RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
DR. SARITA NAIR
PG MD (PATHOLOGY)
DEPT OF PATHOLOGY
AL-AMEEN MEDICAL COLLEGE, BIJAPUR
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / Name of the candidateAnd Address / DR.SARITA NAIR
PG IN PATHOLOGY
DEPARTMENT OF PATHOLOGY
AL-AMEEN MEDICAL COLLEGE,
BIJAPUR,KARNATAKA
2. / Name of the Institution / AL-AMEEN MEDICAL COLLEGE,
3 / Course of study and subject / M.D PATHOLOGY
4 / Date of admission to course / MAY 2012.
5 / Title of the Topic / HISTOPATHOLOGICAL STUDY OF
UTERUS AND CERVIX IN HYSTERECTOMY SPECIMENS
6 / Brief resume of the intended work:
6.1Need for the study
6.2 Review of literature
6.3 Objectives of the study / ANNEXURE – I
ANNEXURE – II
ANNEXURE – III
7 / Material and methods
7.1 Source of data
7.2 Method of collection of data( including sampling procedure if any)
7.3 Does the study require any investigations or interventions to be conducted on patients, humans or animals? If so please describe briefly.
7.4 Has ethical clearance been obtained from your institution in
case of 7.3 / ANNEXURE – IV
ANNEXURE –IV
YES, ANNEXURE –IV
YES
8 / List of References / ANNEXURE –V
9 / Signature of candidate
10 / Remarks of the guide / This is interesting study of Pathological changes in hysterectomies done in North Karnataka region
11 / Name & Designation
11.1 Guide
11.2 Signature
11.3 Head Of The Department
11.4 Signature
12.1 Name of dean
12.2Remarks
12.3 Signature / DR.B.B. SAJJANAR M.D,D.C.P
PROFESSOR
DEPARTMENT OF PATHOLOGY, AL-AMEEN MEDICAL COLLEGE,
BIJAPUR
DR. A. M. PATIL, M.D.
PROFESSOR & HOD,
DEPARTMENT OF PATHOLOGY, AL-AMEEN MEDICAL COLLEGE,
BIJAPUR
Dr B S PATIL
Any help in the study required will be given by the institution.
ANNEXURE-I
6.1 NEED FOR STUDY
The Female genital tract is a hormone responsive system. The configuration of uterus changes dramatically throughout life. It is subject to a variety of disorders, the most common of which results from endocrine imbalances, infections. tumours etc
Women worldwide suffer from gynaecologic and obstetric disorders that require hysterectomy as a treatment option. This may also involve removal of the fallopian tube and ovary depending on clinical indication, age and parity of the woman.1
Hysterectomy is a definite treatment of pelvic pathology including fibroid, abnormal heavy bleeding, chronic pelvic pain, endometriosis, and adenomyosis, uterine prolapse, pelvic inflammatory disease and cancer of reproductive organs.2
Hysterectomy specimens contribute a major component of histopathological work in Pathology laboratories.
Hysterectomy can be done through an abdominal or vaginal route and it can be accompanied by salpingoophorectomy of either one or both sides. Most vaginal hysterectomies are done for uterine prolapse and patients are older than those undergoing abdominal hysterectomies.Uterine fibroids and adenomyosis were the most common benign conditions in hysterectomy specimens in our community with peak incidence at 41-50 years.3 Ultimate diagnosis is only on histology, so every hysterectomy specimen should be subjected to histopathological examination.
The present study is aimed at a detailed histopathological evaluation of all hysterectomy specimens and to study the pattern of pathological changes of different lesions occurring in cervix and uterus in relation to different age groups.
ANNEXURE-II
6.2 REVIEW OF LITERATURE
The adult nulliparous uterus is a hollow, pear shaped organ that weighs 40-80grams and measures 7-8cms along its longest axis.
