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Leiomyoma of the Prostate1
LEIOMYOMA OF THE PROSTATE1 L. H. BARETZ
Excluding the commonly found hyperplasia, new growths of the prostate are comparatively rare. Hinman, in a classification of such new growths, states that (a) 98 per cent or more are carcinomatous, (b) ½ per cent are sarcomatous, and (c) the remainder (less than 0.5 per cent) are mesothelial tumors such as leimyoma, fibromyoma and chondroma. Occurrence of leiomyoma. A review of the literature to date reveals 12 cases of leiomyoma of the prostate reported. The first case was by Leber in 1876. The writer's case is the thirteenth. Leiomyoma is a common tumor as applied to other organs of the body. In the prostate it is rarely found, although it is possible that the discovery of small myomatous nodules within the prostate might be more frequent, were a more careful search made of all sectioned specimens. Symptomatology. Clinically, leiomyoma may be impossible to differentiate from benign prostatic hypertrophy. Four of the cases reported (Danski, Hinman and Sullivan 2 cases, Deuticke) emphasized rectal symptoms, i.e., difficult or painful defecation. These tumors were all unusually large with marked intrarectal encroachment. Danski's case was a tumor weighing 180 grams. Bugbee's was diagnosed as a sarcoma before removal. The cases of Lebec, Rubritius, Wollman, Dial and Halpert, Mitchell and Blaisdell, had symptoms typical of prostatic hypertrophy, viz., frequency, dysuria, etc. On rectal palpation, where only a myomatous nodule exists, the diagnosis is not suspected, but only made postoperatively by examination of gross and microscopic sections. Where the growth is unusually large, and somewhat elastic on palpation, leiomyoma may be suspected and differentiated from true glandular hyperplasia or sarcoma oy microscopic study. Pathology. The gross and microscopic appearance may be identical with leimoyoma of the uterus. The entire prostate may be replaced by a leiomyomatous or smooth muscle tumor, or the latter may merely involve a single lobe or a circumscribed area within a lobe. It may be completely separated from the prostate proper by a pedicle, or a well-defined capsule. 1 Read
at the meeting of the Brooklyn Urological Society January 14, 1936. 664
LEIOMYOMA OF PROSTATE
665
Grossly, the involved portion is firm, perhaps firmer than the usual prostatic hypertrophy, of a grayish white color, and on gross section has a characteristic whorled appearance of interlacing bundles. Microscopically, the glandular tissue or epithelial elements may be completely absent, or may be visible on the periphery of the myomatous area. Never are the glandular elements visible within the tumor. The tumor is frequently surrounded by a fibrous connective tissue capsule and is composed of interlacing smooth muscle bundles with no glandular elements. The muscle cells are quite mature with elongated spindle shaped nuclei. No mitotic figures are present. Between the muscle bundles is a delicate network of fine connective tissue fibrils. Thus the tumor differs from the normal fibromuscular tissue found within areas of benign prostatic hypertrophy. Such masses, as described by Wollman are composed of smooth muscle and fibrous tissue arranged similarly to the interglandular stroma and may show a round cell infiltration. Case report. I. L. aged 79 years, was admitted to the Jewish Hospital on March 31, 1935, complaining of difficulty in starting the urinary stream of 12 weeks' duration. Past history was essentially negative. The patient had a chronic cough of 15 years' duration. There was dyspnoea on slight exertion. For 1 year the patient had noted nocturia 2-3 times nightly. There was no diurnal frequency. About 12 weeks before admission, urinary difficulty had become increasingly marked. Two weeks ago, catheterization was necessary, and yesterday oz. xvi urine was removed. Examination revealed the patient to be fairly well preserved for his age. There were sonorous rales over both chests. Heart sounds were weak and distant. Peripheral vessels were firm, tortuous and difficult to compress. BP was 140/80. Pulse rate 80. The bladder was distended ¾ to the umbilicus. The prostate by rectum was enlarged (third degree), firm and smooth. Urinalysis showed a few white blood cells, but no albumin or sugar. Blood creatinine was 1.15 mgm. per 100 cc. Urea N was 15.3. Blood count was normal. On April 1, 1935, a bilateral vasectomy was done and an indwelling catheter was inserted for gradual decompression. On April 3, 1935, a suprapubic cystostomy was performed under local anesthesia. The prostate as palpated within the bladder was enlarged in all lobes, smooth and firm. The patient did well and was discharged 9 days later with cystostomy tube in place. In spite of the fact that the patient had attacks of dizziness, he had insisted upon a second stage operation and was admitted to the hospital 5 months later, September 9, 1935.
