Uterine Adenomyoma

Prediction of adenomyosis according to revised definitions of morphological uterus sonographic assessment features

Objectives

This study aimed to predict the diagnosis of adenomyosis by revised definitions of morphological uterus sonographic assessment (MUSA) features in individuals who had hysterectomy.

Methods

This was retrospective cohort research conducted at a tertiary facility. Between January 2022 and January 2023, 196 individuals who had hysterectomy were analyzed in the research. The revised definitions of MUSA features of the adenomyosis approach were used to record the direct and indirect results of the sonography. The cases were classified as Group 1 (adenomyosis; n = 40, 20.4%) and Group 2 (control; n = 156, 79.6%) according to histopathology reports.

Results

Hyperechogenic islands and echogenic subendometrial buds and lines were the most predictive direct features (p = 0.02). Globular uterus and irregular junctional zone were the most predictive indirect features (p = 0.04; p = 0.03, respectively). Among all indirect features, the globular uterus was the most predictive (p = 0.02). Total feature >4 was determined as the significant cutoff value to predict adenomyosis (p < 0.001).

Conclusion

This study shows that combinations with a total number of features >4 can be practically used in the evaluation of adenomyosis using the revised definitions of MUSA features.

Stromal p16 and SATB2 Expression Does Not Distinguish Atypical Polypoid Adenomyoma (APA) From its Benign Mimics

Atypical polypoid adenomyoma (APA) is a polypoid biphasic lesion of low malignant potential that arises in the lower uterine segment and uterine corpus. The diagnosis of APA is often challenging on biopsy and curettage specimens, and both benign and malignant processes need to be considered in the differential. Stromal expression of p16 and SATB2 have recently been shown to distinguish APA from myoinvasive endometrioid carcinoma. The authors hypothesized that p16 and SATB2 immunohistochemistry could also aid in the distinction of APA from benign adenomyomatous polyp and endometrioid adenomyoma. The study comprised 10 APAs, 7 adenomyomatous polyps, 11 endometrioid adenomyomas, and 10 myoinvasive endometrioid carcinomas. The majority of APAs showed moderate to strong, diffuse p16 and stromal expression. However, most adenomyomatous polyps and endometrioid adenomyomas also exhibited moderate to strong, focal to diffuse p16 stromal expression. SATB2 showed weak to moderate, focal to diffuse expression in the majority of APAs, adenomyomatous polyps and endometrioid adenomyomas. In contrast, p16 and SATB2 were negative to weak and focal in 90% of myoinvasive endometrioid carcinomas. Our findings demonstrate that p16 and SATB2 may be helpful in the differential diagnosis of myoinvasive endometrioid carcinoma and APA while not useful in separating APA from adenomyomatous polyp and endometrioid adenomyoma.

The typical polypoid adenomyoma is a special form of endometrial polyp: a case-controlled study with a large sample size

PURPOSE

To investigate clinicopathological differences between typical endometrial polypoid adenomyomas (TPAs) and endometrial polyps (EPs) and to determine the risk factors and recurrence of TPA and further clarify the pathogenesis and treatment of TPA.

METHODS

We reviewed the medical records of 488 women with TPA and 500 women with EP. Then, we analyzed the clinical features and manifestations, ultrasonic manifestations, hysteroscopic morphology, and pathological results. In addition, 360 cases of TPA and 367 cases of EP were followed up for 22-77 months and the risk factors TPA recurrence were assessed.

RESULTS

We detected significant differences in age, menopausal status, body mass index (BMI), the number of pregnancies, and parity between the two groups (P < 0.05). Hysteroscopy revealed that the incidence of polyps > 3 cm in diameter and multiple polyps in the TPA group was significantly higher than that in the EP group (P < 0.01). In addition, the rate of recurrence in the TPA group was significantly higher than that in the EP group (P < 0.05). Over three pregnancies, menopause, curettage, and the application of polyp clamps were all identified as independent risk factors for the recurrence of TPA (P < 0.05).

CONCLUSION

In addition to high estrogen levels, endometrial injury was identified as the main contributor to TPA pathogenesis. Hysteroscopic electrotomy was identified as the preferential treatment for TPA to avoid recurrence, especially in women with risk factors. Increasing the depth of ablation may prevent the recurrence of TPA more efficiently.

Transcervical radiofrequency ablation of focal adenomyosis: pilot results

Objective: Adenomyosis is a common gynecological disease, which occurs in women in reproductive age and is characterized by the presence of endometrial glands and stroma within the myometrium. Abnormal uterine bleeding, pelvic pain as well as infertility can be associated with adenomyosis. There are two main types of adenomyosis: diffuse and focal. Previously, adenomyosis was diagnosed only upon histopathological examination after hysterectomy and/or adenomyomectomy. However, the development of imagining techniques such as transvaginal ultrasound and magnetic resonance imaging enables the diagnosis of adenomyosis (diffuse and focal) without any surgical intervention. When medical therapy is contraindicated or ineffective, or if patients have a fertility desire, a surgical treatment may be necessary.Methods: In this study, a total of 13 patients with 16 areas of focal adenomyosis were treated. All patients provided their informed consent to undergo transcervical adenomyosis ablation treatment with the Sonata System, aware that the safety and effectiveness of transcervical radiofrequency (RF) ablation for the treatment of adenomyosis has not been established. Follow-up was performed six months after Sonata treatment.Results: The positive results relating to the improvement of symptoms and reduction of adenomyosis lesion size were observed in our study.Conclusion: Transcervical RF ablation with the Sonata System may be a promising therapeutic alternative method to conventional procedures such as hysterectomy for the treatment of focal adenomyosis, disease which has limited therapeutic approach, and may enable a minimally invasive, uterine preserving option.

