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Primary endometriosis of the cervix
PRIMARY
E~~O~ET~~O~I~
LEfJS.\KI) ~wm~x~, (From.
AVeuzrk
OF THE
M.D., NE\VMK, Brtk
Israel
CERVIX IT. J.
Itospital)
KE of the eal,liest notes of progress in this century’s renaissance era 0: gyuticoiogy ih III
duct;
7&ch arises in continuity \\itll in the uterine 7~11 the lesions
the mocosal lining of the deriveare c,alled adenomyosis or internal
2. E‘ctopic.-That which is called true endometriosis. The condition was recognixerl, hut not well understood, late in the nineteenth century. The lesion is often assoeiated m:ith endometrial hyperplasia and with leiompomas. It occurs in the reproductive life, usualI> The symytomatoloyy is not unlike that found ill between the ages of 30 and 10 years. pelvic inflammatory disease. The lesions of endometriosis occur in the following important regions in this general order of frequent)-: (1) the myometrium; (2) the ovary; (3) the cul-de-sac of Douglas, involving the uterosacral ligaments and/or infiltrating through the posterior \-aginal \-au!t FKI~ extending onto the cervix. This is the most common involvement of the cerrix. Isoiated lesions of the cervix per se are very rare and reports in the literature would bring the total to less than one dozen, none of which were diagnosed prior to surger:-. Other locations, more common than that of the ce,r\is; are in abdominal scars, umbilicus, appendix. round ligament, inguinal canal, and bladder. Occasionally some portion of the intestinal tract is involved in this disease, often a lesion uf the rectosigmoid or terminal ileum has ijeen seen, as well as in remote parts of t,he bad? such as in the lungs. As stated previously, endometriosis of the cervix per se, whet.her or not accompanied bg separate lesions elsewhere, has been rarely recorded. The cervical lesions may fit in with Sampson’s theory of direct implantations or with the theory of Xobert Meyer that the lesi.ons rise from celomic epitheliam, arising in situ from heteroplasia. Frank descriljed adenomatous growths of the cervix as derivatives from Gartner’s duct. However. this embryonic tissue lends itself to Gartner ‘s duct cysts, occurring on the lateral areas of the Novak mentions endomctrixl development in the cervix, in a numl~er cervix and vagina. of instances, but does not specifr whether these are isolated lesions, or the more commolt extensions from the cul-de-sac. The gross characteristics of isolated cervical endometriosis are that the lesions USUall)- have the appearance of small superficial islands or implants of endometrial tissue: pinthe latter to the size of a lemon, as point to pea size, although chocolate cysts map grow, reported in one case.
Case Report Mrs.
I. L., a 31.pear-old white woman, pars plaining of menorrhagia; with small clots, since jirior to her visit. She had had menometrorrhagia 4350
ii, gravida ii, ~3s seen -4pril 5, 1952, corn the birth of her second child 22 months since her last menses on Xarch -0-i. 192?,
‘Volumt:
65
Tumber
6
PRIMARY
Fig.
Fig. Fig. squamous Fig. subnuclear
3.-Section epithelium. 4.-Higher vacuoles
1.
3.
ENDOMETRIOSI8
OF
CER,l’IX
Fig.
1351
2.
Fig.
4.
of cervix showing endometrial glands and stroma beneath stratified ( Hematoxylin and eosin. X 4 0. ) power of the same section showing details of glands and stroma. Note of early secretory phase. ( Hematoxylin and eosin. X 170. )
Volume Number
65 6
PRIMARY
ENDOMETRIOS’IS
OF
CERVIX
1353
associated with luwer backache and right lower quadrant pain. There was no nausea or vomiting. Menstrual periods began at the age of 12, were regular every 28 days, lasting 6 to 7 days, the flow moderate the first 2 days with no clots and only slight lower abdominal pain throughout, not progressive, The first pregnancy was normal 5 years previously. The second had been complicated by hypertension. Both deliveries had been normal. Physical examination showed the patient to be moderately obese, weight 159% pounds, height 64 inches, with pulse 60, and blood pressure 138/84. The head was normal; the thyroid uniformly slightly enlarged, no bruits. Lung sounds were normal. The heart rate was slow, with many extrasystoles, no bruits. The breasts were pendulous, no masses palpable. The abdomen had no masses or rigidity. There was moderate tenderness over the pyloris. Knee reflexes were normal. Pelvic examination revealed a parous introitus, the anterior vaginal wall intact. There was slight reetocele. The cervix was posterior showing five hemorrhagic mottled grayish and white nodules, 3 to 5 mm. in diameter, four at the junction of the vaginal mucosa and cervix at 2, 5, 9, and lo:30 o’clock, and one lesion about 2 cm. above the cervix on the anterior vaginal wall between 12 and 1 o’clock (Figs. 1 and 2). The uterus was anterior: slightly irregular and boggy, the size of an 8 weeks’ gestation. The adnexa and parametria were negative. The impression was primary endometriosis of