한국인 자궁선근증에 관한 병리학적 및 조직화학적 연구

Abstract

[한글]

Histopathological and Histochemical Study on Adenomyosis among Korean Women.

Hong Yul Choi

Department of Medical Science, The Graduate School Yonsei University,

(Directed by Prof. Dong Sik Kim, Yoo Bock Lee, M.D.)

Adenomyuosis, which may be defined heterotopic occurrence of endometrial tissue

in myometrium of the uterus, is frequently observed in parous women of fifth decade

with menstrual disturbance mainly menorrhagia and dysmenorrhea.(Brines and Benson,

1942;Gold and Kearns, 1946; Benson and Sneeden, 1958; Van Praagh, 1965; Hertig and

Gore, 1966)

The pathogenesis of adenomyosis is unknown, but following theories on the origin

of adenomyosis have been postrlated by students of the subject. These include 1)

invasion theory, (Cullen, 1908) 2) theory of Wollffian duct origin, (von

Reckling-hausen, 1896) 3) implantation theory, (Sampson, 1921) and 4) metaplastic

theory from myometrial interstitium. *Brines and Blain, 1943) But it was Cullen

(1908), who demonstrate that there is continuity between the basal layer of

endometrium and ectopic endometrium in adenomyosis, using serial sections. Now the

most gynecologists and pathologists accept the theory of direct invasion offered by

Cullen.

The etiology is more controversial and facters have been discussed are

inflammation of endometrium(Mayer, 1925, 1926), trauma(Zaleski, 1936),

sterility(Emge, 1962), multiparity(Hunter, 1947; Benson and Sneeden, 1958),

hyperesterinism(Lauche, 1923; heffcoate and Potter, 1934; Witherspoon,

1935;Pierson, 1933; Jones, 1944; Yin, 1947; DeLima, 1949; Meissher, et al.'1957)

and disturbance of gonadotrophin production in hypophysis(Shinkareva, 1963). Only

one report is available on adenomyosis among Koreans(Lee, 1968), which state 14% of

incidence. He also observed the occurrence of adenomyosis more frequent in

nulliparouw women. The present study is an attempt to investigate the incidence,

clinical and pathological characteristics of adenomyosis among Koreans, as well as

to search for dtiological factors by analysis of clinical data, histopathological

and histochemical study on endometrium and ovaries.

Material and Methods

Materials consist of 915 uteri removed surgically at Yonsei University Medical

College Hospital for 8 years from 1961 to 1968. Examinations of adnexa were made

when they were available. All specimens were fixed in 10% formalin.

Macroscopically, the size, weighy, shape of each uterus, and appearnace of the

ovaries were examined. For histologic examinations, paraffin embedded blocks were

cut in 6 u thickness and secaions were stained by Hematoxylin-sosin method

routinely. For histochemical examinations, Aleian blue, P.A.S. and Methylgreen

pyronin stains were made. The degree of adenomyosis was determined by the criteria

of Bayly and Yates(1957) and Marcus(1961), the cyclic pattern of endometrium by

Rock(1940) and the degree of ovarian cortical stroma by Woll, et al.(1948). In

additionally, other gistologic features, such as follicular cysts, corpus luteum,

and associated pathologic changes were also checked.

Adenomyosis was diagnosed only when the ectopic endometrium were located at least

one field of 100% magnification from endomyometrial junction. For the 88 cases

whose complete clinical records were available, the history of pregnancy and

delivery, chief complaints and clinical diagnosis were reviewed.

Results and Summary

Among 915 uteri examined during last 8 years, adenomyosis was found in 102 cases,

giving incidence of 11.2% for surgically removed uteri. The age ranged from 23-64

years, half of them being 40-49 years(51.0%) and the average age was 44.8% years.

The ratio of adenomyosis of removed uterus is significantly increased during forth

decades.

Among 88 cases whose clinical records were available 65 cases were multiparous

and 23 cases(26.1%) were nulliparous including 17 cases of primary sterility. The

most frequent chief complaint was irregular uterine bleeding, followed by lower

abdominal pain, and menorrhagia in frequency. The pre-operative clinical diagnosis

was uterine lsiomyoma in 42 cases and a diagnosis of adenomyosis was made only in 3

cases.