Case Report: Benign Uterine Adenomyoma Metastasis in the Right Lung

Background

Pulmonary metastasis of benign uterine leiomyoma and uterine endometriosis has been reported; however, pulmonary benign metastasizing uterine adenomyoma has not been reported. Herein, we report the first case of pulmonary benign metastasizing uterine adenomyoma. It is very important to differentiate from pulmonary primary synovial sarcoma; histopathology and immunohistochemistry are very helpful, molecular pathology can be used if necessary.

Case Presentation

A female patient was admitted to the hospital because of pulmonary nodules. Lung computed tomography (CT) showed a nodular high density shadow in the upper lobe of the right lung, with a clear boundary and a diameter of approximately 1.2 cm. A contrast CT scan showed obvious enhancement, and no obvious lobulation or burr was found. Video-assisted thoracoscopic resection of the tumor was performed. The upper lobe nodules were completely removed. Postoperative pathological report confirmed the lesion as metastatic benign adenomyoma of the right upper lung.

Conclusion

The lung is the most common organ for malignant tumor metastasis, and a few benign tumors can also develop pulmonary metastasis. Pulmonary benign metastasizing adenomyoma is extremely rare, and the prognosis is very good after surgical resection. When pulmonary CT shows a solid high-density shadow, we should consider the possibility of a metastatic benign tumor.

Cystic adenomyoma surgery

OBJECTIVE

Cystic adenomyoma is a lesion located within the myometrium. It is lined with endometrium and has hemorrhagic content. This rare entity has been described as a focal form of adenomyosis. However, it is poorly understood, and the management of symptomatic patients is not codified. Our objective is to evaluate the effectiveness of treatment with planned surgery for cystic adenomyoma on symptoms and fertility in a retrospective series of patients.

STUDY DESIGN

This is a retrospective study between January 2011 and January 2018 in a university hospital of patients that had surgery for cystic adenomyoma with uterine preservation.

RESULTS

Pre-operative, per-operative, and post-operative data were recorded. Of the 18 patients included, 3 were lost to follow-up; 15 underwent laparoscopic surgery and 3 operative hysteroscopies. Complications during and after surgery were rare, involving only 3 patients, and of low severity. One patient saw no improvement in pain after surgery and 2 patients saw only partial improvement in their pain; 7 patients achieved at least one pregnancy with favorable outcome after surgery.

CONCLUSION

Based on this series, we argue that conservative surgical treatment for cystic adenomyoma generally improves pain and fertility without causing morbidity.

[Endometrioide-type cervical adenomyoma]

Adenomyoma of the cervix is a rare, benign lesion. It is a localized form of adenomyosis, which is surrounded by a benign muscle proliferation forming a tumor similar to leiomyoma. Of the three histological variants of adenomyomas, the most frequent is the endocervical type. We present a case of a 34-year-old woman with a tumor in the lower uterine segment which enlarged during pregnancy, replacing the entire cervix and resulting in the occlusion of the endocervical canal. Ultrasound and tomography showed a mixed tumor pushing aside the uterus and bladder. Speculoscopy revealed that the tumor protruded towards the vaginal canal. Histopathological established the diagnosis of a cervical adenomyoma of the endometrioid type.

Intravascular adenomyomatosis: a morphologic variant of intravenous leiomyomatosis associated with endometriosis and potential for misdiagnosis

Intravenous leiomyomatosis (IVL) is a quasi-malignant smooth muscle tumor involving lymphatic and venous spaces of the myometrium. Rare cases of IVL with admixed endometrial glands and stroma have been described, termed intravascular adenomyomatosis. We report four additional cases of intravascular adenomyomatosis and expand the clinicopathologic features of these rare tumors. Patients were 39-45 years old and presented with symptoms of dysmenorrhea, postmenopausal bleeding, or pelvic mass. All cases were associated with endometriosis. Three cases comprised intravascular bland smooth muscle tumors with plexiform features, and in some foci the intravascular tumor contained endometrial type glands and stroma. In one case there was extensive (>10) foci of intravascular adenomyomatosis without evidence of associated smooth muscle neoplasm but did have an endometrial polyp with adenomyomatous features. None of the cases had nuclear atypia, increased mitotic activity, or tumor cell necrosis. The endometrial stromal components were positive for CD10 and negative or weakly positive for desmin by immunohistochemistry. Two cases underwent molecular testing for JAZF1 and PHF1 rearrangements with negative results. Three patients had no evidence of disease at the time of last follow-up, and one had persistent but stable disease 7 years after incomplete surgical removal and megestrol acetate treatment. Intravascular adenomyomatosis is a variant morphology rarely seen in IVL that lacks characteristic morphologic and molecular features of endometrial stromal sarcoma. Like IVL, prognosis is likely linked to completeness of surgical resection. In this study we found that intravascular adenomyomatosis is frequently associated with endometriosis, a novel finding to add to the literature on this rare IVL variant.

A Feasible Technique in Laparoscopic Excision for Juvenile Cystic Adenomyosis: A Case Report, Literature Review, and Surgical Video

Background: Juvenile cystic adenomyosis (JCA) is a rare uterine lesion. We present the case of a young woman who was diagnosed with JCA and subsequently managed with laparoscopic cyst removal with sharp and blunt dissection. Moreover, we provide a literature review and a surgical video. Case: A 22-year-old nulliparous woman presented with severe dysmenorrhea and was assessed using contrast-enhanced abdominal computed tomography, transvaginal ultrasonography and pelvic magnetic resonance imaging, and diagnosed with a cystic lesion on the left side of the myometrium. She underwent laparoscopic cyst excision and uterine reconstruction. Histology was suggestive of JCA. The dysmenorrhea resolved postoperatively. Conclusion: Surgical resection is the first choice of treatment for cystic adenomyosis, and a laparoscopic approach using scissor forceps is effective.