the cervix and endometrial polyposis. Mrs. I. L. was operated on at Newark Beth Israel Hospital on April 11, 1952. All nodules were removed and the bases cauterized with actual cautery. Curettage was performed with removal of profuse amounts of hyperplastic endometrium, much of which re,sembl.ed polyps. The postoperative course was uneventful and the patient was discharged Bpril 14, 1952. She was advised to balance her diet and reduce her weight. Postoperatively the lesions were treated with silver nitrate. The patient was seen on June 26, 1952; her weight was 1371/ pounds and her only complaint was spotting. On examination there was a new lesion only about 2 mm. in diameter, oozing blood. This area was cauterized on the posterior vaginal wall at the very angle of the cul-de-sac. This lesion may have been smaller and not seen at the time of the omperative procedure. The cervix was clean and the uterus anterior, firm, and normal in size. Menses since hospitalization have been free of symptoms. On July 3, 1952, the cauterized area was healed and there was no more spotting. The patient was advised to try for another pregnancy with the hope that this would lessen the tendency to recurrences ,of endometriosis. On Oct. 3, 1952, follow-up showed three more 3 mm. lesions on the cervix. These were removed and sent to the laboratory. Pathologic Report.-(70073A Microscopic, April 11, 1952.) The four fragments eonIn three of sisted of cervical tissue covered in part by stratified squamous epithelium. the four fragments beneath the epithelium there were groups amf rather tortuous irregular containing secretion vacuoles, both glands lined by pseudostratified columnar epithelium, sub- and supranuclear. The epithelium rested on a thin but distinct basement membrane. These glands rested within a cellular stroma made up of small spindle cells. Both glands The phase was distinctly late proliferaand stroma were characteristically endometrial. tive to early secretory, The stroma was vascular and hemorrhagic. The blood vessels were This stroma was distinct from the less cellular cervical stroma. thin..walled capillaries. There was a mild inflammatory infiltrate in and about the endometrial tissue. The fourth fragment contained a hemorrhagic area in which there appeared to be some endometrial stroma but no glands.
E~~O~ET~~O~I~
LEfJS.\KI) ~wm~x~, (From.
AVeuzrk
OF THE
M.D., NE\VMK, Brtk
Israel
CERVIX IT. J.
Itospital)
KE of the eal,liest notes of progress in this century’s renaissance era 0: gyuticoiogy ih III
duct;
7&ch arises in continuity \\itll in the uterine 7~11 the lesions
the mocosal lining of the deriveare c,alled adenomyosis or internal
2. E‘ctopic.-That which is called true endometriosis. The condition was recognixerl, hut not well understood, late in the nineteenth century. The lesion is often assoeiated m:ith endometrial hyperplasia and with leiompomas. It occurs in the reproductive life, usualI> The symytomatoloyy is not unlike that found ill between the ages of 30 and 10 years. pelvic inflammatory disease. The lesions of endometriosis occur in the following important regions in this general order of frequent)-: (1) the myometrium; (2) the ovary; (3) the cul-de-sac of Douglas, involving the uterosacral ligaments and/or infiltrating through the posterior \-aginal \-au!t FKI~ extending onto the cervix. This is the most common involvement of the cerrix. Isoiated lesions of the cervix per se are very rare and reports in the literature would bring the total to less than one dozen, none of which were diagnosed prior to surger:-. Other locations, more common than that of the ce,r\is; are in abdominal scars, umbilicus, appendix. round ligament, inguinal canal, and bladder. Occasionally some portion of the intestinal tract is involved in this disease, often a lesion uf the rectosigmoid or terminal ileum has ijeen seen, as well as in remote parts of t,he bad? such as in the lungs. As stated previously, endometriosis of the cervix per se, whet.her or not accompanied bg separate lesions elsewhere, has been rarely recorded. The cervical lesions may fit in with Sampson’s theory of direct implantations or with the theory of Xobert Meyer that the lesi.ons rise from celomic epitheliam, arising in situ from heteroplasia. Frank descriljed adenomatous growths of the cervix as derivatives from Gartner’s duct. However. this embryonic tissue lends itself to Gartner ‘s duct cysts, occurring on the lateral areas of the Novak mentions endomctrixl development in the cervix, in a numl~er cervix and vagina. of instances, but does not specifr whether these are isolated lesions, or the more commolt extensions from the cul-de-sac. The gross characteristics of isolated cervical endometriosis are that the lesions USUall)- have the appearance of small superficial islands or implants of endometrial tissue: pinthe latter to the size of a lemon, as point to pea size, although chocolate cysts map grow, reported in one case.
