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Pure lipoma of the uterus in association with endometrial carcinoma
European Journal of Obstetrics & Gynecology and Reproductive Biology 80 (1998) 199–200
Pure lipoma of the uterus in association with endometrial carcinoma Giuseppe Di Gesu’, Gennaro Cormio*, Giovanni Di Vagno, Giovanni Antonio Melilli, Giuseppina Renzulli, Luigi Selvaggi Department of Gynecology and Obstetrics and Institute of Pathology, University of Bari, Bari, Italy Received 16 February 1998; received in revised form 3 April 1998; accepted 14 April 1998
Abstract Pure lipoma of the uterus is a very rare entity, with few cases described in the English literature. We report the case of a 71-year-old woman, with pure lipoma of the uterus and coexistent endometrial carcinoma and discuss the possible relationship between these pathologic entities. 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Lipoma of the uterus; Coexistent endometrial carcinoma
1. Introduction Lipomatous tumors of the uterus are neoplasms composed in part or entirely of adult-type adipose tissue [1]. They usually occur as mixed lipoleiomyoma or fibrolipoma, because smooth muscle cells and fibrous tissue are often intermingled with adipocytes [2]. These rare and benign tumors commonly affect postmenopausal women. They usually arise in the uterine corpus with intramural and subserosal location [3]. The clinical presentation and behavior are indistinguishable from typical leiomyomas. The histogenesis is controversial [1]. A patient with pure uterine lipoma and coexistent endometrial carcinoma is reported and the possible relationship between these two pathologic entities is discussed.
*Corresponding author, Piazza Garibaldi 60, 70054 Giovinazzo, Bari, Italy. Tel.: 139 80 5478986; fax: 139 80 5473248.
2. Case report A 71-year-old white woman, gravida 2, para 2, was admitted to our institution for post-menopausal uterine bleeding. Her past medical history was uneventful. Pelvic examination revealed an enlarged uterus, 12 weeks’ size. Ultrasound scan showed a round hyperechogenic lesion on the uterine fundus, which was diagnosed as a calcific or necrotic leiomyoma. Diagnosis of endometrial carcinoma was placed after hysteroscopy and endometrial biopsy. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, removal of the upper third of the vagina and pelvic nodes sampling. The postoperative course was uneventful and the patient was discharged on the 9th postoperative day. On gross examination a well-circumscribed, yellow, greasy, lobulated, intramural adipose mass, that measured 6 cm in its largest dimension, was found in the uterine fundus. Fibrous septa were seen interspersed between the adipose mass, being concentrated in its center. Microscopically, the fundic mass consisted of mature adipocytes, arranged in large confluent nodules, with intermingled thin
0301-2115 / 98 / $19.00 1998 Elsevier Science Ireland Ltd. All rights reserved. PII: S0301-2115( 98 )00094-3
200
G. Di Gesu’ et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 80 (1998) 199 – 200
Fig. 1. The uterine lipoma is formed by mature adipocytes arranged in large confluent nodules. A well-differentiated endometrial adenocarcinoma can be seen on the top of the photomicrograph. (H&E 403).
blood vessels surrounded by minimal amounts of fibrous tissue, and was diagnosed as a pure lipoma. Just below the uterine lipoma a well-differentiated endometrial adenocarcinoma, with deep myometrial invasion, was detected (Fig. 1). There was no evidence of disease outside the uterine corpus. Cytologic results from the peritoneal washings were negative.
3. Discussion Uterine lipoma is a benign tumor composed of a thinly encapsulated, soft, multilobular mass of a typical adult adipose tissue, interspersed by thin septa of fibrous tissue [4] and well defined from the surrounding myometrium [5]. Their precise incidence is unknown; the occurrence of uterine tumors with lipomatous component has been estimated as variable from 0.03% [6] to 0.12% [7]. It is supposed that most of these tumors remain undetected or unreported, because the lipomatous component may be irrelevant or it might be considered as remnants of entrapped lipocytes [8]. The origin of lipomatous tumors is controversial [9]:
1. misplaced embryonal mesodermal rests with a potential for lipoblastic differentiation [10]; 2. lipoblast or pluripotential cells migrating along uterine arteries and nerves [11]; 3. adipose metaplasia of stromal [7] or smooth muscle cells [12] in a leiomyoma. Immunocytochemical studies have revealed reactivity of adipocytes for muscle markers actine, desmin and vimentin confirming the hypothesis of their direct transformation from smooth muscle cells [8]. Moreover, the lack of
reactivity to macrophagic antigens CD68 and MAC 387, would exclude the possible origin of adipocytes of lipomatous tumors from histiocytes [8]. Endometrial carcinoma is the most common gynecological malignancy; its pathogenesis has been related to unbalanced endogenous or exogenous hyperestrogenism [13]. The postmenopausal ovary continues to secrete substantial amounts of testosterone and androstenedione, but virtually no estrogen. It is also well known that estrone, which makes up the largest amount of estrogen produced in the postmenopausal woman is a result of peripheral conversion of androstenedione and of other androgens of adrenal origin, with a small contribution by the ovary. This conversion of precursors to estrone happens especially in large deposits of adipose tissue [14]. The observation in the reported case of adenocarcinomatous neoplastic focii only on the endometrium surrounding the uterine lipoma, might suggest that adipose tissue could have probably favoured and increased local conversion of androgens to estrone, possibly contributing to the development of endometrial cancer.