[Endometriosis and adenomyosis]

Diffuse adenomyosis, focal adenomyosis, ovarian endometrioma, superficial endometriosis and deep infiltrating adenomyosis are all defined by the presence of an endometrioid tissue in an ectopic location that is at distance from the endometrium. Although frequently associated, these lesions represent different clinico-pathological entities that the pathologist should recognized. Herein, we review the clinical and pathological features of these entities, as well as related current physiopathological understandings and differential diagnoses that could be raised by some morphological variants. The statistical association between endometriosis and several ovarian tumors, mainly endometrioid and clear cell carcinomas and seromucinous borderline tumors is well established and we present some molecular and morphological features that support this transformation potential.

Adenomatoid Tumor of the Uterus: A Report of 6 Unusual Cases With Prominent Cysts Including 4 With Diffuse Myometrial Involvement, 4 With Uterine Serosal Involvement, and 2 Presenting in Curettage Specimens

We evaluated the clinicopathologic features of 6 adenomatoid tumors of the uterus with unusual features. All the tumors differed grossly from the usual adenomatoid tumor, typically being ill-defined and occupying >50% of the myometrium, essentially replacing it in 4. The neoplasm extended to the endometrium in 2 cases and in one of these it formed an intracavitary mass; in both the tumor was first diagnosed in a curettage. In the other 4 cases, the adenomatoid tumor was discovered in a hysterectomy specimen performed for irregular vaginal bleeding (3 patients), and the finding of a pelvic mass on a computed tomography scan in a patient with right lower quadrant pain. The tumors extended to the uterine serosa in the form of small grape-like vesicles or cysts in 4 cases. All tumors contained the typical small often irregularly shaped spaces but also had prominent cysts. When cysts involved the serosa, the microscopic appearance mimicked that of peritoneal inclusion cysts. In one case with serosal involvement, a prominent papillary pattern was also present. The cysts were typically closely packed with minimal intervening stroma but were occasionally separated by conspicuous smooth muscle bundles. The stroma in one case was extensively hyalinized. Two tumors were focally infarcted. A striking, but minor, solid growth in which the tumor cells were arranged in tightly packed nests or interanastomosing cords and trabeculae was seen in 2 tumors. The unusual gross and microscopic features of these tumors can cause significant diagnostic difficulty and bring into the differential diagnosis entities that are usually not realistic considerations. The presentation of 2 tumors in a curettage specimen represents an unusual clinical aspect.

Detection of MED12 mutations in mesenchymal components of uterine adenomyomas

Adenomyoma of the uterus is a biphasic nodular lesion composed of a mesenchymal component with smooth muscle differentiation and a glandular epithelium. The neoplastic nature of uterine adenomyomas has been controversial because some are considered to be nodular adenomyosis. MED12 mutations are involved in the pathogenesis of uterine smooth muscle tumors (leiomyomas and leiomyosarcomas) and biphasic tumors of the breast (fibroadenomas and phyllodes tumor). To investigate the histogenesis of uterine adenomyomas, we performed pathological and genetic analyses, including Sanger sequencing of MED12. In total, 15 cases of uterine adenomyomas were retrieved and assessed for clinicopathological factors. Immunohistochemistry for smooth muscle actin, desmin, and CD10 was performed. Exon 2 of MED12 was Sanger sequenced using DNA obtained by macrodissection of the adenomyomas. For cases that were positive for somatic MED12 mutations, we next performed microdissection of the mesenchymal and epithelial components. The DNA extracted from each component was further analyzed for MED12 mutations. MED12 mutations were detected in two adenomyomas (2/15, 13%), all in a known hot spot (codon 44). In both lesions, MED12 mutations were detected in multiple spots of the mesenchymal component. The epithelial component did not harbor MED12 mutations. The relatively low frequency of MED12 mutations suggests that not all adenomyomas are leiomyomas with entrapped glands. However, the results of our study suggest that a subset of uterine adenomyomas are true mesenchymal neoplasms.

Successful laparoscopic surgery of accessory cavitated uterine mass in young women with severe dysmenorrhea

Accessory cavitated uterine mass (ACUM) is a rare and unique condition seen in young women. We report cases of ACUMs in two patients, a 14-year-old girl and a 25-year-old woman, both with complaints of severe dysmenorrhea that had started at menarche and had progressively worsened since. A large cystic lesion was localized in the anterolateral wall of the myometrium separate from the endometrium, which was difficult to distinguish from congenital uterine anomalies. Laparoscopic excision of the ACUMs was successful and completely resolved the dysmenorrhea. Early investigation of severe dysmenorrhea in young women can provide appropriate management and relieve symptoms.

Question Mark Sign and Transvaginal Ultrasound Uterine Tenderness for the Diagnosis of Adenomyosis: A Prospective Validation

OBJECTIVES

To evaluate the diagnostic accuracy of the classic ultrasound (US) signs of adenomyosis, the question mark sign and transvaginal ultrasound (TVUS) uterine tenderness, in the diagnosis of adenomyosis.