666
L. H. BARETZ
Under general anesthesia, September 12, 1935, the prostate was removed, and enucleation took place without difficulty. The packing was removed 2 days later. On September 18, 1935, the patient voided spontaneously and he was discharged completely healed on September 25, 11 days post operative. When last seen 2 months later, his urine was clear. He was voiding normally without difficulty. His general condition appeared very good. Pathological report. The pathology as reported by Dr. Bela Halpert was as follows: "Several masses of tissue said to be prostate, measured from 2 by 1 by 1 cm. to 3.5 by 2 by 1.7 cm. The surfaces were smooth, firm and gray. On section the tissue presented several circumscribed areas of gray, yellow, ap-
pearing finely granular and surrounded by a delicate capsule of gray tissue. These circumscribed areas measured from 3 mm. to 1 cm. in diameter. "Microscopic sections (figs . 1 and 2) from the prostate showed groups of lumina with frequent infoldings lined by cylindrical epithelium, with light staining cytoplasms and basally placed vesicular nuclei. Other lumina were lined by flat cells and contained pink stain material, separated by incomplete septa and lined by flat or cuboidal cells. All of these were imbedded in a fibromuscular stroma in places infiltrated with smooth round cells and large mononuclear cells. "In some areas the epithelial elements predominated, in others the stroma predominated. " In another preparation, there were 2 circumscribed areas composed of interlacing bundles of smooth muscle cells, imbedded in a loose vascular fibrous connective tissue stroma. There was a condensation of the structures in the periphery of the circumscribed area.
LEIOMYOMA OF PROSTATE
667
"Preparations stained by Mallory and Van Geisen stains verified the structure described. In the Mallory, the smooth muscles were red and stroma blue; in the Van Geisen, the muscle cells were yellow in a pink staining net work. "The microscopic diagnosis was (1) Adenomatous overgrowth of prostate gland. (2) Leiomyoma of the prostate. (3) Chronic prostatitis." SUMMARY
Neoplastic proliferation of the stroma of the prostate is uncommon. This case, reported because of its rarity, is the thirteenth case presented to date. Clinically, leiomyoma cannot be diagnosed, but it should be borne in mine, when a prostate on palpation, is firm, elastic or somewhat unusual in consistency. Leiomyoma is benign, and its symptomatology differs in no way from a benign prostatic hypertrophy with the possible exception of increased rectal symptoms. It can only be differentiated from benign hyperplasia or sarcoma by histological study. It may involve only a small portion of the gland or may have entirely replaced it so that no glandular elements are present.
25 Eastern Parkway, Brooklyn, New York. REFERENCES BUGBEE, H. G. : Jour. Urol., 16: 67, 1926. DANSKI, A.: Ztschrft. f. Urol. Chir., 16: 47, 1924. DEUTIKE, PAUL: Deutche Ztcht. f . Chir., 236: 475, 1932. DIAL, D., AND HALPERT, B.: Arch. Path., 16: 332, 1933. HINMAN: Principles and Practice of Urology. Saunders 1935, p. 897. HINMAN F., AND SULLIVAN, J. T .: Jour. Urcil., 26: 475, 1931. LEBEC: Progre med., 4: 471 , 1876. MITCHELL, R., AND BLAISDELL, J . L. : Brit. Jour. Urol., 6: 381, 1933. RuBRITIUS: Ztschrft. f. Urol. Chir., 24: 418, 1928. WOLLMAN, I. J. : Jour. Urol., 25: 93, 1931.
