Massive lymphocytic infiltration of uterine leiomyomas associated with GnRH agonist treatment

Uterine myoma with massive lymphocytic infiltration - case report

Introduction

Uterine leiomyomas are the most common neoplasm of the uterus in women. Massive lymphocytic infiltration in a myoma is an unusual finding. It is characterised by the varying intensity of lymphocyte infiltration, the presence of scattered plasma cells, eosinophilia, and rarely, other items. We would like to call attention to such a rare lesion.

Case description

We present the case of a 31-year-old woman who had undergone surgical excision of a uterine tumour. Grossly, it had the typical uterine smooth muscle wall consistency. The microscopic examination revealed leiomyoma with heavy infiltration composed mainly of lymphocytes. On immunohistochemistry, in the lymphocytic infiltrate the T mature (CD3+/CD5+/TdT–) lymphocytes, small and of cytotoxic (CD8+/CD56–) type, prevailed, with moderate proliferative activity (expression of Ki67 found in ca. 30-40% of the cells), whereas B lymphocytes (CD20+/CD5–/TdT–) were innumerous and present in nodular aggregates. Despite a strong suspicion of neoplastic lymphoproliferation, the histopathological diagnosis was: leiomyoma with massive lymphoid infiltration. The cause of this feature is not known, although the gonadotropin-releasing hormone agonist and post-menopausal processes may promote such transformations. In differential diagnosis, malignant lymphoma, inflammatory pseudotumour, and pyomyoma should be included.

Conclusions

Lymphocytic infiltration within the uterine myoma is rare. The recognition of its distinct histological features is important to avoid possible misdiagnosis.

Unusual Morphologic Features of Uterine Leiomyomas Treated with Gonadotropin Releasing Hormone Agonists: Massive Lymphoid Infiltration and Vasculitis

This report describes 2 unusual morphologic features of leiomyomas in patients who had been treated preoperatively with gonadotropinreleasing hormone (GnRH) agonists. In 1 case there was extensive and widespread infiltration of the leiomyoma by numerous small mature lymphocytes, in keeping with a leiomyoma with massive lymphoid infiltration. In the other leiomyoma there were fibrin and foamy histiocytes within the walls of many arterioles, in keeping with a vasculitis. These 2 features, massive lymphoid infiltration and vasculitis, have rarely been described in association with GnRH agonists. Since GnRH agonists are increasingly being used in the management of uterine leiomyomas, pathologists should be aware of these unusual morphologic features in order to avoid diagnostic confusion.

[Uterine leiomyoma with massive lymphoid infiltration: case report]

Uterine leiomyoma with massive lymphoid infiltration is a rare and unusual pathological finding; only 20 cases have been reported in the literature. We report a case of this unusual lesion in a 35-year-old woman who underwent a myomectomy. On gross examination, the tumor was of white color and firm consistency. Histological sections showed interlacing bundles of spindle shaped cells of low density with moderate to severe lymphocytic infiltrate associated to lymphoid follicles and few plasma cells. Immunohistochemically, the diffusely infiltrating lymphoid cells were predominantly of T cell phenotype. The interspersed spindle shaped cells were positive with alpha smooth muscle actin, desmin and h-caldesmon. The cause of this unusual lesion is not clear, but the recognition of its distinct histological features is important to avoid possible confusion with differential diagnosis including malignant lymphoma, inflammatory pseudotumor and pyomyoma.

Uterine leiomyoma with massive lymphoid infiltrate after colon cancer chemotherapy: an immunohistochemical investigation with special reference to lysosome-associated membrane protein expression

Uterine leiomyoma with massive lymphoid infiltration is a rare morphologic phenomenon. We describe the first case of uterine leiomyoma with lymphoid infiltration observed in a patient after chemotherapy for sigmoid cancer. We performed immunohistochemical analysis with a panel of antibodies to several markers. Detection of CD20, CD3, Ki67, CD68 and Epstein-Barr virus nuclear antigen assisted in the differential diagnosis and partial elucidation of the pathogenesis. In addition, we examined the lysosome-associated membrane proteins LAMP-1 and LAMP-2 for the first time in this lesion. Their expression was elevated, indicating enhanced autophagy, an indirect sign of degenerative changes in this benign tumor characterized by massive lymphoid infiltration.