The histopathological studies revealed that the most frequently associated

pathology was lsiomyoma of the uterine body(38.2%). The endometrial carcinoma was

found in only one case and enlometrial tuberculosis was associated in three cases.

The external endometriosis was found in one case in the fallopian tube.

The surface epithelium of endometrium showed broliferative phase in 24

cases(33.8%), hyperplasia in 21 cases(29.6%), secretory phase in 18 cases(25.3%),

and endometrium of 4 cases were in the state of decidua formation. But the ectopic

endometrial tissue revealed proli erative phase in 24 cases(33.8%), hyperplasia in

42 cases(59.2%), only 3 cases in secretory pahse, and two in the state of decidua

formation.

The amount of acid mucopolysaccharide, demonstrate by Alcian blue staining at the

functional layer varied considerably depending on the menstrual cycle, but at the

basal layer and ectopic endometrium, especially in the latter, rather large amount

was present irrespective to the menstrual cycle. With the methylgreen pyronin stain

for RNA, the pyronophilic substances were increased in amount at proliferative

phase and hyperplasia, but it failed to reveal significant variation among

functional, basal and ectopic endometrial layers. With the P.A.S stain for glycogen

and glycoproteins, P.A.S, positive substance was found in glandular epithelium of

functional layer at secretory phase, and only in two instances at ectopic site. The

ovaries showed 5 cases of benign and malignant tumors. The ovaries showed some

degree of cortical stromal hyperplasia in 34 cases(49.3%) out of 69 cases,

follicular cysts in 32 cases(46.4%) and 5 cases showed benign and malignant

neoplasm.

From the data obtained by present investigation, the following conclusion can be

made. The incidence of adenomyosis among Korean women is equivalent to those

reported in the other contries. Multiparity can not be regarded as dominant

etiologic factor in view of considerable cases in nulliparous women. Although these

all some evidence to suggest toward hyperesterinism, evidenced by higher incidence

of endometrial hyperplasia, follicular cysts and cortical stromal hyperplasia of

the ovaries, associated with adenomyosis, the evidences are still insufficient to

attribute hyperesterinism as the major cause of adenomyosis. While ectopic

endometrial tissue usually does not respond to cyclic change, the formation of

decidua in two cases indicate that it does respond to pregesterone if strong enough.

[영문]

Adenomyuosis, which may be defined heterotopic occurrence of endometrial tissue in myometrium of the uterus, is frequently observed in parous women of fifth decade with menstrual disturbance mainly menorrhagia and dysmenorrhea.(Brines and Benson, 1942;Gold and Kearns, 1946; Benson and Sneeden, 1958; Van Praagh, 1965; Hertig and Gore, 1966)

The pathogenesis of adenomyosis is unknown, but following theories on the origin of adenomyosis have been postrlated by students of the subject. These include 1) invasion theory, (Cullen, 1908) 2) theory of Wollffian duct origin, (von

Reckling-hausen, 1896) 3) implantation theory, (Sampson, 1921) and 4) metaplastic theory from myometrial interstitium. *Brines and Blain, 1943) But it was Cullen (1908), who demonstrate that there is continuity between the basal layer of endometrium and ectopic endometrium in adenomyosis, using serial sections. Now the most gynecologists and pathologists accept the theory of direct invasion offered by Cullen.

The etiology is more controversial and facters have been discussed are inflammation of endometrium(Mayer, 1925, 1926), trauma(Zaleski, 1936), sterility(Emge, 1962), multiparity(Hunter, 1947; Benson and Sneeden, 1958), hyperesterinism(Lauche, 1923; heffcoate and Potter, 1934; Witherspoon, 1935;Pierson, 1933; Jones, 1944; Yin, 1947; DeLima, 1949; Meissher, et al.'1957)

and disturbance of gonadotrophin production in hypophysis(Shinkareva, 1963). Only one report is available on adenomyosis among Koreans(Lee, 1968), which state 14% of incidence. He also observed the occurrence of adenomyosis more frequent in nulliparouw women. The present study is an attempt to investigate the incidence, clinical and pathological characteristics of adenomyosis among Koreans, as well as

to search for dtiological factors by analysis of clinical data, histopathological and histochemical study on endometrium and ovaries.