Excluding the commonly found hyperplasia, new growths of the prostate are comparatively rare. Hinman, in a classification of such new growths, states that (a) 98 per cent or more are carcinomatous, (b) ½ per cent are sarcomatous, and (c) the remainder (less than 0.5 per cent) are mesothelial tumors such as leimyoma, fibromyoma and chondroma. Occurrence of leiomyoma. A review of the literature to date reveals 12 cases of leiomyoma of the prostate reported. The first case was by Leber in 1876. The writer's case is the thirteenth. Leiomyoma is a common tumor as applied to other organs of the body. In the prostate it is rarely found, although it is possible that the discovery of small myomatous nodules within the prostate might be more frequent, were a more careful search made of all sectioned specimens. Symptomatology. Clinically, leiomyoma may be impossible to differentiate from benign prostatic hypertrophy. Four of the cases reported (Danski, Hinman and Sullivan 2 cases, Deuticke) emphasized rectal symptoms, i.e., difficult or painful defecation. These tumors were all unusually large with marked intrarectal encroachment. Danski's case was a tumor weighing 180 grams. Bugbee's was diagnosed as a sarcoma before removal. The cases of Lebec, Rubritius, Wollman, Dial and Halpert, Mitchell and Blaisdell, had symptoms typical of prostatic hypertrophy, viz., frequency, dysuria, etc. On rectal palpation, where only a myomatous nodule exists, the diagnosis is not suspected, but only made postoperatively by examination of gross and microscopic sections. Where the growth is unusually large, and somewhat elastic on palpation, leiomyoma may be suspected and differentiated from true glandular hyperplasia or sarcoma oy microscopic study. Pathology. The gross and microscopic appearance may be identical with leimoyoma of the uterus. The entire prostate may be replaced by a leiomyomatous or smooth muscle tumor, or the latter may merely involve a single lobe or a circumscribed area within a lobe. It may be completely separated from the prostate proper by a pedicle, or a well-defined capsule. 1 Read
at the meeting of the Brooklyn Urological Society January 14, 1936. 664
LEIOMYOMA OF PROSTATE
665
Grossly, the involved portion is firm, perhaps firmer than the usual prostatic hypertrophy, of a grayish white color, and on gross section has a characteristic whorled appearance of interlacing bundles. Microscopically, the glandular tissue or epithelial elements may be completely absent, or may be visible on the periphery of the myomatous area. Never are the glandular elements visible within the tumor. The tumor is frequently surrounded by a fibrous connective tissue capsule and is composed of interlacing smooth muscle bundles with no glandular elements. The muscle cells are quite mature with elongated spindle shaped nuclei. No mitotic figures are present. Between the muscle bundles is a delicate network of fine connective tissue fibrils. Thus the tumor differs from the normal fibromuscular tissue found within areas of benign prostatic hypertrophy. Such masses, as described by Wollman are composed of smooth muscle and fibrous tissue arranged similarly to the interglandular stroma and may show a round cell infiltration. Case report. I. L. aged 79 years, was admitted to the Jewish Hospital on March 31, 1935, complaining of difficulty in starting the urinary stream of 12 weeks' duration. Past history was essentially negative. The patient had a chronic cough of 15 years' duration. There was dyspnoea on slight exertion. For 1 year the patient had noted nocturia 2-3 times nightly. There was no diurnal frequency. About 12 weeks before admission, urinary difficulty had become increasingly marked. Two weeks ago, catheterization was necessary, and yesterday oz. xvi urine was removed. Examination revealed the patient to be fairly well preserved for his age. There were sonorous rales over both chests. Heart sounds were weak and distant. Peripheral vessels were firm, tortuous and difficult to compress. BP was 140/80. Pulse rate 80. The bladder was distended ¾ to the umbilicus. The prostate by rectum was enlarged (third degree), firm and smooth. Urinalysis showed a few white blood cells, but no albumin or sugar. Blood creatinine was 1.15 mgm. per 100 cc. Urea N was 15.3. Blood count was normal. On April 1, 1935, a bilateral vasectomy was done and an indwelling catheter was inserted for gradual decompression. On April 3, 1935, a suprapubic cystostomy was performed under local anesthesia. The prostate as palpated within the bladder was enlarged in all lobes, smooth and firm. The patient did well and was discharged 9 days later with cystostomy tube in place. In spite of the fact that the patient had attacks of dizziness, he had insisted upon a second stage operation and was admitted to the hospital 5 months later, September 9, 1935.
