Leiomyoma of prostate

LEIOMYOMA OF PROSTATE M I C H A E L M. M I C H A E L S , M.D. H A R O L D E. BROWN, M.D. C. JAMES FAVINO, M.D. From the Geisinger Medieal Center, Danville, Pennsylvania.

A:BSTBACT-Leiomyoma of the prostate appears in one of two pathologic forms: multiple discrete ~odules scattered throughout benign prostatic tissue, or a solid mass. A case report of each type is ~resented, with a review of the literature.

~eiomyoma of the prostate is seen only oeeasion~iy. The first case was reported by L e b e e 1 in aris in 1876. It was not until 1924 that Damski, 2 ~molensk, Russia, reported the second ease. ~ u g b e e 3 reported the first case in the United ~tates in 1926. Occasional observers have re10rted cases of leiomyoma of the prostate varying size from a single isolated nodule to massive ~volvement of the gland. Hinman 4 reported 0.5 J6r cent incidence of benign connective tissue mors of the prostate. Eight prostatic leiomyomas ere found in 14,000 autopsies by MaeCallum, an ~cidence of 0.06 per cent? Alcoek reported an fi~idenee of 1 per cent in a series of 700 prosta~etomies? Patch and Rhea, s by using differential itains on large whole sections of the prostate, ~ported a 25 per cent ineidenee in 181 cases. ~0ung and Geraghty reported leiomyomatous I~hanges in I1 per cent in a series of 120 operative pecimens." The youngest patient was reported by Tovarn l~nd Vasilescu. a four-year-old boy in 1938 who inderwent suprapubic cystostomy and died i ~ecause of persistent b l e e d i n g ? The oldest ~atient, an eighty-year-old man, was reported iY Patch and Rhea. s

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to symptoms. One group had benign prostatic hyperplasia in which the symptoms were predominantly that of urinary obstruction. The seeond group had predominantly rectal symptoms with little or no urinary symptoms. This latter group varied in age from twenty-four to forty-nine years with the exception of one patient aged sixty-five. Akin's T patient had priapism and dribbling of seminal flow.

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S ymptomatology A number of observers stated that, clinically, ~teiomyoma of the prostate is impossible to differentiate from benign hyperplasia. Excluding Ihhe case of the four-year-old boy, the eases reViewed by us were put in two groups according

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Case Reports

Case 1 A sixty-six-year-old white man was admitted to the Geisinger Hospital on February 3, 1966, b e c a u s e of gross hematuria with clots which lasted one day and occurred four days prior to admission. H e had minimal obstructive urinary symptoms. R e v i e w of systems and past medical history were unremarkable. Physical examination results were normal except for a grade II prostatic enlargement which felt benign. The residual urine was 180 ee. Results of complete blood count, ehest x-ray examination, electrocardiogram, blood urea nitrogen, and urinalysis were within normal limits. Urine culture was sterile. Intravenous pyelogram showed normal upper tracts. Cystourethroscopy showed trilobar prostatic enlargement. A total of 35 Gin. of prostatic tissue were resected transurethrally. His postoperative course was uneventful. Pathologic diagnosis was benign prostatic hyperplasia with focal areas of leiomyoma.

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" : •" ',': "";' :!2"::'? Ficum~ 1. Case I, (A) Benign prostatic hypertrophy. (B) Leiomyoma of prostate. (C) High-power view of pro' static leiomyoma. (D) Less cellular field of prostatic leiomyoma.

Case 2 A seventy-six-year-old white man with acute urinary retention was admitted on S e p t e m b e r i8, 1971. H e had diftlculty in urinating with marked hesitancy and terminal dribbling of several years' duration• Pertinent past history included myocardial infarction in August, 1971, suprapubic cystolithotomy in 1960, and adult-onset diabetes mellitus. Review of systems was unremarkable. Physical examination revealed a patient in acute distress from urinary discomfort which was relieved by catheterization• The bladder was palpable to the umbilicus• Systemic examination was unremarkable except for unilateral right prostatic lobar enlargement which we b e l i e v e d to be benign. Electrocardiogram showed occasional premature ventrieular contractions and evidence of old inferoseptal infarction. Chest x-ray film showed evidence of mild congestive cardiac failure. Urinalysis showed 5 to 8 red and 6 to 10 white blood cells per high-power field and triple-phosphate crystals. The urine cultured 300,000 colonies of Proteus vulgaris per cubic

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milliliter which was readily controlled by ampicillin. Intravenous urogram showed a small right calyceal diverticulum with fish-hooking of the lower end of both ureters and a basilar fillin~ defect in the bladder compatible with benign prostatic hyperplasia. Cystourethroseopy showed a heavily trabeculated bladder with two large white calculi which obscured adequate visualization of the ureteral orifices. The view from the. verumontanum s h o w e d 3 to 4 plus obstrueti0n by prostatic tissue especially prominent on: the right side. After eleven days of Foley catheter drainag~ the blood urea mtr"ogen had d r o p p e d from 50t~ 28 mg. per 100 ml., and the mild congestive ear" diae failure was adequately controlled. On the twelfth hospital day, suprapubic eystolithotomY and prostatectomy were performed with the re"' moval of a single spherical mass weighing 48 Gra, from the right lobe of the prostate. The postoper" ative course was uneventful. Following remOV~ of the catheter the patient voided freely with good control a n d no residual urine. Patholog!e diagnosis was leiomyoma of the prostate.