DEVELOPMENT OF UTERUS AND CERVIX-
Uterus is developed by fusion of intermediate horizontal and adjoining vertical part of mullerian ducts which begins at 7 to 8 weeks and completes by 12th week. Cervix is developed from fused lower vertical parts of the two paramesonephric ducts. The lining epithelium and the glands of the uterus and cervix are developed from the coelomic epithelium. Myometrial and endometrial stoma are developed from the mesoderm of the paramesonephric ducts.4
ANATOMY
The uterus has three distinctive anatomic and functional regions: the cervix, the lower uterine segment, and the corpus. The cervix is further divided into the vaginal portio (ectocervix) and the endocervix.Ectocervix is lined by squamous epithelium and endocervix is lined by columnar epithelium. The point at which the squamous and endocervical mucinous columnar epithelium meet is termed the squamocolumnar junction. 5
The area of the cervix where the columnar epithelium is ultimately replaced by squamous epithelium is termed the transformation zone. Metaplasia of glandular epithelium to squamous epithelium at the squamocolumnar junction produces multilayered, initially immature, squamous epithelium known as “squamous metaplasia.” These immature squamous cells are susceptible to human papillomavirus (HPV) infection and, it is at the squamocolumnar junction where precancerous lesions and cervical carcinomas develop.5
The uterus has two major components: the myometrium and the endometrium.
The myometrium is composed of tightly interwoven bundles of smooth muscle that form the wall of the uterus.5
COMMON LESIONS OF MYOMETRIUM-
A) BENINGN LESIONS:
I) LEIOMYOMAS-
Uterine leiomyomas (commonly called fibroids) are perhaps the most common tumor in women. They are benign smooth muscle neoplasm’s. On histological examination, the leiomyoma is composed of whorled bundles of smooth muscle cells that resemble the uninvolved myometrium.5
II) ADENOMYOSIS-
It is defined as the presence of endometrial tissue within the uterine wall (myometrium). On microscopic examination, irregular nests of endometrial stroma, with or without glands, is arranged within the myometrium, separated from the basal is by at least 2 to 3 mm.5
B) MALIGNANT LESIONS:
I) LEIOMYOSARCOMA-
It is the malignant counterpart of leiomyoma. It is the most common sarcoma of the uterus. Microscopically, leiomyosarcoma is composed of sheets of pleomorphic spindle cells with elongated nuclei, high-grade cytologic atypia, and a high mitotic rate with frequent atypical mitotic figures.6
II) OTHER RARE TUMOUR-Malignant mixed Müllerian tumor or MMMT) comprises approximately 10% of all the uterine malignancies. Microscopically, they consist of areas of adenocarcinoma intermixed with a wide range of malignant mesenchymal elements such as smooth muscle, undifferentiated sarcoma, cartilage, or skeletal muscle .6
COMMON LESIONS OF ENDOMETRIUM-
A) BENINGN LESIONS:
I)ENDOMETRITIS- Acute endometritis is defined by the presence of acute neutrophilic inflammation in the stroma of the non menstruating endometrium.Chronic endometritis is defined by the presence of plasma cells in the endometrial stroma.Common causes of chronic endometriosis include Chlamydia trachomatis, Urea plasma urealyticum, cytomegalovirus, and herpes virus infection. Granulomatous inflammation is caused by Mycobacterium tuberculosis infection, fungal infections.6
II) ENDOMETRIAL POLYPS-A local overgrowth of endometrial glands and stroma that protrudes into the endometrial cavity forms an endometrial polyp.6
III) ENDOMETRIAL HYPERPLASIA- Endometrial hyperplasia is thought to develop as a result of unopposed estrogenic stimulation.6
MALIGNANT TUMORS OF THE ENDOMETRIUM
I) CARCINOMA OF THE ENDOMETRIUM- Endometrial carcinoma is the most common invasive cancer of the female genital tract. It is classified into two types (type I and type II).The majority are well differentiated and mimic proliferative endometrial glands and, are referred to as endometrioid carcinoma. They typically arise in the setting of endometrial hyperplasia, type II tumours are by definition poorly differentiated. They usually arise in the setting of endometrial atrophy. The most common subtype is serous carcinoma.6
LESIONS OF CERVIX-
I) INFLAMMATION AND INFECTION