METHODS

This was a prospective study including 78 patients waiting for hysterectomy for uterine benign diseases and undergoing preoperative US examinations to evaluate all criteria for US diagnosis of adenomyosis as reported by the consensus statement of the Morphological Uterus Sonographic Assessment group. A US diagnosis of adenomyosis was made in the presence of 2 or more Morphological Uterus Sonographic Assessment features. Moreover, the question mark sign and TVUS uterine tenderness were evaluated. Ultrasound features were compared with the histologic examination, which was considered the reference standard for the diagnosis of adenomyosis. The Cohen κ coefficient was used to measure the accordance between US and histologic results. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of each US feature were calculated.

RESULTS

The prevalence of adenomyosis in the sample was 33.3%. The sensitivity, specificity, PPV, NPV, and accuracy of TVUS in the diagnosis of adenomyosis were 77%, 96%, 91%, 89%, and 90%, respectively. Myometrial heterogeneity was the most frequently encountered feature (100%) but showed low specificity (7%). The question mark sign and TVUS uterine tenderness showed sensitivity, specificity, PPV, NPV, and accuracy of 41%, 96%, 83%, 77%, and 69% and 69%, 65%, 66%, 81%, and 67%.

CONCLUSIONS

The question mark sign and TVUS uterine tenderness are useful tools for the diagnosis of adenomyosis.

Laparoscopic treatment of a large cystic adenomyosis of the uterus: A case report

•

Cystic adenomyosis is rarely reported in the medical literature.

•

It is easy for clinicians to misdiagnose or miss the diagnosis because of its low incidence, rare clinical and atypical clinical features.

•

In case of large cystic adenomyoma, the surgeon can diagnose and treate the patient with laparoscopic.

Introduction

We describe a patient with a large cystic adenomyosis of the uterus who was treated by a laparoscopic approach.

Case presentation

A 38-year-old woman presented with dysmenorrhoea for 4 months. A 104 mm × 55 mm × 60 mm cystic mass was detected on the right side of the posterior wall of the uterus by ultrasound. Laparoscopy was performed, during which a bumpy mass was discovered protruding from the surface of the uterine myometrium. Both ovaries were normal. When the wall of the cystic mass was opened, chocolate-colored fluid was visible. The cyst was completely removed, and postoperative histopathology confirmed a cystic adenomyosis. One month later, the uterus was found to be normal on ultrasound.

Discussion

Endometriosis is a common disease in women and is divided into ovarian endometrioid cysts, superficial endometriosis, deep infiltrating endometriosis and other special types according to pathological characteristics. As a special type of endometriosis, the incidence of cystic adenomyosis is low, and its specific incidence is unknown. Cystic adenomyosis is clinically characterized by the appearance of one or more cystic cavities between the walls of the uterine muscles.

Conclusion

Laparoscopic surgery is an effective method for the diagnosis and treatment of large cystic masses in the uterine myometrium.

Adenomyomas of the Uterine Cervix in the First-Trimester of Pregnancy: A Case Report

Cervical adenomyomas of endocervical type (endocervical adenomyomas) are very rare benign lesions. Here we report the case of a 33-year-old woman who referred to the Perinatology Clinic of Ommolbanin Hospital (Mashhad, Iran) in September 2017. The patient was 8 weeks pregnant and complained of spotting and feeling a mass protruding from her vagina for 2 months. Physical examination revealed the presence of three masses of approximately 10 cm in the vagina, which were treated surgically. Histopathological examination of the excised specimen showed the presence of glands lined by a single layer of endocervical-type mucinous epithelium with smooth muscle fibers. Clinicians should be aware of such lesions in order to differentiate them from other malignancies and to individualize treatment.

Polypoid Adenomyoma of the Uterus

Polypoid adenomyoma is a rare uterine endometrial polypoid tumor of mixed epithelial and mesenchymal origin. Although the clinical and pathologic features of polypoid adenomyomas have been described extensively, imaging findings for these tumors have not been frequently reported in the literature. On imaging, their features may be confused with prolapsed leiomyomas or malignancy. Hemorrhagic cystic spaces in a prolapsed uterine tumor within the vagina should raise consideration of a diagnosis of polypoid adenomyoma. Such blood-containing cystic spaces would be unusual findings in leiomyomas and malignancy. Diagnosing polypoid adenomyoma is vital because it can potentially be managed by hysteroscopic resection, unlike an ordinary form of adenomyosis.

MR imaging findings differentiating uterine submucosal polypoid adenomyomas from endometrial polyps

OBJECTIVE:

This study aimed to assess the efficacy of MRI for differentiating between uterine submucosal polypoid adenomyomas (PAs) and endometrial polyps (EPs).

METHODS:

MRI was used to examine 40 histopathologically confirmed benign polypoid endometrial tumors (8submucosal PAs and 32 EPs). Atypical PAs were excluded from this study. Quantitative measurements (maximum tumor diameter, maximum cyst diameter, number of cysts, and apparent diffusion coefficient values) and qualitative imaging findings (predominance of cystic or solid components as well as presence of cysts, hemorrhage, myometrial invasion, fluid-fluid level, and fibrous core) were correlated with the two pathologies.

RESULTS:

The predominance of cystic components (37% vs 6%; p < 0.05) was more frequently observed in PAs than in EPs. The frequency of cysts (88% vs 25%; p < 0.01), hemorrhage (50% vs 9%; p < 0.05), and myometrial invasion (25% vs 0%; p < 0.05) were significantly higher in PAs than in EPs. No significant differences were observed in terms of the maximum tumor diameter, maximum cyst diameter, number of cysts, apparent diffusion coefficient values, and presence of fluid-fluid level and fibrous core between PAs and EPs.

CONCLUSION:

The differences of MR findings with emphasis on cystic components and hemorrhage may be useful for differentiating between PAs and EPs.