Case Report Mrs.
I. L., a 31.pear-old white woman, pars plaining of menorrhagia; with small clots, since jirior to her visit. She had had menometrorrhagia 4350
ii, gravida ii, ~3s seen -4pril 5, 1952, corn the birth of her second child 22 months since her last menses on Xarch -0-i. 192?,
‘Volumt:
65
Tumber
6
PRIMARY
Fig.
Fig. Fig. squamous Fig. subnuclear
3.-Section epithelium. 4.-Higher vacuoles
1.
3.
ENDOMETRIOSI8
OF
CER,l’IX
Fig.
1351
2.
Fig.
4.
of cervix showing endometrial glands and stroma beneath stratified ( Hematoxylin and eosin. X 4 0. ) power of the same section showing details of glands and stroma. Note of early secretory phase. ( Hematoxylin and eosin. X 170. )
Volume Number
65 6
PRIMARY
ENDOMETRIOS’IS
OF
CERVIX
1353
associated with luwer backache and right lower quadrant pain. There was no nausea or vomiting. Menstrual periods began at the age of 12, were regular every 28 days, lasting 6 to 7 days, the flow moderate the first 2 days with no clots and only slight lower abdominal pain throughout, not progressive, The first pregnancy was normal 5 years previously. The second had been complicated by hypertension. Both deliveries had been normal. Physical examination showed the patient to be moderately obese, weight 159% pounds, height 64 inches, with pulse 60, and blood pressure 138/84. The head was normal; the thyroid uniformly slightly enlarged, no bruits. Lung sounds were normal. The heart rate was slow, with many extrasystoles, no bruits. The breasts were pendulous, no masses palpable. The abdomen had no masses or rigidity. There was moderate tenderness over the pyloris. Knee reflexes were normal. Pelvic examination revealed a parous introitus, the anterior vaginal wall intact. There was slight reetocele. The cervix was posterior showing five hemorrhagic mottled grayish and white nodules, 3 to 5 mm. in diameter, four at the junction of the vaginal mucosa and cervix at 2, 5, 9, and lo:30 o’clock, and one lesion about 2 cm. above the cervix on the anterior vaginal wall between 12 and 1 o’clock (Figs. 1 and 2). The uterus was anterior: slightly irregular and boggy, the size of an 8 weeks’ gestation. The adnexa and parametria were negative. The impression was primary endometriosis of the cervix and endometrial polyposis. Mrs. I. L. was operated on at Newark Beth Israel Hospital on April 11, 1952. All nodules were removed and the bases cauterized with actual cautery. Curettage was performed with removal of profuse amounts of hyperplastic endometrium, much of which re,sembl.ed polyps. The postoperative course was uneventful and the patient was discharged Bpril 14, 1952. She was advised to balance her diet and reduce her weight. Postoperatively the lesions were treated with silver nitrate. The patient was seen on June 26, 1952; her weight was 1371/ pounds and her only complaint was spotting. On examination there was a new lesion only about 2 mm. in diameter, oozing blood. This area was cauterized on the posterior vaginal wall at the very angle of the cul-de-sac. This lesion may have been smaller and not seen at the time of the omperative procedure. The cervix was clean and the uterus anterior, firm, and normal in size. Menses since hospitalization have been free of symptoms. On July 3, 1952, the cauterized area was healed and there was no more spotting. The patient was advised to try for another pregnancy with the hope that this would lessen the tendency to recurrences ,of endometriosis. On Oct. 3, 1952, follow-up showed three more 3 mm. lesions on the cervix. These were removed and sent to the laboratory. Pathologic Report.-(70073A Microscopic, April 11, 1952.) The four fragments eonIn three of sisted of cervical tissue covered in part by stratified squamous epithelium. the four fragments beneath the epithelium there were groups amf rather tortuous irregular containing secretion vacuoles, both glands lined by pseudostratified columnar epithelium, sub- and supranuclear. The epithelium rested on a thin but distinct basement membrane. These glands rested within a cellular stroma made up of small spindle cells. Both glands The phase was distinctly late proliferaand stroma were characteristically endometrial. tive to early secretory, The stroma was vascular and hemorrhagic. The blood vessels were This stroma was distinct from the less cellular cervical stroma. thin..walled capillaries. There was a mild inflammatory infiltrate in and about the endometrial tissue. The fourth fragment contained a hemorrhagic area in which there appeared to be some endometrial stroma but no glands.