Acute cervicitis is a pattern of inflammation marked by a stromal and epithelial neutrophilic infiltrate, with associated stromal edema, and, often, reactive epithelial atypia. Chronic cervicitis consists of a lymphoplasmacytic infiltrate that is also nonspecific.7
INFECTIOUS CERVICITIS-It includes bacterial, viral, fungal and granulomatous (caused by mycobacterium tuberculosis)
II) METAPLASTIC LESIONS-it includes tubal metaplasia, transitional cell metaplasia.7
III) CERVICAL NEOPLASIA-A) Benign-It includes leiomyoma of cervix and benign melanoplastic proliferation of cervical epithelium.7
B) Dysplasia- (CERVICAL INTRAEPITHELIAL NEOPLASIA)
The three-tier classification system has been recently simplified to a two-tiered system, with CIN I renamed low-grade squamous intraepithelial lesion (LSIL) and CIN II and CIN III combined into one category referred to as high-grade squamous intraepithelial lesion (HSIL).5
Classification Systems for Premalignant Squamous Cervical Lesions
Dysplasia/Carcinoma in Situ / Cervical Intraepithelial Neoplasia (CIN) / Squamous Intraepithelial Lesion (SIL), Current Classification /Mild dysplasia / CIN I / Low-grade SIL (LSIL)
Moderate dysplasia / CIN II / High-grade SIL (HSIL)
Severe dysplasia / CIN III / High-grade SIL (HSIL)
Carcinoma in situ / CIN III / High-grade SIL (HSIL)
C) Malignant-
The major risk factor for cervical cancer is sexually transmitted HPV infection. Squamous cell carcinoma is the most common histological subtype of cervical cancer. HSIL (High-grade squamous intraepithelial lesion) .is an immediate precursor of cervical squamous cell carcinoma. The second most common tumour type is cervical adenocarcinoma.7
EARLIER STUDIES REGARDING THE UTERUS, CERVIX PATHOLOGY -
Bupathy Arunachalam, Jayasree Manivasakan carried a clinico- pathological study of adenomyosis from January 2007 to December 2010. Two hundred and fifty patients were studied. The prevalence of adenomyosis was 23.5%. Eighty percent of the patients were seen in the age group of 31-50 years.8
Madiha Sajjad et al carried a study to determine histopathologic pattern of lesions associated with menorrhagia in different age groups from jan2008 to dec2009. 93 abdominal hysterectomy cases done for the treatment of menorrhagia were included in the study. Fifty one percent (n=47) of patients belonged to the 41-50 years age group. 44% (n=42) were from 30-40 years age group and 5% (n=4) were from 51-60 yrs age group. 39% cases (n=36) showed leiomyomas, followed by adenomyosis, 19% (n=18). 5% cases (n=4) showed dual pathology consisting of both leiomyomas and adenomyosis. In 22% of cases (n=20), no gross or microscopic abnormality was detected. 9
RSarfraz, MSAhmed, Kamal F, Afsar Acarried a study for pattern of benign morphological myometrial lesions in total abdominal hysterectomy specimens. The study concluded that the commonest benign histopathological lesion in myometrium was leiomyoma (69%) followed by adenomyosis (47%).10
Geetanjali Gupta et al. carried a study to correlate clinical and pathological entities in hysterectomy specimens from April 2008 to March 2010. Utero-vaginal prolapse was the most common pre-operative diagnosis found in 40% cases followed by leiomyoma in 34.06% cases, adenomyosis (10.02%), endometrial polyp (1%) and ovarian cyst (2.77%). The clinical and pathological correlation is 100% in cases of leiomyoma, adenomyosis and endometrial polyps.11
Khan R, Sultana H, carried a study to compare the clinical, preoperative and histopathological findings of different cases of fibroid uterus, dysfunctional uterine bleeding and chronic cervicitis which needed abdominal hysterectomy. 100Cases of abdominal hysterectomy were done over a period of two years. 38 cases were of myoma diagnosed clinically but histopathological findings of 8 patients were different. Among 20 cases of clinically diagnosed dysfunctional uterine bleeding, 6 cases were found to have myoma and adenomyosis on histopathological examination. This study confirms that benign pathologies are more common in hysterectomy specimens than their malignant counterparts and that most common pathology identified in hysterectomy specimen is leiomyoma and then adenomyosis.12
ANNEXURE-III
6.3 OBJECTIVES OF STUDY
1) To study the prevalence and various types of lesions in the hysterectomy specimens .