ADVANCES IN KNOWLEDGE:

The predominance of cystic or solid components and the presence of cysts, hemorrhage, and myometrial invasion were useful MR findings for differentiating between PAs and EPs.

Understanding Obesity as a Risk Factor for Uterine Tumors Using Drosophila

Multiple large-scale epidemiological studies have identified obesity as an important risk factor for a variety of human cancers, particularly cancers of the uterus, gallbladder, kidney, liver, colon, and ovary, but there is much uncertainty regarding how obesity increases the cancer risks. Given that obesity has been consistently identified as a major risk factor for uterine tumors, the most common malignancies of the female reproductive system, we use uterine tumors as a pathological context to survey the relevant literature and propose a novel hypothesis: chronic downregulation of the cyclin-dependent kinase 8 (CDK8) module, composed of CDK8 (or its paralog CDK19), Cyclin C, MED12 (or MED12L), and MED13 (or MED13L), by elevated insulin or insulin-like growth factor signaling in obese women may increase the chances to dysregulate the activities of transcription factors regulated by the CDK8 module, thereby increasing the risk of uterine tumors. Although we focus on endometrial cancer and uterine leiomyomas (or fibroids), two major forms of uterine tumors, our model may offer additional insights into how obesity increases the risk of other types of cancers and diseases. To illustrate the power of model organisms for studying human diseases, here we place more emphasis on the findings obtained from Drosophila melanogaster.

Adenolipoleiomyoma Polyp of the Uterus: A Case Report and Review of the Literature

Adenolipoleiomyoma is a very rare lesion of the uterus. Only four cases were reported. We describe one case of adenolipoleiomyoma presenting as a polyp in a postmenopausal woman with menorrhagia. Adenolipoleiomyoma is a very rare lesion and the histogenesis remains unclear. We discuss the origin and the differential diagnosis of this lesion.

MRI of prolapsed polypoid adenomyoma: Expanding the differential diagnosis for the broccoli sign

We report a 44 year old previously healthy premenopausal woman who presented with a three month history of vaginal bleeding and a 5 cm vaginal mass obscuring the cervix on physical examination. Ultrasound evaluation was non diagnostic. Pelvic MRI demonstrated a 6 cm soft tissue mass in the vagina prolapsed from the uterine cavity with a visible connecting stalk, which is termed the broccoli sign. The initial radiological differential diagnosis included prolapsed uterine malignancy or leiomyoma. Surgical pathology revealed a polypoid adenomyoma. We conclude polypoid adenomyoma should be included in the differential diagnosis for prolapsed uterine tumor demonstrating the broccoli sign.

Recurrence-associated factors of laparoscopic adenomyomectomy for severely symptomatic adenomyoma

The present study aimed to identify which patients with adenomyoma would benefit from sparing the uterus and which patients should undergo a hysterectomy to avoid secondary surgery. Patients with pathology-proven adenomyoma admitted to Beijing Chao-Yang Hospital between November 2005 and November 2015 were retrospectively reviewed. Relief and reappearance of dysmenorrhea following laparoscopic adenomyomectomy were evaluated. All 49 patients (mean age, 40.6±5.2 years; age range, 26-51 years) presented with severe dysmenorrhea prior to surgery. Dysmenorrhea was identified to be relieved in 83.7% (41/49) of patients at the 6-month follow-up. No factors were revealed to have a significant effect on the surgical outcome. The median follow-up period was 4.6 (1-11) years; and 24.5% (12/49) of patients experienced recurrence of dysmenorrhea. Multivariate analysis identified preoperative serum cancer antigen 125 (CA 125) levels [hazard ratio (HR), 2.356; 95% confidence interval (CI), 1.271-3.570; P=0.011], postoperative gonadotropin-releasing hormone agonist (GnRH-a) treatment (HR, 0.540; 95% CI, 0.241-0.873; P=0.017) and accompanying endometriosis (HR, 2.182; 95% CI, 1.556-3.031; P=0.003) as independent risk factors for relapse. Laparoscopic adenomyomectomy is effective for alleviating dysmenorrhea in patients with adenomyoma. Patients with lower preoperative serum CA 125 levels without accompanying endometriosis benefited greater from adenomyomectomy compared with all other patients. Postoperative GnRH-a treatment strengthens therapeutic effects.

An unusual case of uterine cotyledonoid dissecting leiomyoma with adenomyosis

Background

Cotyledonoid dissecting leiomyoma is a rare variant of uterine smooth muscle tumor with an unusual growth pattern that shows intramural dissection within uterine myometrium and often a placenta-like appearance in its extrauterine components.

Case presentation

We present a unique case of cotyledonoid dissecting leiomyoma with adenomyosis. A 40-year-old Japanese female presented with prolonged menorrhagia and severe anemia. She had a pelvic mass followed-up for 6 years with a diagnosis of leiomyoma. However, increase in tumor size and cystic changes with hemorrhage were found by magnetic resonance imaging, and total abdominal hysterectomy with bilateral salpingectomy was performed. Macroscopically, the placenta-like exophytic mass protruding from the posterior uterine wall was composed of multiple nodules containing numerous hemorrhagic cysts. The mass showed continuity as a white multinodular dissecting mass infiltrating the posterolateral myometrium. Microscopically, both extra–and intrauterine portions of the mass were composed of nodules that contained swirled neoplastic smooth muscle cells with marked hyalinized degeneration, as observed in cotyledonoid dissecting leiomyomas of conventional type. In addition, numerous non–neoplastic glands of endometrial type surrounded by abundant endometrium–like stromal cells and non–neoplastic smooth muscle cells were found in the tumor, suggesting that it involved a part of concomitant adenomyosis originating from the nontumoral myometrium.

