Definition/General

Introduction:
-Cervical fibroids (cervical leiomyomas) are benign smooth muscle tumors arising from the cervical smooth muscle
-They account for approximately 5-10% of all uterine leiomyomas and can cause significant clinical symptoms.
Origin:
-Arise from smooth muscle cells within the cervical wall
-May develop from vascular smooth muscle or from primitive mesenchymal cells that differentiate into smooth muscle.
Classification:
-WHO Classification categorizes as benign smooth muscle tumor (leiomyoma)
-May be pedunculated, intramural, or subserosal
-Similar to uterine leiomyomas but with cervical location.
Epidemiology:
-Less common than uterine corpus fibroids
-Peak incidence 30-50 years
-More common in African American women
-Associated with hormonal factors (estrogen, progesterone).

Clinical Features

Presentation:
-Palpable cervical mass
-Abnormal vaginal bleeding
-Dyspareunia
-Urinary symptoms due to mass effect
-May cause cervical elongation or distortion.
Symptoms:
-Abnormal uterine bleeding (menorrhagia, metrorrhagia)
-Pelvic pressure or pain
-Dyspareunia
-Urinary frequency or retention
-Constipation
-Infertility.
Risk Factors:
-Reproductive age
-African American ethnicity
-Nulliparity
-Obesity
-Family history
-Early menarche
-Hypertension
-Diet high in red meat.
Screening:
-Pelvic examination reveals enlarged, irregular cervix
-Ultrasound shows hypoechoic mass
-MRI provides detailed anatomy
-Hysteroscopy may be needed.

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Gross Description

Appearance:
-Well-circumscribed, firm, white to tan colored masses
-Cut surface shows whorled pattern characteristic of smooth muscle
-May be single or multiple.
Characteristics:
-Size variable (few cm to >10 cm)
-Firm, rubbery consistency
-White to tan color
-Whorled, fascicular cut surface
-Well-demarcated borders.
Size Location:
-Can arise from any part of cervix
-May be intramural, subserosal, or pedunculated
-Can cause cervical enlargement and distortion.
Multifocality:
-May be solitary or multiple
-Often associated with uterine corpus leiomyomas
-Can have different sizes within same patient.

Microscopic Description

Histological Features:
-Composed of mature smooth muscle cells arranged in interlacing fascicles
-Cells have elongated, cigar-shaped nuclei and eosinophilic cytoplasm
-Minimal mitotic activity.
Cellular Characteristics:
-Spindle-shaped smooth muscle cells
-Elongated nuclei with blunt ends
-Abundant eosinophilic cytoplasm
-Well-defined cell borders
-Minimal nuclear atypia.
Architectural Patterns:
-Interlacing fascicles of smooth muscle cells
-Whorled pattern in some areas
-Variable amounts of fibrous tissue
-Blood vessels throughout.
Grading Criteria:
-Benign tumor (no grading system)
-Distinguished from leiomyosarcoma by low mitotic count (<5/10 HPF), lack of necrosis, minimal atypia.

Immunohistochemistry

Positive Markers:
-Smooth muscle actin (SMA) positive
-Desmin positive
-Caldesmon positive
-Estrogen receptor (ER) positive
-Progesterone receptor (PR) positive.
Negative Markers:
-CD117 (c-kit) negative
-CD34 negative
-S100 negative
-Cytokeratin negative
-EMA negative.
Diagnostic Utility:
-SMA and desmin confirm smooth muscle differentiation
-Caldesmon helps distinguish from other spindle cell tumors
-Hormone receptors support leiomyoma diagnosis.
Molecular Subtypes:
-No specific molecular subtypes
-Hormone-responsive tumors similar to uterine leiomyomas.

Molecular/Genetic

Genetic Mutations:
-Similar to uterine leiomyomas: MED12 mutations (70%), HMGA2 rearrangements, FH mutations
-Chromosomal abnormalities including del(7q), t(12;14).
Molecular Markers:
-Hormone receptors (ER, PR) expressed
-Ki-67 proliferation index typically low (<1%)
-Normal p53 expression
-Smooth muscle markers positive.
Prognostic Significance:
-Excellent prognosis as benign tumor
-May recur if incompletely excised
-Malignant transformation extremely rare (<0.1%).
Therapeutic Targets:
-Hormonal therapy (GnRH agonists, selective estrogen receptor modulators)
-Surgical excision (myomectomy, hysterectomy)
-Uterine artery embolization.

Differential Diagnosis

Similar Entities:
-Cervical leiomyosarcoma
-Inflammatory myofibroblastic tumor
-Solitary fibrous tumor
-Cervical sarcoma
-Gastrointestinal stromal tumor (GIST).
Distinguishing Features:
-Leiomyoma: low mitoses, no necrosis, minimal atypia
-Leiomyosarcoma: high mitoses (>5/10 HPF), necrosis, significant atypia
-GIST: CD117+.
Diagnostic Challenges:
-Cellular leiomyoma may have increased cellularity
-Atypical leiomyoma shows nuclear atypia but low mitoses
-Size and location can complicate diagnosis.
Rare Variants:
-Cellular leiomyoma
-Epithelioid leiomyoma
-Myxoid leiomyoma
-Atypical leiomyoma (symplastic leiomyoma).

Sample Pathology Report

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Sample Pathology Report

Complete Report: This is an example of how the final pathology report should be structured for this condition.

Specimen Information

[specimen type], measuring [size] cm in greatest dimension

Diagnosis

[diagnosis name]

Classification

Classification: [classification system] [grade/type]

Histological Features

Shows [architectural pattern] with [nuclear features] and [mitotic activity]

Size and Extent

Size: [X] cm, extent: [local/regional/metastatic]

Margins

Margins are [involved/uninvolved] with closest margin [X] mm

Lymphovascular Invasion

Lymphovascular invasion: [present/absent]

Lymph Node Status

Lymph nodes: [X] positive out of [X] examined

Special Studies

IHC: [marker]: [result]

Molecular: [test]: [result]

[other study]: [result]

Prognostic Factors

Prognostic factors: [list factors]

Final Diagnosis

Final diagnosis: [complete diagnosis]