2) To study the pattern of occurrence of different lesions in relation to age.
3) To study the different lesions in cervix and uterus.
ANNEXURE-IV
7. MATERIAL AND METHODS:
7.1 SOURCE OF DATA
All hysterectomy specimens received in department of pathology, AMCH, BIJAPUR Data for study will be obtained from clinical examination, clinical records and request received with specimens.
7.2 METHOD OF COLLECTION OF DATA
The hysterectomy specimens sent for histopathological examination to department of pathology, Al-Ameen Medical College Bijapur constitute the material for study. Gross examination will be carried out on specimens. Specimens immediately transferred to 10 % formalin. Bits are given from endomyometrium, cervix and lesions if any. Tissue bits routinely processed, 3 to 5 micron thick sections made from paraffin embedded blocks and will be stained with H&E stain. Special stains will be done whenever necessary.
INCLUSION CRITERIA
All hysterectomy specimens (uterus and cervix) are included in the study.
EXCLUSION CRITERIA.
Hysterectomy specimens showing secondaries, gross infection, massive haemorrhage and necrosis are excluded.
SAMPLE SIZE (650 cases Approx)
Duration of study- 5 years
3 years Retrospective -May2009 to May 2012
2 years Prospective -June 2012 to June 2014.
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR
OTHER HUMAN OR ANIMALS? IF SO, PLEASE DESCRIBE
BRIEFLY?
No, the study does not require any investigations to be conducted on patients.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUTION?
YES
INSTITUTIONAL ETHICAL CLEARANCE CERTIFICATE:
ETHICAL COMMITTEE
The following study entitled “HISTOPATHOLOGICAL STUDY OF UTERUS AND CERVIX IN HYSTERECTOMY SPECIMENS” By Dr. Sarita Nair PG student in MD Pathology 2012 batch has been cleared from the ethical committee of this institution for the purpose of dissertation work.
Date: Chairman
Ethical Committee,
Al Ameen Medical College,
Bijapur.
PROFORMA
Case No Date:
Name: IP/OP No Histopathology No
Age: Hospital / NH
Ref By
Clinical History and Duration of Symptoms:
USG findings -
PS/PV exam -
Clinical diagnosis-
Nature of Surgery-
Type of hysterectomy-
PATHOLOGY EXAMINATION -
Specimen received on-
GROSS:
A) UTERUS:
a. Myometrium
b. Endometrium
c. Endometrial canal
B) CERVIX:
a. Ectocervix
b. Endocervix
HISTOPATHOLOGY SECTIONS:
A) UTERUS
B) CERVIX
· ROUTINE STAIN-H&E
-SPECIAL STAINS (WHEREVER INDICATED)
· MICROSCOPY-
· HISTOPATHOLOGICAL DIAGNOSIS-
ANNEXUREV
LIST OF REFERENCES
1.) Samaila Modupeola et al. Clinico-pathological assessment of hysterectomies in Zaria. Eur J Gen Med. 2009;6(3):150-3.
2.) Perveen S, Tayyaba S. Clinicopathological review of elective abdominal hysterectomy. J of Surgery Pakistan (International). 2008;13(1):26-9.
3.) Sobande A, Eskander M, Archibong E, Damole I. Elective hysterectomy: A clinicopathogical review from Abha catchment area of Saudi Arabia. West African Journal of Medicine. 2005;24(1):31-5.
4.) Development of genital organs and gonads.In: Konar H.Dutta.D Textbook of Gynecology including contraception. 5th ed.Calcutta:New Central Book Agency;2009.p.35