Conclusions

Thus far, over 30 cases of cotyledonoid dissecting leiomyoma have been reported, none of which have described the presence of adenomyosis within the tumor. The present case suggested that cotyledonoid dissecting leiomyoma might have a unique clinical presentation involving concomitant uterine adenomyosis. It is critical for pathologists, gynecologists, and radiologists to be cognizant of cotyledonoid dissecting leiomyoma variants for timely and appropriate diagnosis and treatment.

A practical approach to the diagnosis of mixed epithelial and mesenchymal tumours of the uterus

The current 2014 World Health Organization (WHO) Classification of mixed epithelial and mesenchymal tumours of the uterus includes categories of carcinosarcoma, adenosarcoma, adenofibroma, adenomyoma and atypical polypoid adenomyoma, the last two lesions being composed of an admixture of benign epithelial and mesenchymal elements with a prominent smooth muscle component. In this review, each of these categories of uterine neoplasm is covered with an emphasis on practical tips for the surgical pathologist and new developments. In particular, helpful clues in the distinction between carcinosarcoma and dedifferentiated endometrial carcinoma will be discussed. In addition, salient features to help distinguish between adenofibroma, adenosarcoma, embryonal rhabdomyosarcoma and other mesenchymal neoplasms in the differential diagnosis will be outlined. Finally, a discussion of adenomyoma and its main differential diagnostic considerations will be covered.

Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group

The MUSA (Morphological Uterus Sonographic Assessment) statement is a consensus statement on terms, definitions and measurements that may be used to describe and report the sonographic features of the myometrium using gray-scale sonography, color/power Doppler and three-dimensional ultrasound imaging. The terms and definitions described may form the basis for prospective studies to predict the risk of different myometrial pathologies, based on their ultrasound appearance, and thus should be relevant for the clinician in daily practice and for clinical research. The sonographic features and use of terminology for describing the two most common myometrial lesions (fibroids and adenomyosis) and uterine smooth muscle tumors are presented.

Surgical Management of Abnormal Uterine Bleeding in Fertile Age Women

Abnormal uterine bleeding is a common gynecological disease and represents one of the most frequent reasons for hospital admission to a specialist unit, often requiring further surgical treatment. Following the so-called PALM-COEIN system we will attempt to further clarify the surgical treatments available today. The first group (PALM) is characterized by structural lesions, which may be more appropriately treated by means of surgical management. Although hysterectomy remains the definitive and decisive choice, there are many alternative techniques available. These minimally invasive procedures offer the opportunity for a more conservative approach. Precise and accurate counseling facilitates better patient selection, based on the patient's desires, age and disease type, allowing treatment to be individually tailored to each woman.

Rare case of giant cystic adenomyoma mimicking a uterine malformation, diagnosed and treated by hysteroscopy

We describe a case of giant cystic uterine adenomyoma that was diagnosed and treated by hysteroscopy. In a 27-year-old woman with menometrorrhagia, severe dysmenorrhea, and chronic pelvic pain, pelvic ultrasonography revealed an enlarged uterine cavity filled with homogeneous low echogenic fluid content. A large cornual hematometra of 8.0 cm in diameter in a bicornuate uterus was suspected, and this hypothesis was also supported by magnetic resonance imaging findings. On the contrary, hysteroscopy revealed a bilocular huge cystic lesion of the posterior uterine wall that was removed by means of monopolar loop resection. The operative finding and the histopathologic examination confirmed the diagnosis of cystic adenomyoma of the uterus. Hysteroscopy may represent a valid tool for diagnosis and minimally invasive treatment of cystic adenomyoma, including those of large volume. Its use is helpful in differential diagnosis between cystic adenomyoma and uterine malformations as a possible cause of pelvic pain.

MR manifestations of uterine polypoid adenomyoma

PURPOSE

Polypoid adenomyoma (PA) is an uncommon benign tumor of the uterus appearing as a submucosal polypoid mass, or rarely as a subserosal polypoid mass. PA should be differentiated from atypical polypoid adenomyoma or malignant uterine tumors. The purpose of our case series is to evaluate magnetic resonance (MR) manifestations of PA for the differential diagnosis.

METHODS

Seven cases with surgically proven PA, five submucosal, and two subserosal, were evaluated. MR imaging findings including contrast enhancement in six cases (four cases with dynamic contrast-enhanced MR study), diffusion-weighted imaging (DWI) in five cases, and susceptibility weighted imaging (SWI) in two cases were retrospectively reviewed.

RESULTS

All seven lesions exhibited isointensity compared with the myometrium and 4 of 7 lesions (57%) contained high signal intensity hemorrhagic areas on T1-weighted images. On T2-weighted images, signal intensity was variable and all seven lesions contained cysts. None of five lesions with DWI exhibited high signal intensity compared with the normal myometrium. All six lesions showed intense contrast enhancement similar to that of the myometrium on post-contrast T1-weighted images. Punctate low intensity areas reflecting blood contents were revealed in all two lesions with SWI.

CONCLUSIONS

Submucosal or subserosal polypoid masses containing hemorrhagic areas, and cysts reflecting functional endometrium and dilatation of endometrial glands are suggestive for PA. Intense contrast enhancement similar to that of the myometrium may be another characteristic finding for PA.

Exogenic Adenomyoma of the Cervix: Report of 2 Cases and Review of the Literature

Purpose

Exogenic adenomyoma of the cervix is very rare. To date, very few cases have been reported, and the presentation and diagnosis are not clear. The aim of this study was to present 2 cases of exogenic adenomyoma of the cervix and summarize what is known about this disease by conducting a literature review of reported findings.