References [1] Mesenchymal tumors of the uterus. In: Kurman, RJ editor. Blaueinstein’s pathology of the female genital tract. New York: SpringerVerlag, 1993:495–513. [2] Jacobs DS, Cohen H, Johnson JS. Lipoleiomyomas of the uterus. Am J Clin Pathol 1965;44:45–51. [3] Gupta RK, Hunter RE. Lipoma of the uterus: review of literature with view of histogenesis. Obstet Gynecol 1964;24:255–7. [4] Robbins SL. Clinical aspect of neoplasia. In: Pathologic basis of disease. Philadelphia: WB Saunders, 1974:158–159. [5] Herting AT, Gore H. Tumors of the female sex organs. Atlas of tumors pathology. Armed Forces Institute of Pathology 1960;part 2, fascicle 33:235–246. [6] Robertson JW, Barber H. Lipoma of the uterus. Am J Obstet Gynecol 1953;65:920–2. [7] Salm R. The histogenesis of uterine lipoma. Beitr Path 1973;149:284–92. [8] Resta L, Maiorano E, Piscitelli D, Botticella MA. Lipomatous tumors of the uterus. Path Res Pract 1994;190:378–83. [9] Sieinski W. Lipomatous neometaplasia of the uterus. Reports of 11 cases with discussion and histogenesis and pathogenesis. Int J Gynecol Pathol 1989;8:357–63. [10] Demopoulos RI, Denarvaez F, Kaji V. Benign mixed mesodermal tumors of the uterus: a histogenic study. Am J Clin Pathol 1973;60:377–83. [11] Gonzales-Angulo A, Kaufman RH. Lipomatous tumors of the uterus. Report of a case. Obstet Gynecol 1962;19:494–8. [12] Pounder DJ. Fatty tumors of the uterus. J Clin Pathol 1982;35:1380– 3. [13] DiSaia PJ, Creasman WT. Adenocarcinoma of the uterus. In: Clinical gynecologic oncology, 4th ed. Saint Louis: Mosby, 1993:156–193. [14] Schapira DV, Kumar NB, Lyman GH et al. Upper-body fat distribution and endometrial cancer risk. J Am Med Assoc 1991;266:1808.
Pure lipoma of the uterus in association with endometrial carcinoma Giuseppe Di Gesu’, Gennaro Cormio*, Giovanni Di Vagno, Giovanni Antonio Melilli, Giuseppina Renzulli, Luigi Selvaggi Department of Gynecology and Obstetrics and Institute of Pathology, University of Bari, Bari, Italy Received 16 February 1998; received in revised form 3 April 1998; accepted 14 April 1998
Abstract Pure lipoma of the uterus is a very rare entity, with few cases described in the English literature. We report the case of a 71-year-old woman, with pure lipoma of the uterus and coexistent endometrial carcinoma and discuss the possible relationship between these pathologic entities. 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Lipoma of the uterus; Coexistent endometrial carcinoma
1. Introduction Lipomatous tumors of the uterus are neoplasms composed in part or entirely of adult-type adipose tissue [1]. They usually occur as mixed lipoleiomyoma or fibrolipoma, because smooth muscle cells and fibrous tissue are often intermingled with adipocytes [2]. These rare and benign tumors commonly affect postmenopausal women. They usually arise in the uterine corpus with intramural and subserosal location [3]. The clinical presentation and behavior are indistinguishable from typical leiomyomas. The histogenesis is controversial [1]. A patient with pure uterine lipoma and coexistent endometrial carcinoma is reported and the possible relationship between these two pathologic entities is discussed.
*Corresponding author, Piazza Garibaldi 60, 70054 Giovinazzo, Bari, Italy. Tel.: 139 80 5478986; fax: 139 80 5473248.
2. Case report A 71-year-old white woman, gravida 2, para 2, was admitted to our institution for post-menopausal uterine bleeding. Her past medical history was uneventful. Pelvic examination revealed an enlarged uterus, 12 weeks’ size. Ultrasound scan showed a round hyperechogenic lesion on the uterine fundus, which was diagnosed as a calcific or necrotic leiomyoma. Diagnosis of endometrial carcinoma was placed after hysteroscopy and endometrial biopsy. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, removal of the upper third of the vagina and pelvic nodes sampling. The postoperative course was uneventful and the patient was discharged on the 9th postoperative day. On gross examination a well-circumscribed, yellow, greasy, lobulated, intramural adipose mass, that measured 6 cm in its largest dimension, was found in the uterine fundus. Fibrous septa were seen interspersed between the adipose mass, being concentrated in its center. Microscopically, the fundic mass consisted of mature adipocytes, arranged in large confluent nodules, with intermingled thin
0301-2115 / 98 / $19.00 1998 Elsevier Science Ireland Ltd. All rights reserved. PII: S0301-2115( 98 )00094-3
200
G. Di Gesu’ et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 80 (1998) 199 – 200
Fig. 1. The uterine lipoma is formed by mature adipocytes arranged in large confluent nodules. A well-differentiated endometrial adenocarcinoma can be seen on the top of the photomicrograph. (H&E 403).
