Clinico-pathological Assessment of Hysterectomies in Zaria

Aim: To assess and compare accuracy of the clinical indications and histopathological diagnoses from hysterectomy specimens in Zaria.

All hysterectomy specimens received in the department of Pathology, Ahmadu Bello University Teaching Hospital, Zaria from January 1995 to December 2005 were analyzed. The speci- mens were fixed in formalin, processed in paraffin wax and his- tology slides stained with haematoxylin and eosin were studied. Frequency of clinical indications were compiled and compared with histopathological diagnoses.

317 hysterectomies were analyzed. Of these 288 (90.9%) were associated with salpingo-oophrectomies. Median age of pa- tients’ was 45 years and mean age was 44.6 years. Parity of the women ranged from 0-11 with an average of 4. The clinical indications comprised non-neoplastic- 47 (14.8%) and neoplastic-226 (71.3%) causes. The commonest benign neoplastic indication was uterine fibroid 196 (61.8%). Malignant neoplastic in- dication included cervical cancer 12 (3.8%) and endometrial cancer 6 (1.9%). Cervical intraepithelial neoplasia (CIN), a preneoplastic lesion accounted for 44 (13.9%). Histopathological diagnosis of leiomyoma was made in 218 (68.8%), cervical cancer –20 (6.3%) and CIN- 49 (15.5%). Incidental pathologies seen included chronic cervi- citis -24, adenomyosis- 13 and cystadenoma – 8. Clinical indications in 14 (4.4%) patients were at variance with histological diagnosis.

The clinical indication for hysterectomy and histo - pathological outcome are comparable in over 90% of cases. The commonest indication and histological finding in our setting is leiomyoma. Key words: Hysterectomy, Indication, Pathology, Leiomyoma. Departments of Pathology1 and Obstetrics &Gynaecology2 Ahmadu Bello University Teaching Hospital, Shika- Zaria, Nigeria Eur J Gen Med 2009; 6(3): 150-153 Correspondence: Dr, MOA Soetan Samaila FMCPath Department of Pathology A.B.U.T.H, Zaria, Nigeria. Postal code: 810001 Fax no:+23469332271-2 Email: mamak97@ yahoo.com Mobile: +2348035891007 Samaila Modupeola OA1, Adesiyun AG2, Agunbiade OA2, Mohammed-Duro A2 151 Modupeola et al. European Journal of General Medicine

Women world wide suffer from gynaecologic and obstetric disorders that require hysterectomy as a treatment option (1-3). This may involve removal of the fallopian tube and ovary depending on clinical indication, age and parity of the woman (4). The pro- cedure is not well embraced in developing countries, in particular Nigeria due to socio cultural reasons (5). Thus, the clinical indication for the procedure should be justifiable. This study is a comparative assessment of the accuracy of clinical indication for hysterec - tomy and the histopathological outcome.

All hysterectomy specimens sent to the Department of Pathology, Ahmadu Bello University Teaching Hospital, Zaria over a period of 11 years (1995-2005) were studied. Specimens were received from in- pa- tients in the teaching hospital, general, private and federal medical center hospitals within and border- ing Zaria. These specimens were received in 10% formalin and processed in paraffin wax. Histology sections stained with haematoxylin and eosin (H&E) were studied. Relevant information on the clinical indication, age, parity and duration of symptoms of patients were retrieved from accompanying request cards. Histopathological diagnoses of these specimens were compared with the clinical indications for the procedure. All hysterectomies without histology re- port or where slides or tissue blocks could not be traced were excluded from the study.