Methods

The clinical data from 2 cases of women with exogenic adenomyoma of the cervix admitted to Peking University First Hospital were analyzed retrospectively, and a systematic literature review was carried out.

Results

In our cases, exogenic adenomyoma of the cervix presented as a mass with mixed solid and cystic lesions in the pelvis and could not be separated from the cervix. Postoperative examination of the surgical specimen using pathological tests confirmed the tumors were composed of a proliferation of endocervical glands and smooth muscle, based on which exogenic adenomyoma of the cervix was confirmed.

Conclusions

Exogenic adenomyoma of the cervix should be considered in the diagnosis, in cases of mixed solid and cystic pelvic masses found in close relationship with the cervix.

Decidualization of uterine adenomyoma in a pregnant woman: a case report with immunohistochemical study

BACKGROUND

Decidualization of uterine adenomyoma has not been reported, to the best of the author's knowledge.

AIM

To report a case of uterine adenomyoma with decidualization.

CASE REPORT

A 43-year-old pregnant woman with "myoma" underwent cesarean operation and "myomectomy" at 37 gestation weeks. The operation was successful, and the baby and mother were healthy. Grossly, the "myoma" measured 12 × 10 × 10 cm, and the consistency was firm. Microscopically, the tumor was adenomyoma consisting of smooth muscle bundles and endometrial islands. Characteristically, the endometrial stroma showed marked decidualization. An immunohistochemical study showed that the decidual cells were positive for pancytokeratin AE1/3, pancytokeratin CAM5.2, cytokeratin (CK)7, CK18, vimentin, CA125, CD10, estrogen receptor (ER), progesterone receptor (PgR), and Ki-67 (labeling 1 %). They were negative for CK34βE12, CK5/6, CK8, CK14, CK19, CK20, EMA, p63, desmin, α-smooth muscle actin, S100 protein, CK34, CD68, and p53. These results show that marked decidualization occurs in adenomyoma during pregnancy, and that the decidual cells are positive for pancytokeratin AE1/3, pancytokeratin CAM5.2, CK7, CK18, vimentin, CA125, CD10, ER, and PgR.

CONCLUSION

A rare case of uterine adenomyoma with decidualization is reported.

Infiltrating adenomyosis of the cervix with features of a low-grade stromal sarcoma: a case report and a literature review

Adenomyosis is a common, non-neoplastic, chronic gynecologic disorder that is detected in 5% to 70% of hysterectomy specimens. It is characterized by the presence of ectopic endometrial glands and stroma within the myometrium, and it occurs mostly in late reproductive age women. Adenomyosis has a propensity to present in the uterine fundus and is rarely seen in the cervix. At present, the most reliable way to diagnose adenomyosis is by pathologic examination of the hysterectomy specimens. Herein, we report a case of infiltrating adenomyosis in the cervix with unusual clinical and pathologic findings.

Large uterine cervical adenomyoma excised by vaginal approach: case report, images, and literature review

Uterine adenomyoma is often overlooked, and cervical adenomyoma is extremely rare. Previous reports suggest that a uterine adenomyoma usually occurs in the uterine corpus but rarely in the uterine cervix. Approximately 20 reports of cervical adenomyoma have been published to date. However, cervical adenomyoma has been rarely investigated using magnetic resonance imaging. We encountered a large multicystic tumor in the uterine cervix of a 26-year-old woman that was difficult to diagnose preoperatively. On the basis of cytology, biopsy, and imaging findings, the cervical multicystic tumor measured approximately 13.0 cm. The patient underwent vaginal adenomyomectomy, and the tumor was completely resected. A histologic diagnosis of cervical adenomyoma was made because of proliferation of endocervical glands and the presence of rounded smooth muscle stroma. Awareness of this tumor in the uterine cervix is important for accurate diagnosis and treatment. Herein we present a rare case of a large cervical adenomyoma, with imaging studies, an image of the operation, histologic findings, and a literature review.

Adenofibroma in a young patient: a rare entity in an uncommon age

Adenofibroma is an extremely uncommon benign tumor composed of glandular and fibrous tissues. It occurs more often in the endometrium but it can also occur in the cervix and extrauterine sites. We report a case of a 32-year-old asymptomatic woman with cervical adenofibroma, first detected in a routine endovaginal ultrasound, as a cervical mass containing multiple cystic components. Histopathologic findings diagnosed its nature. As adenofibromas are very rare, we present this case with a brief review of the literature.

Adenomyomatous Polyp of the Endometrium With Prominent Epithelioid Smooth Muscle Differentiation

A minor component of smooth muscle may be present in the stroma of benign endometrial polyps and 2 distinctive endometrial polypoid lesions, atypical polypoid adenomyoma and adenomyoma, are characterized by stroma with a predominant smooth muscle component. In this report, we describe 2 unusual endometrial polyps in 43- and 60-year-old women in which the stromal component was predominantly composed of smooth muscle with an epithelioid appearance, a phenomenon which, as far as we are aware, has not been previously reported.

