who had a severe eosinophilic infiltration of the Fallopian tube in association with a bicornuate uterus and hydrosalpinx. The oldest was a 66-year-old woman in whom eosinophilia of the myometrium was found in association with a radium-treated adenocarcinoma of the endometrium. The average age of our cases was 38.3 years. Parity. Nine of our patients had never been pregnant and 16 had had one or more children. Four of our patients were pregnant at the time of operation. Eosinophilia was found in the myometrium of 2 patients UR-
its severity, and final main pathologic
findings
in 25 cases _____.
Site of eosinophilia
I /
Severity
I I
I Instances
Main
pathologic
diagnosis
Cervix
Severe Marked Moderate
1 1 3
Squamous carcinoma, cervix Leiomyomas uteri Intraepithelial carcinoma, cervix Chronic cervicitis. nonspecific
Endocervix
Severe Moderate
1 2
Salpingitis, acute and chronic, Chronic cervicitis, nonspecific Intrapartum rupture, uterus
Endometrium
Severe
Salpingitis,
Myometrium
Severe Marked Moderate
Salpingitis, acute and chronic, nonspecific Intraepithelial carcinoma, cervix Leiomyomas uteri Intrapartum rupture, uterus Puerpural uterus Adenocarcinoma, endometrium Teratocarcinoma, ovary
Severe
Salpingitis, acute and chronic, nonspecific Tuboovarian abscess Ectopic tubal pregnancy Tuboovarian abscess Bicornuate uterus with hydrosalpinx
Fallopian
tube
Marked Moderate Ovary
Severe Marked Moderate
1 2 5 -_.
Tuboovarian Tuboovarian Tuboovarian Endometriosis Leiomyomas
acute
and
chronic,
nonspecific
nonspecific
abscess abscess abscess uteri
.__
Vofume
84
Number
6
dergoing’cesarean section, in one in the site of occult rupture of a previous cesarean section scar. Two patients had eosinophilic infiltration of a Fallopian tube that was the site of an ectopic pregnancy. Previous operation. Nine of the patients presenting tissue eosinophilia had undergone some form of gynecologic operation within the 6 months prior to the procedure at which eosinophilia was found. Six of these operations were curettings, 3 associated with cervical biopsies. One patient had received intravaginal radiotherapy (1,600 r) in the course of radiosensitivity testing followed by a cervical biopsy, one had a myomectomy 6 months prior to a tubal pregnancy, and one had had several attempts at incision and drainage of a pelvic abscess.
History of allergy and parasitic infestation. A history of allergy was obtained in only 6 patients. This ranged from mild food allergy to severe bronchial asthma. In only one case was there a parasitic infestation. In 13 cases a history of allergy was denied and in 6 cases no statement as to allergy was noted in the charts. Peripheral blood eosinophilia. A peripheral blood eosinophilia of 3 per cent or more was considered to be of significant value. This figure is given by several of the stand-
Eosinophilia
in female
genital
organs
763
ard textbooks on hematology.s, 9 Ten of our patients had an eosinophilia of 3 per cent or greater. The highest value of 14 per cent was found in a patient with a history of asthma in whom moderate eosinophilia was encountered in the endocervix and myometrium at the time of cesarean section. Table I lists the clinical diagnosis as recorded prior to the final operative procedure. The localization of the eosinophilia, its severity in the female reproductive tract, and the main pathologic diagnoses are summarized in Table II. Summary
1. In 2,542 obstetric and gynecologic pathologic specimens examined at the pathology laboratory of the Sloane Hospital for Women, 25 showed moderate to severe degrees of tissue cosinophilia. ‘2. The literature on this topic has been reviewed and the degree of eosinophilia correlated to clinical data. The possibility that the presence of eosinophilia in tissue represents a local allergic response, although highly selective, to breakdown of tissue due to neoplasia, bacterial inflammation, or previous surgical procedure is taken into consideration.
REFERENCES
1. BGhmig, R.: Beitr. path. Anat. allg. Path. 83: 333, 1929. 2. Fluhmann, C. F.: AM. J. OBST. & GYNEC. 13: 174, 1927. 3. Goecke, H:. Arch. GynIk. 176: 407, 1949. 4. Lahm, W.: Strahlentherapie 25: 22, 1927. 5. Linell, F., and Maansson, B.: Acta radiol. 41: 453, 1954. 6. Ormos, P.: Ztschr. Krebsforsch. 36: 119, 1932.
7. 8. 9.
