European Journal of Cardiovascular Medicine

Uterus, a vital reproductive organ is exposed to a wide range of pathological lesions both benign and malignant diseases. Numerous disorders occur in the uterus, most commonly emanating from endocrine imbalance, pregnancy complications, and neoplasms.¹ Hysterectomy is the most common gynaecological procedure done inspite of many treatment options like medical and conservative surgery throughout the world.² There are many indications for hysterectomy and the uterus can be removed using any of a variety of techniques and approaches, including abdominal, vaginal, or laparoscopic.³ It is the definitive cure for many of its indications which include dysfunctional uterine bleeding, fibroids and gynaecological cancers.

Importance of histopathological examination of hysterectomy specimens carries both diagnostic and therapeutic implications. Few studies were done seeking to analyze the clinical parameters of patients afflicted by these tumors and tumor-like lesions  in hysterectomy specimens to discover possible correlations between preoperative clinical indication, gross findings and histopathological diagnosis. This study aims to identify the different types of uterine tumors and tumor-like lesions in hysterectomy specimens in our institution and categorizing their gross and histopathological findings using the latest World Health Organization classification of uterine corpus tumors.

This is a retrospective study conducted in the Department of Pathology, Government Medical College, Srikakulam over a period of one year from January 2024 to December 2024. The study material comprised of hysterectomy specimens received in the Department of Pathology for a period of one year. The clinical diagnosis and other relevant radiological investigation details of the patients who underwent hysterectomy during this period were correlated.

he hysterectomy specimens received by the Department of Pathology were properly labelled, numbered and fixed in 10% buffered formalin. After a thorough gross examination of the specimens, multiple bits were taken from representative sites, subjected to tissue processing and paraffin blocks were made. The blocks were sectioned and stained routinely with hematoxylin and eosin. A detailed microscopic examination of the stained slides was carried out and the lesions were given a histopathological diagnosis. The tumors and tumor-like lesions  lesions were classified using the latest edition of the World Health Organization (WHO) Classification of Tumours.

A total of 180 cases were studied. The hysterectomies were distributed over a wide age range of 20 to 77 years. Of these 180 cases, 52.75% cases were encountered in the age group of 40 - 49 years which is the most common age group (Table 1).

Table 1: Age-wise distribution of uterine lesions.

Table 2: Distribution of various types of uterine lesions.

Indications for hysterectomies varied from menstrual abnormalities to suspected pelvic malignancy. Majority of the patients presented with fibroid uterus diagnosed on  ultrasound followed by menorrhagia. The most common pathology encountered was leiomyoma (Figure 1, Figure 2) in 110 cases (63.33%) followed by adenomyosis (Figure 3) in 32 cases (17.77%). 89 cases. Other cases included endometrial polyps in 22 cases (12.22%), 1 cases of endometrial carcinoma (Figures 4, 5 and 6) (0.55%), 9 cases of non-atypical endometrial hyperplasia (5%), 1 case of atpical endometrial hyperplasia (0.55%) and 1 case of endometritis (0.55%).

Figure 1: Gross photograph of uterine leiomyoma, cut section showing interstitial leiomyoma.

Figure 2: Microphotograph of leiomyoma showing interlacing fascicles of bland monomorphic spindle (smooth muscle) cells; H and E; 100X

Figure 3: Photomicrograph of adenomyosis showing endometrial glands and stroma are seen in the myometrium. H and E; 50X.

Figure 4: Gross photograph of endometrial carcinoma showing polypoidal greyish white growth filling the endometrial cavity.

Figure 5: Photomicrograph of endometrioid type endometrial carcinoma showing myometrial invasion. H and E; 100X.

Figure 6: photomicrograph of endometrioid type endometrial carcinoma showing glands lined by atypical cells and the stroma is almost absent. H and E; 400x.

Hysterectomy is the most common gynaecological procedure done inspite of many treatment options like medical and conservative surgery throughout the world. It is a successful operation in terms of symptomatic relief and patient satisfaction and provides definitive cure to many diseases involving the uterus.

Regarding histopathological analysis of hysterectomy specimens and relationship between the preoperative clinical diagnosis and histopathological diagnosis very little data is available in our community. This study was conducted to identify and analyze the different patterns of lesions in hysterectomy specimens in our institution, correlate the findings with the clinical diagnosis and to compare our findings with those of other workers. 