Frequency, Histological, and Immunohistochemical Properties of Massive Inflammatory Lymphocytic Infiltration of Leiomyomas of the Uterus: An Entity Causing Diagnostic Difficulties

Massive lymphocytic infiltration of the leiomyomas of the uterus is rare and causes diagnostic difficulties. The objective of this study is to estimate the frequency, to analyze the clinicopathologic features, to explore the possible pathogenetic factors, and to discuss the differential diagnosis of this entity. We reviewed the pathology reports of 379 patients who underwent surgery for leiomyomas at our institution, from 1999 until 2003, and we identified five cases of leiomyomas with massive lymphocytic infiltration. Thereafter, we reviewed the records of these five patients to identify the clinical, ultrasonographic, and surgical findings they had presented. Leiomyomas with lymphocytic infiltration were characterized by the presence of small lymphocytes, few plasma cells, and occasional germinal lymphocytes such as lymphoblasts confined into the leiomyoma. Immunohistochemistry was positive for desmin and leukocyte common antigen and showed a positive reaction to kappa and lambda light chains that is consistent with the polyclonal nature of an inflammatory infiltration. Gross appearance and ultrasonographic and color Doppler findings were the same as of a typical leiomyoma. Lymphocytic infiltration of leiomyomas is a rare histological entity. Although an inflammatory process seems to be the pathogenetic factor, other mechanisms such as an immunological or autoimmune response, a specific human leukocyte antigen alteration, or a viral infection could also be the cause of this entity. Differential diagnosis must be made from malignant lymphoma, pyomyoma, and inflammatory pseudotumor of the uterus, based on their special histological characteristics.

Uterine leiomyoma with massive lymphoid infiltration: Case report and review of the literature

Uterine leiomyoma with massive lymphoid infiltration is a rare and unusual pathological finding. Only 13 cases have been reported in English literature. A case of uterine leiomyoma showing massive lymphoid infiltration in a 45-year-old woman is described. The tumor was relatively soft compared with usual leiomyomas. Microscopically, the tumor showed the typical features of leiomyoma with moderate to severe lymphocytic infiltrate consisting of mature lymphocytes, a few plasma cells and occasional histiocytes. This cellular infiltration was confined to the leiomyoma. Immunohistochemically, the diffusely infiltrated lymphoid cells were stained by antibodies to CD45RO, CD3 and CD8. Germinal centers were stained by antibodies to CD20 and CD79a. Some CD68+ histiocytes were seen. Lymphoid infiltration within the leiomyoma is a peculiar histological morphology, although the cause is not clear. The recognition of its distinct histological features is important to avoid possible confusion with differential diagnoses including malignant lymphoma, inflammatory pseudotumor and pyomyoma.

Gonadotropin-releasing hormone alters the T helper cytokine balance in the pregnant rat

The interactions between immune-endocrine and reproductive systems are heightened during pregnancy as an adaptive mechanism, and are regulated by a complex array of hormones and cytokines that control the survival of a semiallogeneic conceptus. GnRH can exert direct effects on the immune system via its receptor (GnRH-R) on lymphoid cells. In the present study, we employed in vitro, ex vivo, and in vivo approaches to investigate the role of GnRH in the modulation of T helper cytokines in pregnant rats undergoing termination of pregnancy. Day 8 pregnant rats were infused with a GnRH agonist (GnRH-Ag) for 24 h using an osmotic minipump. Sham control rats were infused with the vehicle, saline. Lymphocytes were isolated from sham and treated rats and polyclonally stimulated with immobilized anti-CD3 antibody. The levels of the signature T helper 1 (Th-1) cytokines (interferon-gamma [IFN-gamma] and interleukin-2 [IL-2]) and Th-2 cytokines (IL-4 and IL-10) were measured in culture supernatants. Using immunoflourescence confocal microscopy, we demonstrated for the first time the spatial localization of GnRH-R protein on the surface of lymphocytes. We observed a marked increase in IFN-gamma and inhibition of IL-4 production from lymphocytes of pregnant rats treated in vitro with different doses of GnRH-Ag. Further, the responsiveness of lymphocytes to produce IFN-gamma was markedly increased in cells cultured ex vivo from GnRH-Ag infused rats, whereas the capacity of lymphocytes to produce IL-4 was significantly inhibited. In addition, GnRH-Ag infusion in pregnant rats induced a shift toward Th-1 cytokines in the serum. We did not observe any significant difference in IL-2 and IL-10 production in response to GnRH-Ag. Our results suggest an additional function for GnRH as a Th-1 inducer and Th-2 inhibitor. GnRH can thus skew the cytokine balance to predominantly Th-1 type in pregnancy, leading to the termination of pregnancy in rats.