Stiiper, P.: Strahlentherapie 92: 108, 1953. Sturgis, C. C.: Hematology, Springfield, Ill., 1955, Charles C Thomas, Publisher, p. 735. Wintrobe, M. M.: Clinical Hematology, Philadelphia, 1956, Lea & Febiger, p. 232.
620 West 168th St. New York 32, New York
M.
A. York,
DIVACK,
JANOVSKI, New
M.D. M.D.
York
M o R E attention must be paid to tissue eosinophilia as this phenomenon has not been fully appreciated in obstetric and gynecologic pathology. Further study and correlation of the pathologic and clinical material, with particular attention to the question of allergy, seems definitely indicated. It is a known fact that tissue eosinophilia has been encountered in a number of cases of squamous carcinoma of the cervix.‘> a This has been utilized by some investigators in an attempt to arrive at criteria for prognosis in this disease.“, 4-c Thus, Lahm,4 in reporting on 156 cases of cervical carcinoma treated by radiation, cites a 40 per cent cure rate in those cases where marked cosinophilia was seen on the biopsy specimen as against a 17 per cent cure rate where it was absent. More recently Stiiper’ found significant tissue eosinophilia in 24 per cent of 1,045 cases of carcinoma of the cervix. He believed, on the basis of statistical analysis of his clinical material, that this constituted a favorable prognostic sign. Line11 and Maansson” cite a 61.9 per cent over-all incidence of eosinophilia in 291 cases of cervical carcinoma treated with radium. They could not attach to its presence in tissue any prognostic significance.
Tissue eosinophilia was noted in 25 per cent of cases of squamous carcinoma of the vulva and vagina reviewed by Stiiper. The same author was able to find only one case of eosinophilia in association with nearly 200 cases of adenocarcinoma of the different parts of the female reproductive tract. This was also noted by Goecke,3 who reported that carcinoma of the endometrium was not associated with any amount of eosinophilia. Aside from this work, however, little attention has been paid to the eosinophils in ‘the female genital tract; their appearance in such tissue is considered to be an occasional accompaniment of a nonspecific inflammation.
Methods
and
materials
The pathologic material of the Sloane Hospital for Women for the 8 month period Aug. 1, 1960, to March 31, 1961, has been reviewed. During this time some 2,542 major and minor surgical specimens have been examined. In this material a total of 25 cases presented a striking appearance of eosinophilia in association with the underlying pathologic entity. This represents an incidence of approximately 1 per cent of tissue eosinophilia encountered in unselected gynecologic and obstetric material. Our classification of eosinophilia on a histologic basis was as follows: moderate, eosinophils occasionally scattered in the connective tissue stroma of the examined organs, approximately 5 to 10 cells per high power field; marked, eosinophils scattered or forming
l:rom the Departments of Pathology and Obstetrics and Gynecology, College of Physicians und Surgeons, Columbia University, and the Obstetrical and Gynecological Division, Presbyterian Hospital (Sloane Hospital for Women), Columbia Presbyterian Medical Center.
761
762
Divack
and
Seplcnlbel
Janovski
small aggregates in the connective tissue stroma of the examined organs, approximately 20 to 50 per high power field; severe, eosinophils massively infiltrating the connective tissue stroma or being the predominant element of the inflammatory exudate of examined organs.
Table I. Preoperative with
diagnoses
in patients
tissue eosinophilia Diagnoses
No. patients
Adnexitis, acute and/chronic Leiomyomas uteri Carcinoma of the cervix Ovarian cyst Prolapse uteri Term pregnancy Ectopic tubal pregnancy Pyometra Carcinoma of the endometrium Endocervical nolv Total -
6 5 3 3 2 2 1 1 1 1 25
Table II. Site of eosinophilia, encountered
15, 1962
Am. J. Obst. & Cynrc.
-
Analysis
of
clinical
data
The clinical material has been examined with particular emphasis to age, parity, peripheral blood eosinophilia, history of allergy, history of parasitic diseases, previous surgical procedures, and clinical diagnosis. Age. There appeared to be no selectivity for any age group. The youngest patient was a 13-year-old girl who had a severe eosinophilic infiltration of the Fallopian tube in association with a bicornuate uterus and hydrosalpinx. The oldest was a 66-year-old woman in whom eosinophilia of the myometrium was found in association with a radium-treated adenocarcinoma of the endometrium. The average age of our cases was 38.3 years. Parity. Nine of our patients had never been pregnant and 16 had had one or more children. Four of our patients were pregnant at the time of operation. Eosinophilia was found in the myometrium of 2 patients UR-
its severity, and final main pathologic
findings
in 25 cases _____.