Material and Methods

Materials consist of 915 uteri removed surgically at Yonsei University Medical College Hospital for 8 years from 1961 to 1968. Examinations of adnexa were made when they were available. All specimens were fixed in 10% formalin.

Macroscopically, the size, weighy, shape of each uterus, and appearnace of the ovaries were examined. For histologic examinations, paraffin embedded blocks were cut in 6 u thickness and secaions were stained by Hematoxylin-sosin method routinely. For histochemical examinations, Aleian blue, P.A.S. and Methylgreen pyronin stains were made. The degree of adenomyosis was determined by the criteria of Bayly and Yates(1957) and Marcus(1961), the cyclic pattern of endometrium by Rock(1940) and the degree of ovarian cortical stroma by Woll, et al.(1948). In

additionally, other gistologic features, such as follicular cysts, corpus luteum, and associated pathologic changes were also checked.

Adenomyosis was diagnosed only when the ectopic endometrium were located at least one field of 100% magnification from endomyometrial junction. For the 88 cases whose complete clinical records were available, the history of pregnancy and delivery, chief complaints and clinical diagnosis were reviewed.

Results and Summary

Among 915 uteri examined during last 8 years, adenomyosis was found in 102 cases, giving incidence of 11.2% for surgically removed uteri. The age ranged from 23-64 years, half of them being 40-49 years(51.0%) and the average age was 44.8% years.

The ratio of adenomyosis of removed uterus is significantly increased during forth decades.

Among 88 cases whose clinical records were available 65 cases were multiparous and 23 cases(26.1%) were nulliparous including 17 cases of primary sterility. The most frequent chief complaint was irregular uterine bleeding, followed by lower abdominal pain, and menorrhagia in frequency. The pre-operative clinical diagnosis was uterine lsiomyoma in 42 cases and a diagnosis of adenomyosis was made only in 3 cases.

The histopathological studies revealed that the most frequently associated pathology was lsiomyoma of the uterine body(38.2%). The endometrial carcinoma was found in only one case and enlometrial tuberculosis was associated in three cases. The external endometriosis was found in one case in the fallopian tube.

The surface epithelium of endometrium showed broliferative phase in 24 cases(33.8%), hyperplasia in 21 cases(29.6%), secretory phase in 18 cases(25.3%), and endometrium of 4 cases were in the state of decidua formation. But the ectopic

endometrial tissue revealed proli erative phase in 24 cases(33.8%), hyperplasia in 42 cases(59.2%), only 3 cases in secretory pahse, and two in the state of decidua formation.

The amount of acid mucopolysaccharide, demonstrate by Alcian blue staining at the functional layer varied considerably depending on the menstrual cycle, but at the basal layer and ectopic endometrium, especially in the latter, rather large amount was present irrespective to the menstrual cycle. With the methylgreen pyronin stain for RNA, the pyronophilic substances were increased in amount at proliferative phase and hyperplasia, but it failed to reveal significant variation among functional, basal and ectopic endometrial layers. With the P.A.S stain for glycogen and glycoproteins, P.A.S, positive substance was found in glandular epithelium of functional layer at secretory phase, and only in two instances at ectopic site. The ovaries showed 5 cases of benign and malignant tumors. The ovaries showed some

degree of cortical stromal hyperplasia in 34 cases(49.3%) out of 69 cases, follicular cysts in 32 cases(46.4%) and 5 cases showed benign and malignant neoplasm.

From the data obtained by present investigation, the following conclusion can be made. The incidence of adenomyosis among Korean women is equivalent to those reported in the other contries. Multiparity can not be regarded as dominant etiologic factor in view of considerable cases in nulliparous women. Although these

all some evidence to suggest toward hyperesterinism, evidenced by higher incidence of endometrial hyperplasia, follicular cysts and cortical stromal hyperplasia of the ovaries, associated with adenomyosis, the evidences are still insufficient to attribute hyperesterinism as the major cause of adenomyosis. While ectopic

endometrial tissue usually does not respond to cyclic change, the formation of decidua in two cases indicate that it does respond to pregesterone if strong enough.