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Pathologic Diagnosis lease 1 Gross examination of the specimen revealed iultiple fragments of firm rubbery pink tissue, aips of prostate gland removed at transurethral ~section. Histologie examination revealed many ganges consistent with a diagnosis of benign Fperplasia (Fig. 1A). These include a nodular ~ttern composed of fibromuseular tissue, similar ~i the normal stroma, and hyperplastic glands. ~he glands are large, tortuous, and lined by a ~)aline basement membrane. The active colum~ epithelium forms papillae. Prostatic con..... are present. ntrast, however, there are also multiple noted which are considered benign ms of smooth m u s c l e s - l e i o m y o m a s tverage 2 ram. or less in diameter (Fig. tumor is seen at the right of the picture, atively normal stroma to the left. CroSsing tographic field vertically, near the center, adocapsule of compressed stromal tissue. nor is differentiated from the adjacent by the architectural pattern of interi~vining whorled bundles of fairly uniform mat t e spindle cells. A scanty background of fibrous ~hotomicrograph demonstrates the elongated ~iunt~ended (rod-shaped) nuclei, and the virtual ~bsence of mitotic figures (Fig. 1C). Figure 1D ~ o w s many less cellular areas in which the derlying architectural pattern is nevertheless ~dintained.

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This specimen represents a variant by size iorn the case described. The tumor nodule was :::::firm globular mass weighing 48 Gm. and ~easuring 5.2 cm. in maximum dimension. Cut '~ction revealed homogeneous gray tissue with ~all central loci of hemorrhagic degeneration ~ig. 2A). The lesions differ only in size. The iiStologic pattern is identical (Fig. 2B). Pathogenesis The following theories have been proposed by Various authors. Infection and inflammation transforms adenomatous tissue into smooth muscle with ~e formation of myomas, as suggested by Tandler and Zuckerkandl. s Chronic prostatitis stimulates "hyperplasia" of smooth muscle tissue which at times mav i~imulate neoplasm. This theory was proposecl PY Ewing, '~ who also believed that isolated

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FICUrtE 2. Case 2. (A) Gross specimen ofleiomyoma of prostate, and (B) microscopic section showing identical histologic pattern. pedunculated myomas may arise in the prostate and that they differed microscopically from the fibromuscular tissue observed in ordinary hypertrophy and in chronic infection. Arteriosclerosis or infection produces degeneration of hyperplastic nodules, leaving only fibrous tissue and smooth muscle stroma, as proposed by Adrion. 1° Blum and Rubritius 11 believed that leiomyoma represents hypertrophy in an organ in which glandular, muscular, and connective tissue are present and in which any one element may predominate, although adenomatous hyperplasia is the most prevalent form. Patch and Rhea 6 stated that leiomyomas were tumors of embryologic enlage. They also pointed out that pure leiomyomas are to be differentiated from the small fibromuscular nodules seen in the leiomyomatous forms of prostatic enlargements. Deming 12 stated that prostatic enlargement starts as a fibromuseular nodule in the prostatic urethra, and that this nodule is invaded by epithelium from the prostatic ducts which in turn may become adenomatous and replace the fibromuscular tissue. As evidence for his proposed theory, he points out that often smooth muscle tumors can be demonstrated in the muscular wall of the prostatic urethra.

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Deming also believes that leiomyomas arise from the lower Mull6rian duct fibers which form the verumontanum and pierce the posterior urethra where they intermix with the muscle tissue in the urethral wall. These fibers were first pointed out by Lowsley in 1912.13 Jaeoby 14 did not believe that leiomyomas ever occur and stated that epithelial elements always exist. This does not seem to concur with the eases of pure leiomyomas of the prostate reported in the literature. Summary Thirty-eight eases of leiomyoma of the prostate have been reported. Two additional eases are added. The condition cannot be distinguished from benign prostatic hyperplasia on a clinical basis. It may occur either in pure form or in combination with adenomatous hyperplasia. Geisinger Medical Center D a n v i l l e , P e n n s y l v a n i a 17821 (DR. B R O W N ) References 1. LEBEC, M.: (1876).

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Myome de la prostate, Prog. M6d. 4: 47i

2. DAMSKI, A.: Large myoma in prostate, Z. Urol. Chit. 1 6 : 4 7 (19"24). :3. BUGBEE, II. G.: Leiomyoma of prostate, J. Urol. 16: 67 (1926). ,t. HINMAN, F.: The Principles and Practice of Urology., Philadelphia, W. B. Sannders Co., 1935, p. 897. 5. KEEN, M. R.: The leiomyomatous prostate, J. Urok 42:158 (1939). 6. PATCH, F. S., and RHEA, L.J.: Leiomyoma of prostate gland, Br. J. Urol. 7:213 (1935). 7. AKIN, R. It.: Leiomyoma of prostate with associate4 painful priapism, Urol. Cutan. Rev. 40:558 (1936). 8. TANDLER, J., and ZUCKERKANDL, O.: Studien zur Anatomie und Klinik der Prostatahypertrophie, Berlifi'i Springer, 1922, p. 130. 9. EWlNG, J.: Neoplastic Diseases, 4th ed., Philadelphia: W. B. Saunders Co., 1940, pp. 239, 842. 10. ADtlXON, W.: Ein Beitrag zur Aetiologie der Prostata~ hypertrophic, Beitr. z. path Anat. u.z.allg. Path, 70i~ 179 (1922). 11. BLUM, V., and RUBRITIUS, H.: Die Erkrankungen dcr, Prostata, in Von Lichtenberg, A., Voelcker, F., and Wil~ bolz, H.: Handbuch der Urologic, 3rd ed., Berli~i Verlag-Springer, 1928, vol. 5, p. 508. 12. DEMING, C.L.: Significance ofleiomyomataofprostate2 Trans. Am. Assoc. Genitourin. Surg. 32:263 (1939). 13. LOWSLEY, O. S.: The development of die haman prostate gland with reference to the development/2of other structures at the neck of the urinary bladder, Anii J. Anat. 13:299 (1912). ]4. JACOBY, M.: Zur Prostatahypertrophie, Z. Urol: chris, 14:6 (1923).

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