Recent advances in the pathology of smooth muscle tumours of the uterus

Smooth muscle tumours of the uterus are common and the majority are benign leiomyomas. However, there are some tumours which exhibit unusual morphological features or growth patterns that cause difficulty in their distinction from malignant neoplasms and those with endometrial stromal differentiation. Such lesions are reviewed in this article with detailed descriptions of their morphology, differential diagnosis and correlation with biological behaviour.

Effect of gonadotropin-releasing hormone agonists on monocyte chemotactic protein-1 production and macrophage infiltration in leiomyomatous uterus

OBJECTIVE

The level of monocyte chemotactic protein-1 (MCP-1), a potent chemoattractant for monocytes, is fivefold higher in myometrium than in leiomyoma. We have previously shown that myometrium from women using GnRH agonists (GnRH-a) express the highest levels of MCP-1, which has antiproliferative effects on leiomyoma cells. We hypothesized that MCP-1 may have a direct paracrine effect in leiomyomatous uterus rather than acting by way of chemoattraction of macrophages.

DESIGN

Cross-sectional study.

SETTING

University medical center.

PATIENT(S)

Women with leiomyoma (n = 32).

INTERVENTION(S)

Immunohistochemical analysis performed in the myometrium and leiomyoma of women receiving (n = 11) and not receiving (n = 21) GnRH-a treatment.

MAIN OUTCOME MEASURE(S)

The MCP-1 levels and macrophage counts determined by immunohistochemistry in the myometrium and leiomyoma of women receiving GnRH-a were compared to the levels and counts in women not receiving GnRH-a.

RESULT(S)

Samples from all 11 patients using GnRH-a revealed strong MCP-1 staining, whereas staining was only weakly present in 11 and absent in 10 samples from patients not receiving GnRH-a, revealing a significant difference in MCP-1 expression between GnRH-a users versus nonusers (P=.006). The number of tissue macrophages between GnRH-a users and nonusers was not significantly different.

CONCLUSION(S)

We found that there is an increase in the MCP-1 protein expression in the myometrium of women receiving GnRH-a treatment. On the other hand, we have not observed a difference in the macrophage count and distribution with GnRH-a treatment, suggesting a potentially direct antiproliferative role for MCP-1 rather than acting by means of chemoattraction of macrophages.

Uterine leiomyomas with Eosinophils: a clinicopathologic study of 3 cases

Although leiomyomas (LMs) of the uterus are common, hematopoietic components within these tumors are not. Lymphoid and other hematopoietic elements have been previously recognized, but eosinophilic infiltrates in LMs have received little attention in the literature. The clinical and pathologic features of 3 cases of uterine LM with eosinophilic infiltration were studied. The patients ranged in age from 35 to 62 years and presented with abdominal and/or pelvic pain and abnormal uterine bleeding. None had peripheral blood eosinophilia or clinical evidence of allergy or parasitic infection. One patient had a benign LM, and the other 2 patients had smooth muscle tumors of uncertain malignant potential. The tumors contained variable numbers of eosinophils and Giemsa stains showed variable numbers of mast cells in addition to the eosinophils. We also performed immunohistochemical and in situ hybridization studies to assess for interleukin-5 (IL-5) and eotaxin in these LMs. There was no consistent association between the presence of eosinophils and either IL-5 or eotaxin in smooth muscle cells, suggesting that mechanisms other than IL-5 or eotaxin production may account for the eosinophilia. Because eosinophils are believed to be involved in wound healing, tissue remodeling, and fibrosis, their presence within LMs may reflect a response to tissue injury produced by the neoplasm rather than intrinsic recruitment by chemotactic factors produced by the smooth muscle cells. Their presence, however, does not appear to have any clinical significance.

Spontaneous expulsion of a uterine submucosal leiomyoma after administration of a gonadotropin-releasing hormone agonist

A 40-year-old primigravida presented with acute urine retention. Ultrasound examination revealed a large uterine submucosal leiomyoma and GnRH-a was administered. The leiomyoma grew to over twice its original size and protruded through the introitus. After 10 days, it was expelled completely and removed by resectohysteroscopy. The expulsion of the leiomyoma was most likely a result of GnRH-a's flare-up effect.

Pathology of uterine fibroids

The pathological appearances of uterine leiomyomas at macroscopic, histological and ultrastructural levels are described and illustrated. Features useful in the differential diagnosis from other uterine spindle cell lesions are included, and an outline is given of the variable features found in different studies of the effects of gonadotrophin hormone releasing hormone analogues on uterine leiomyomas.