Site of eosinophilia
I /
Severity
I I
I Instances
Main
pathologic
diagnosis
Cervix
Severe Marked Moderate
1 1 3
Squamous carcinoma, cervix Leiomyomas uteri Intraepithelial carcinoma, cervix Chronic cervicitis. nonspecific
Endocervix
Severe Moderate
1 2
Salpingitis, acute and chronic, Chronic cervicitis, nonspecific Intrapartum rupture, uterus
Endometrium
Severe
Salpingitis,
Myometrium
Severe Marked Moderate
Salpingitis, acute and chronic, nonspecific Intraepithelial carcinoma, cervix Leiomyomas uteri Intrapartum rupture, uterus Puerpural uterus Adenocarcinoma, endometrium Teratocarcinoma, ovary
Severe
Salpingitis, acute and chronic, nonspecific Tuboovarian abscess Ectopic tubal pregnancy Tuboovarian abscess Bicornuate uterus with hydrosalpinx
Fallopian
tube
Marked Moderate Ovary
Severe Marked Moderate
1 2 5 -_.
Tuboovarian Tuboovarian Tuboovarian Endometriosis Leiomyomas
acute
and
chronic,
nonspecific
nonspecific
abscess abscess abscess uteri
.__
Vofume
84
Number
6
dergoing’cesarean section, in one in the site of occult rupture of a previous cesarean section scar. Two patients had eosinophilic infiltration of a Fallopian tube that was the site of an ectopic pregnancy. Previous operation. Nine of the patients presenting tissue eosinophilia had undergone some form of gynecologic operation within the 6 months prior to the procedure at which eosinophilia was found. Six of these operations were curettings, 3 associated with cervical biopsies. One patient had received intravaginal radiotherapy (1,600 r) in the course of radiosensitivity testing followed by a cervical biopsy, one had a myomectomy 6 months prior to a tubal pregnancy, and one had had several attempts at incision and drainage of a pelvic abscess.
History of allergy and parasitic infestation. A history of allergy was obtained in only 6 patients. This ranged from mild food allergy to severe bronchial asthma. In only one case was there a parasitic infestation. In 13 cases a history of allergy was denied and in 6 cases no statement as to allergy was noted in the charts. Peripheral blood eosinophilia. A peripheral blood eosinophilia of 3 per cent or more was considered to be of significant value. This figure is given by several of the stand-
Eosinophilia
in female
genital
organs
763
ard textbooks on hematology.s, 9 Ten of our patients had an eosinophilia of 3 per cent or greater. The highest value of 14 per cent was found in a patient with a history of asthma in whom moderate eosinophilia was encountered in the endocervix and myometrium at the time of cesarean section. Table I lists the clinical diagnosis as recorded prior to the final operative procedure. The localization of the eosinophilia, its severity in the female reproductive tract, and the main pathologic diagnoses are summarized in Table II. Summary
1. In 2,542 obstetric and gynecologic pathologic specimens examined at the pathology laboratory of the Sloane Hospital for Women, 25 showed moderate to severe degrees of tissue cosinophilia. ‘2. The literature on this topic has been reviewed and the degree of eosinophilia correlated to clinical data. The possibility that the presence of eosinophilia in tissue represents a local allergic response, although highly selective, to breakdown of tissue due to neoplasia, bacterial inflammation, or previous surgical procedure is taken into consideration.
REFERENCES
1. BGhmig, R.: Beitr. path. Anat. allg. Path. 83: 333, 1929. 2. Fluhmann, C. F.: AM. J. OBST. & GYNEC. 13: 174, 1927. 3. Goecke, H:. Arch. GynIk. 176: 407, 1949. 4. Lahm, W.: Strahlentherapie 25: 22, 1927. 5. Linell, F., and Maansson, B.: Acta radiol. 41: 453, 1954. 6. Ormos, P.: Ztschr. Krebsforsch. 36: 119, 1932.
7. 8. 9.
Stiiper, P.: Strahlentherapie 92: 108, 1953. Sturgis, C. C.: Hematology, Springfield, Ill., 1955, Charles C Thomas, Publisher, p. 735. Wintrobe, M. M.: Clinical Hematology, Philadelphia, 1956, Lea & Febiger, p. 232.
620 West 168th St. New York 32, New York