blood vessels surrounded by minimal amounts of fibrous tissue, and was diagnosed as a pure lipoma. Just below the uterine lipoma a well-differentiated endometrial adenocarcinoma, with deep myometrial invasion, was detected (Fig. 1). There was no evidence of disease outside the uterine corpus. Cytologic results from the peritoneal washings were negative.
3. Discussion Uterine lipoma is a benign tumor composed of a thinly encapsulated, soft, multilobular mass of a typical adult adipose tissue, interspersed by thin septa of fibrous tissue [4] and well defined from the surrounding myometrium [5]. Their precise incidence is unknown; the occurrence of uterine tumors with lipomatous component has been estimated as variable from 0.03% [6] to 0.12% [7]. It is supposed that most of these tumors remain undetected or unreported, because the lipomatous component may be irrelevant or it might be considered as remnants of entrapped lipocytes [8]. The origin of lipomatous tumors is controversial [9]:
1. misplaced embryonal mesodermal rests with a potential for lipoblastic differentiation [10]; 2. lipoblast or pluripotential cells migrating along uterine arteries and nerves [11]; 3. adipose metaplasia of stromal [7] or smooth muscle cells [12] in a leiomyoma. Immunocytochemical studies have revealed reactivity of adipocytes for muscle markers actine, desmin and vimentin confirming the hypothesis of their direct transformation from smooth muscle cells [8]. Moreover, the lack of
reactivity to macrophagic antigens CD68 and MAC 387, would exclude the possible origin of adipocytes of lipomatous tumors from histiocytes [8]. Endometrial carcinoma is the most common gynecological malignancy; its pathogenesis has been related to unbalanced endogenous or exogenous hyperestrogenism [13]. The postmenopausal ovary continues to secrete substantial amounts of testosterone and androstenedione, but virtually no estrogen. It is also well known that estrone, which makes up the largest amount of estrogen produced in the postmenopausal woman is a result of peripheral conversion of androstenedione and of other androgens of adrenal origin, with a small contribution by the ovary. This conversion of precursors to estrone happens especially in large deposits of adipose tissue [14]. The observation in the reported case of adenocarcinomatous neoplastic focii only on the endometrium surrounding the uterine lipoma, might suggest that adipose tissue could have probably favoured and increased local conversion of androgens to estrone, possibly contributing to the development of endometrial cancer.
References [1] Mesenchymal tumors of the uterus. In: Kurman, RJ editor. Blaueinstein’s pathology of the female genital tract. New York: SpringerVerlag, 1993:495–513. [2] Jacobs DS, Cohen H, Johnson JS. Lipoleiomyomas of the uterus. Am J Clin Pathol 1965;44:45–51. [3] Gupta RK, Hunter RE. Lipoma of the uterus: review of literature with view of histogenesis. Obstet Gynecol 1964;24:255–7. [4] Robbins SL. Clinical aspect of neoplasia. In: Pathologic basis of disease. Philadelphia: WB Saunders, 1974:158–159. [5] Herting AT, Gore H. Tumors of the female sex organs. Atlas of tumors pathology. Armed Forces Institute of Pathology 1960;part 2, fascicle 33:235–246. [6] Robertson JW, Barber H. Lipoma of the uterus. Am J Obstet Gynecol 1953;65:920–2. [7] Salm R. The histogenesis of uterine lipoma. Beitr Path 1973;149:284–92. [8] Resta L, Maiorano E, Piscitelli D, Botticella MA. Lipomatous tumors of the uterus. Path Res Pract 1994;190:378–83. [9] Sieinski W. Lipomatous neometaplasia of the uterus. Reports of 11 cases with discussion and histogenesis and pathogenesis. Int J Gynecol Pathol 1989;8:357–63. [10] Demopoulos RI, Denarvaez F, Kaji V. Benign mixed mesodermal tumors of the uterus: a histogenic study. Am J Clin Pathol 1973;60:377–83. [11] Gonzales-Angulo A, Kaufman RH. Lipomatous tumors of the uterus. Report of a case. Obstet Gynecol 1962;19:494–8. [12] Pounder DJ. Fatty tumors of the uterus. J Clin Pathol 1982;35:1380– 3. [13] DiSaia PJ, Creasman WT. Adenocarcinoma of the uterus. In: Clinical gynecologic oncology, 4th ed. Saint Louis: Mosby, 1993:156–193. [14] Schapira DV, Kumar NB, Lyman GH et al. Upper-body fat distribution and endometrial cancer risk. J Am Med Assoc 1991;266:1808.