666
L. H. BARETZ
Under general anesthesia, September 12, 1935, the prostate was removed, and enucleation took place without difficulty. The packing was removed 2 days later. On September 18, 1935, the patient voided spontaneously and he was discharged completely healed on September 25, 11 days post operative. When last seen 2 months later, his urine was clear. He was voiding normally without difficulty. His general condition appeared very good. Pathological report. The pathology as reported by Dr. Bela Halpert was as follows: "Several masses of tissue said to be prostate, measured from 2 by 1 by 1 cm. to 3.5 by 2 by 1.7 cm. The surfaces were smooth, firm and gray. On section the tissue presented several circumscribed areas of gray, yellow, ap-
pearing finely granular and surrounded by a delicate capsule of gray tissue. These circumscribed areas measured from 3 mm. to 1 cm. in diameter. "Microscopic sections (figs . 1 and 2) from the prostate showed groups of lumina with frequent infoldings lined by cylindrical epithelium, with light staining cytoplasms and basally placed vesicular nuclei. Other lumina were lined by flat cells and contained pink stain material, separated by incomplete septa and lined by flat or cuboidal cells. All of these were imbedded in a fibromuscular stroma in places infiltrated with smooth round cells and large mononuclear cells. "In some areas the epithelial elements predominated, in others the stroma predominated. " In another preparation, there were 2 circumscribed areas composed of interlacing bundles of smooth muscle cells, imbedded in a loose vascular fibrous connective tissue stroma. There was a condensation of the structures in the periphery of the circumscribed area.
LEIOMYOMA OF PROSTATE
667
"Preparations stained by Mallory and Van Geisen stains verified the structure described. In the Mallory, the smooth muscles were red and stroma blue; in the Van Geisen, the muscle cells were yellow in a pink staining net work. "The microscopic diagnosis was (1) Adenomatous overgrowth of prostate gland. (2) Leiomyoma of the prostate. (3) Chronic prostatitis." SUMMARY
Neoplastic proliferation of the stroma of the prostate is uncommon. This case, reported because of its rarity, is the thirteenth case presented to date. Clinically, leiomyoma cannot be diagnosed, but it should be borne in mine, when a prostate on palpation, is firm, elastic or somewhat unusual in consistency. Leiomyoma is benign, and its symptomatology differs in no way from a benign prostatic hypertrophy with the possible exception of increased rectal symptoms. It can only be differentiated from benign hyperplasia or sarcoma by histological study. It may involve only a small portion of the gland or may have entirely replaced it so that no glandular elements are present.
25 Eastern Parkway, Brooklyn, New York. REFERENCES BUGBEE, H. G. : Jour. Urol., 16: 67, 1926. DANSKI, A.: Ztschrft. f. Urol. Chir., 16: 47, 1924. DEUTIKE, PAUL: Deutche Ztcht. f . Chir., 236: 475, 1932. DIAL, D., AND HALPERT, B.: Arch. Path., 16: 332, 1933. HINMAN: Principles and Practice of Urology. Saunders 1935, p. 897. HINMAN F., AND SULLIVAN, J. T .: Jour. Urcil., 26: 475, 1931. LEBEC: Progre med., 4: 471 , 1876. MITCHELL, R., AND BLAISDELL, J . L. : Brit. Jour. Urol., 6: 381, 1933. RuBRITIUS: Ztschrft. f. Urol. Chir., 24: 418, 1928. WOLLMAN, I. J. : Jour. Urol., 25: 93, 1931.