The commonest estimated age range of hysterectomy in the present study is 40-49 years which is similar to study done by Jaisingbhai et al² whereas in Sharadrutha, et al³ and Nwokoro et al⁴ studies the most common age group encountered was 30-39 years. This may be related to the fact that most benign uterine lesions are hormone dependent, or pregnancy related and as such more common in the reproductive age group.⁵ The decrease in incidence in the age group of 30-39 years compared to 40 -49 years could be as consequence of a decrease in uterine corporal lesions because of early screening and detection of lesions, inducing appropriate interventions.

The most common clinical diagnosis in our study was fibroid uterus followed by menorrhagia (abnormal uterine bleeding or dysfunctional uterine bleeding) which was similar to study done by Gupta et al⁶ whereas others like Sobande et al⁷ and Kawthalkar et al¹ have reported menorrhagia as the most common clinical indication for hysterectomy compared to fibroid.

In the present study, the commonest pathology observed was leiomyoma comprising of 114 cases which were discovered post-hysterectomy on gross inspection and later confirmed by histopathology. These accounted for 63.33% of the total number of cases of leiomyoma which was similar to Nwokoro et al⁴ (69.5%) and Ezejiofor et al⁸ (90%) studies.  Leiomyomas and its variants are the most common uterine mesenchymal tumors and routinely occur in women between 40 to 50 years of age which was also the commonest estimated age range of hysterectomy in the present study. It is salient for surgical pathologists to be acquainted with the histopathologic changes in leiomyoma associated with hormonal treatment because a history of medication treatment is not always provided by the clinician.⁹

The likelihood that leiomyomata will cause symptoms is related to their number, location and size, although it seems equally probable that myomata may customarily represent an incidental, rather than causal finding. Most of them were small seedling fibroids ranging in size from 0.5-1.0 cm and also a few bigger fibroids that could not be diagnosed clinically and missed on ultrasound examination. These findings in our study confirmed the significance of a thorough gross examination of all the specimens received which enabled us to observe those lesions that were missed both clinically and radiologically, and establishing a precise diagnosis by means of histopathological examination for prognostication and further management of the patient.

Adenomyosis was the second most common myometrial pathology in our study which was similar to kumar et al¹⁰, Shetty et al¹¹ and lahori et al¹² studies. Adenomyosis is infrequently diagnosed preoperatively and is still largely under diagnosed as it has no specific symptoms of its own¹³. It is usually diagnosed by histopathological examination after hysterectomy.¹⁴ In the present study, only one case was recorded with a preoperative clinical diagnosis of adenomyosis; other cases either presented with menorrhagia or were other incidental findings. Many cases in this study revealed the presence of both adenomyosis and leiomyoma. Hyperoestrogenism and myometrial hypertrophy can lead to the enmeshment of endometrial glands, which could explain the concurrence of these lesions together.¹⁵

We also encountered 22 cases of endometrial polyps which was the most common tumor-like lesion, accounting for 12.22% of tumor-like lesions which was similar to Sajjad et al¹⁵ and Sharadrutha, et al³ studies. Abnormal uterine bleeding was the most common clinical diagnosis in these cases.

We have received 10 cases(5.55%) of endometrial hyperplasias (9 non-atypical & 1 atypical), which was similar to  the study conducted by Sajjad et al which showed endometrial hyperplasia in 3.1% of cases. We received one case of chronic nonspecific endometritis observed in the age group of 30-39years age group.

Carcinoma and other malignancies of the body of uterus is less common than other gynaecological malignancies. We received one case of Endometrial carcinoma in the age group of >60yrs (0.55%) out of total received 7 specimens from this age group which was similar to study in Enugu, Nigeria by Okeke et al¹⁷ which accounted for 1% and in a retrospective study by Viraj et al¹⁸ which accounted for 0.7% of malignant pathology.

The present study provides a fair cognizance into the histological spectrum of lesions in hysterectomy specimens in our institution. A thorough histopathological examination of hysterectomy specimens can reveal an ample range of lesions. Even though the clinical and gross diagnosis correlates with the histopathological analysis, few incidental findings were also seen. Hence, it is mandatory that every hysterectomy specimen should be subjected to detailed gross and histopathological examination to ensure proper postoperative management of patients.