Stromal liver kinase B1 [STK11] signaling loss induces oviductal adenomas and endometrial cancer by activating mammalian Target of Rapamycin Complex 1

Germline mutations of the Liver Kinase b1 (LKB1/STK11) tumor suppressor gene have been linked to Peutz-Jeghers Syndrome (PJS), an autosomal-dominant, cancer-prone disorder in which patients develop neoplasms in several organs, including the oviduct, ovary, and cervix. We have conditionally deleted Lkb1 in Müllerian duct mesenchyme-derived cells of the female reproductive tract and observed expansion of the stromal compartment and hyperplasia and/or neoplasia of adjacent epithelial cells throughout the reproductive tract with paratubal cysts and adenomyomas in oviducts and, eventually, endometrial cancer. Examination of the proliferation marker phospho-histone H3 and mammalian Target Of Rapamycin Complex 1 (mTORC1) pathway members revealed increased proliferation and mTORC1 activation in stromal cells of both the oviduct and uterus. Treatment with rapamycin, an inhibitor of mTORC1 activity, decreased tumor burden in adult Lkb1 mutant mice. Deletion of the genes for Tuberous Sclerosis 1 (Tsc1) or Tsc2, regulators of mTORC1 that are downstream of LKB1 signaling, in the oviductal and uterine stroma phenocopies some of the defects observed in Lkb1 mutant mice, confirming that dysregulated mTORC1 activation in the Lkb1-deleted stroma contributes to the phenotype. Loss of PTEN, an upstream regulator of mTORC1 signaling, along with Lkb1 deletion significantly increased tumor burden in uteri and induced tumorigenesis in the cervix and vagina. These studies show that LKB1/TSC1/TSC2/mTORC1 signaling in mesenchymal cells is important for the maintenance of epithelial integrity and suppression of carcinogenesis in adjacent epithelial cells. Because similar changes in the stromal population are also observed in human oviductal/ovarian adenoma and endometrial adenocarcinoma patients, we predict that dysregulated mTORC1 activity by upstream mechanisms similar to those described in these model systems contributes to the pathogenesis of these human diseases.

Peutz-Jeghers Syndrome patients have autosomal dominant mutations in the LKB1/STK11 gene and are prone to developing cancer, predominantly in the intestinal tract but also in other tissues, including the reproductive tracts and gonads. To elucidate the mechanisms disrupted by the loss of LKB1 in the reproductive tract, we have developed a mouse model with deletion of Lkb1 specifically in stromal cells of gynecologic tissues. These mice show stromal cell expansion and develop oviductal adenomas and endometrial cancer. Deletion of either Tsc1 or Tsc2 genes, which are mutated in patients with Tuberous Sclerosis Complex and whose protein products are indirect downstream targets of LKB1 signaling, resulted in some of the same defects observed in Lkb1 mutant mice. Activation of mammalian Target Of Rapamycin Complex 1 (mTORC1), a common effector of disrupted LKB1, TSC1, and TSC2 signaling, was observed in all mutant tissues examined, suggesting that uninhibited mTORC1 activity is necessary for the phenotypes. Suppression of mTORC1 signaling by rapamycin reduced tumor burden in Lkb1 mutant mice, confirming the link between dysregulation of mTORC1 to development of the Lkb1 mutant phenotype and suggesting that therapeutic targeting of LKB1/TSC1/TSC2/mTORC1 signaling would benefit human Peutz-Jeghers Syndrome and Tuberous Sclerosis patients with reproductive tract disease.

Pathology of mixed Müllerian tumours

The term 'mixed Müllerian tumour' applies to uterine tumours composed of epithelial and mesenchymal elements of Müllerian origin. These neoplasms are classified into adenomyomas, adenofibromas, adenosarcomas, and carcinosarcomas (malignant Müllerian mixed tumours) based on whether the epithelial and stromal elements are benign or malignant. The rare atypical polypoid adenomyoma usually involves the lower uterine segment and, on curettings, may be confused with invasive adenocarcinoma. Adenosarcomas are low-grade neoplasms classified halfway along the spectrum of mixed Müllerian tumours, with adenofibromas at one end and carcinosarcomas (malignant Müllerian mixed tumours) at the other. Some tumours currently classified as 'adenofibromas' on the basis of their low mitotic count and lack of nuclear atypia are, in fact, well differentiated adenosarcomas. Carcinosarcoma is composed of admixed but distinctive carcinomatous and sarcomatous elements. On the basis of the clonal origin of both tumour components, carcinosarcomas are currently thought to be metaplastic carcinomas rather than uterine sarcomas.

The cavitated accessory uterine mass: a Müllerian anomaly in women with an otherwise normal uterus

OBJECTIVE

To present clinical cases of women who had an accessory and cavitated noncommunicating uterine mass with functioning endometrium associated with a normal uterus, suggestive of a new type of Müllerian anomaly.

METHODS

We report on five institutional cases: four cases of cavitated accessory uterine mass and a case of true adenomyoma. A review of the literature was performed by looking for these terms and others related in MEDLINE.

RESULTS

Including ours, there are 18 cases in the literature showing an accessory cystic cavity lined by endometrioid epithelium with an otherwise normal uterus. Another 11 cases only partially fulfilled the inclusion criteria. All of the first cases were in young women presenting with severe dysmenorrhea (n=4). Generally, the tumor was located in the anterior wall of the uterus at the level of insertion of the round ligament. It presents a certain similarity with the cavitated true adenomyomas observed in older women in whom the endometrial lining of the cystic cavity is generally absent. For differential diagnosis with cavitated noncommunicating rudimentary uterine horns, hysterosalpingography showing a normal eutopic uterine cavity is decisive.

CONCLUSION

Noncommunicating accessory uterine cavities and isolated cystic adenomyomas correspond to the same pathology: cavitated accessory uterine mass associated with an otherwise normal uterus. They present problems of differential diagnosis with true cavitated adenomyomas and cavitated rudimentary uterine horns. Accessory uterine mass could be caused by duplication and persistence of ductal Müllerian tissue in a critical area at the attachment level of the round ligament, possibly related to a gubernaculum dysfunction.

LEVEL OF EVIDENCE

III.