Xanthogranulomatous inflammation of the perimetrium with infiltration into the uterine myometrium in a postmenopausal woman: a case report

Exploring the Diagnostic Challenges of Uterine Lesions in Frozen Section: A Comprehensive Study at a Tertiary Care Center

Introduction Uterine masses are commonly submitted for frozen section, to guide the surgeon, regarding the type and extent of the procedure during surgery. Despite the technical difficulties in processing, sectioning, and staining of frozen section samples, it remains a fairly reliable intraoperative tool. Aim This study aims to analyze the diverse spectrum of uterine masses sent for frozen sections for two years. In addition, it aims to analyze the histomorphology of the uterine masses sent for the frozen section and correlate it with that of the routine histopathological findings, thereby justifying the diagnostic value of the frozen section with this study. Furthermore, the study aims to classify the lesions into benign and malignant, quantify their frequency, and list the most common lesions seen in the uterine mass specimens sent for frozen section analysis. Methodology This retrospective descriptive study includes data from January 2021 to December 2022, retrieved from the archives of the Department of Pathology at Saveetha Medical College. This study includes a total of 76 cases, including all the uterine masses sent for frozen section analysis during the study period. Results Of the total of 76 cases received, 17 (22.4%) were malignant and 59 (77.6%) were benign. Of the malignant cases reported, the most common was endometrial carcinoma, and the least common entities encountered were carcinosarcoma and leiomyosarcoma. Of the benign cases, benign endometrial polyp was the most common endometrial lesion and leiomyoma with and without degeneration was the most common myometrial lesion encountered. Of the 50 cases of leiomyoma encountered, 16 had extensive degenerative changes. The most common degeneration seen in the fibroid was hyaline degeneration, and the least common was xanthogranulomatous degeneration. Conclusions The intraoperative frozen section analysis is a very important diagnostic tool, but we need to be aware of its limitations. The accuracy, sensitivity, and specificity rates were found to be high. Thus, frozen section diagnoses can be very valuable in the clinical management of uterine tumors. Careful gross examination, sampling from representative areas, and good communication between the pathologist and surgeon may help in avoiding its limitations.

Xanthogranulomatous inflammation of the female genital tract: An 11-year single institutional study of 40 cases

BACKGROUND AND OBJECTIVES

Xanthogranulomatous inflammation (XGI) is a rare form of chronic inflammation that affects the female genital tract (FGT). The absence of a standard lexicon in the literature has contributed to the relative obscurity of this condition. We attempt to study this lesion with its various clinicopathological associations.

METHODOLOGY

We conducted an 11-year retrospective study of cases diagnosed with XGI of the FGT, analyzing relevant clinical and pathological parameters.

RESULTS

Our study identified 40 cases reported as XGI. The mean age was 43.8 (+/- 11.8 SD) years. The most common clinical presentation was abdominal pain (27.5 %). Abdominal mass was seen in 37.5 % of which 22.5 % was primarily attributed to XGI and was not associated with malignancies. The most common site involved was adnexa(87.5 %), with rare involvement of myometrium(7.5 %) and endometrium(5 %). Adnexal involvement was either as tubo-ovarian masses or isolated ovary/fallopian tube involvement. XGI was also seen associated with other primary lesions of FGT like high-grade serous carcinoma(7.5 %) and mature cystic teratoma (7.5 %), while non-neoplastic associations included tubal gestation, foreign body, and Aspergillus infection in the ovary. Histologically, the infiltrate comprised of chronic inflammatory cells in all cases with additional acute inflammatory cells(60 %). Multinucleated giant cells were seen in 40 % of cases. Urine culture showed bacterial colonies in 23 % of cases.

CONCLUSIONS

XGI of FGT is an extremely rare lesion and can present as isolated lesions or in association with other primary lesions of FGT. Adnexal involvement was more common than uterine XGI. It is essential to recognize this lesion because it can mimic malignancy and has a destructive nature.

Xanthogranulomatous Endometritis: A Report of Two Cases

Xanthogranulomatous endometritis (XGE) or histiocytic endometritis is a chronic inflammatory pathology of rare presentation, characterized by an exaggerated inflammatory infiltrate that can mimic an endometrial carcinoma. We report two cases of this disease, one of them with a classic presentation of endometritis and the other one with a severe compromise in which the clinical presentation and imaging findings suggested a possible endometrial carcinoma. Knowledge of this unusual and rare pathology, including its etiopathogenesis, is important since it can be included in the differential diagnosis of endometrial carcinoma and, therefore, whenever it is found, to avoid excessive treatment.

Xanthogranulomatous Change in a Leiomyoma: First Report of an Extremely Rare Variant/Degenerative Change

Xanthogranulomatous inflammation, a specific form of chronic inflammation, is marked by parenchymal destruction, proliferative fibrosis, and infiltration of typical foamy histiocytes admixed with hemosiderin-laden macrophages and foreign-body giant cells. Myometrial xanthomatosis, a term designated for nodular or diffuse histiocytic hyperplasia of the myometrium, has been reported in association with pregnancy-related procedures. Moreover, a 2-3-fold increase in histiocytic counts has been observed in leiomyomatous areas than in adjacent normal myometrium. The first evidence of collections of lipid-laden macrophages was documented in the form of yellowish degeneration of uterine leiomyomas. We report a case of xanthogranulomatous change in a leiomyoma in a 47-year-old female who presented with abnormal uterine bleeding. To the best of our knowledge, this is the first report of xanthogranulomatous variant/degenerative change in a leiomyoma. This case highlights a new variant of leiomyoma which both gynecologists and pathologists should be aware of as it may pose a diagnostic challenge both clinically as well as pathologically.

Xanthogranulomatous Salpingo-Oophoritis Presenting as an Ovarian Malignancy

Xanthogranulomatous salpingo-oophoritis is an extremely rare entity. The clinical features are similar to the common benign and malignant adnexal diseases, making it difficult to diagnose. Here we present a case of pelvic mass with high level of tumor markers who was operated with suspicion of adnexal tumor. Histopathology revealed it to be a case of xanthogranulomatous salpingo-oophoritis.

Cervical xanthogranuloma in a case of postmenopausal pyometra

Xanthogranuloma is a non-neoplastic presentation of chronic inflammation commonly seen in gallbladder, kidney and rarely seen in genital organs. Only one case has been reported in cervix. Here, we report a case of 60-year-old postmenopausal lady who presented with history of fever and purulent discharge per-vaginum. On speculum examination, cervix had an ulcer extending from 3 to 5 o'clock position. Uterus was bulky. On probing the ulcer, a 1-cm deep sinus was identified. Ultrasound showed enlarged uterus and fluid collection suggestive of pyometra. Pyometra was drained and cervical biopsy was taken from the ulcerated lesion; histopathology revealed granulomatous inflammation with predominantly xanthous cells suggestive of tuberculosis. High index of clinical suspicion needs to be maintained in abnormal cervix. It is a perplexing and rare entity for a clinician and also a diagnosis of exclusion; only histopathology can help for diagnosis. It mimics like malignancy and chronic infections.