Despite the continued benefits of medical and minimally invasive procedures which are conservative treatments in appropriately selected patients, unexpected histopathologic diagnoses can occur and should be managed appropriately by hysterectomy.

1. Kawthalkar AS, Pandav AB, Momin YA. Uterine corpus tumors and tumor-like lesions: A clinicopathological evaluation of 430 patients. MGM J Med Sci 2023;10:378-88.
2. Jaisingbhai GN, Dharaiya CM, Savjibhai TR, Goswami H. Histopathological analysis of hysterectomy specimens in tertiary care center. International Journal of Clinical and Diagnostic Pathology. 2024;7(3):20-23.
3. Sharadrutha A, Janaki M. Spectrum of Uterine corpus lesions in hysterectomy specimens. Perspectives in Medical Research 2017;5(2):54-58
4. Nwokoro et al., Histopathologic spectrum of uterine corpus lesions – An eleven-year review. Tropical Journal of Obstetrics & Gynaecology. Vol. 41. No. 2 (2023)
5. Ngan, S., & Seckl, M. J. (2007). Gestational trophoblastic neoplasia management: an update. Current opinion in oncology , 19 (5), 486–491.
6. Gupta G, Kotasthane DS, Kotasthane VD. Hysterectomy: a clinic-pathological correlation of 500 cases. Internet J Gynaecol Obstetrics. 2010;14(1):1-6.
7. Sobande AA, Eskander M, Archibong EI, Damole IO. Elective hysterectomy: a clinicopathological review from Abha Catchment Area of Saudi Arabia. West Afr J Med. 2005;24(1):31-5.
8. Ezejiofor, I. F., Olaofe, O. O., Chika, O. C., Menkiti, F. E., Enesi, A. S., & Ike, E. G. (2020). Histopathological Evaluation of Myometrial Lesions of the Uterus in Nnewi Teaching Hospital:(Five‑Year Retrospective Study). Nigerian Journal of Medicine , 29 (3), 494-498.
9. Krisztina Z. Hanley, MD; George G. Birdsong, MD; Marina B. Mosunjac, MD. Recent Developments in Surgical Pathology of the Uterine Corpus. Arch Pathol Lab Med—Vol 141, April 2017. 528-541
10. Kumar D, Lal PK, Chaudhary PK, Singh RVN. Clinicopathological study on uterine fibroid in a Medical College Hospital. Ann Int Med Den Res 2019;5:PT16-8.
11. Shetty DS, Gosavi AV, Murarkar PS, Sulhyan KR. Great mimickers: Tumor-like lesions of the uterine corpus. Int J Health Sci (Qassim) 2020;14:18-23.
12. Lahori M, Malhotra  AS, Sakul, Khajuria  A, Goswami  Clinicopathological spectrum of uterine leiomyomas in a state of  Northern India: A hospital based study. Int J Reprod Contracept Obstet Gynecol 2016;5:2295-9.
13. Weiss G, Maseelall P, Schott LL, Brockwell SE, Schocken M, Johnston JM. Adenomyosis a variant, not a disease? Evidence from hysterectomised menopausal women in the study of Women's Health Across the Nation (SWAN). Fertil Steril. 2009;91(1):201-6.
14. Shrestha A, Shrestha R, Sedhai LB, Pandit U. Adenomyosis at hysterectomy: prevalence, patient characteristics, clinicalprofile and histopathological findings. Kathmandu Univ Med J. 2012;37(1):53-6.
15. Bulun SE, Yildiz S, Adli M, Wei JJ. Adenomyosis pathogenesis: Insights from next-generation sequencing. Hum Reprod Update 2021;27:1086-97.
16. Sajjad M, Akram M, Khan ZA, Ghafoor A. Pattern of histological lesions in uterine corpus of hysterectomy specimens. Gomal J Med Sci 2015; 13: 58-61.
17. Okeke, T.; Onah, N.; Ikeako, L.; Ezenyeaku, C. The frequency and pattern of female genital tract malignancies at the university of Nigeria teaching hospital, enugu, Nigeria. Ann Med Health Sci Res 2013, 3 (3), 345-348. DOI: 10.4103/2141- 9248.117938 From NLM.
18. Viraj R, N.; Jindal, M.; Naik, S. Spectrum of histopathological lesions of female genital tract - study in a tertiary care centre. International Journal Of Scientific Research 2021, 10 (02), 19