317 hysterectomies were analysed. Of these 288 (90.9%) included a salpingo-oophrectomy. 26 (8.2%) cases were from outside the teaching hospital. Median age of patients’ was 45years and mean age was 44.6 years. The peak age for the procedure in these patients was the fifth decade (40-49 years) (Table 1). Parity of the women ranged from 0-11 with an aver- age of 4 and duration of symptoms ranged from six months to three years. The clinical indications comprised non-neoplastic-47 (14.8%), pre-neoplastic- 44 (13.9%) and neoplastic-226 (71.3%) causes (Table I). The commonest benign neoplastic clinical indication was uterine fibroid 196 (61.8%). Malignant neoplastic indication included cervical cancer 12 (3.8%) and en- dometrial cancer- 6 (1.9%). Histopathological diagnoses were categorized into non-neoplastic- (%), pre-neoplastic- (%) and neoplas - tic- (%) (Table 2). Table 1. Age groups and clinical indications. Indications Age in Years a. Nonneoplastic 20-29 30-39 40-49 50+ Total (%) Adenomyosis 0 2 4 0 6 (1.9) Pelvic pain 0 1 5 0 6 (1.9) Polyp 0 0 1 1 2 (0.6) UV prolapse 0 0 4 2 6 (1.9) Vaginal bleeding 0 2 10 3 15 (4.7) Uterine rupture 0 2 0 0 2 (0.6) Ovarian cyst 2 3 5 0 10 (3.2) Subtotal 2 10 29 6 47 (14.8) b. Pre-neoplastic Dysplasia 0 8 34 2 44 (13.9) c. Neoplastic Fibroid 0 29 126 41 196 (61.8) Ovarian tumour 1 1 3 0 5 (1.6) Cervical cancer 0 2 7 3 12 (3.8) Endometrial cancer 0 2 3 1 6 (1.9) Adenocarcinoma 0 0 2 2 4 (1.3) Choriocarcinoma 0 0 2 1 3 (0.9) Subtotal 1 34 143 48 226 (71.3) Total 3 52 206 56 317 Hysterectomies in Zaria European Journal of General Medicine152 Incidental pathologies seen included chronic cervi- citis -24, adenomyosis -13, cystadenoma -7 and hy - datidiform mole -3. Clinical indications in 14 (4.4%) patients were at variance with histological diagnosis.

Hysterectomy is a major surgical procedure which involves the total removal of the uterus with or with- out the fallopian tubes and ovaries (4). Many women in Africa and Nigeria in particular are reluctant to undergo this procedure because of the socio-cultural attachment to procreation and taboos associated with lack of menstruation (5). As such indication for the procedure must be cogent. Hysterectomy specimens accounted for 1.5% of all specimens received in our department within the study period. Reports on the incidence of hysterec - tomies ranges from 14.3% to 22.7% (1, 2,6-8). The low frequency rate in this review may be related to reluctance of our women to part with their uterus. Age and parity are factors usually considered before hysterectomy is performed in our setting (9). The peak age for the procedure was the fifth decade (40-49). Estimated age range is 31- 60 years (5,8,10- 12). The average parity in our study was four with a range of 0-11. Our finding is comparable with the 3-9 parity range reported in Ibadan, Western Nigeria (10). Twenty- five of the women were nulliparous. Gyna ecologists practicing in developing countries, in particular Nigeria are usually reluctant to perform hysterectomy in young nulliparous females except in advanced malignant diseases, unsuccessful myomec- tomy for uterine fibroids and uterine rupture which is a medical emergency (9,13). In developed countries, parity is not a limiting factor (1,2,10). The most frequent clinical indication was uterine fibroid, a disease with predilection for black wom- en. This correlated well with histologic findings of bundles of spindle cells having fairly uniform rod shaped nuclei arranged in predominant interlacing patterns in a fibrocollagenized stroma. 22 incidental leiomyomata were also found in specimens removed for other reasons. Many studies in Nigeria and oth- er parts of Africa have documented fibroid as the Table 2. Spectrum of histopathological diagnoses. Histological diagnosis Frequency a. Nonneoplastic Actual Incidental pathology Total Chronic cervicitis 8 24 32 Squamous metaplasia 0 10 10 Adenomyosis 6 13 19 Hydatidiform mole 0 3 3 Subtotal 14 50 64 b. Preneoplastic CIN 44 5 49 c. Neoplastic Leiomyoma 196 22 218 Thecoma 1 0 1 Cystadenoma 6 8 14 Mature teratoma 3 0 3 Cystadenocarcinoma 5 0 5 Dysgerminoma 1 0 1 Embryonal carcinoma 1 0 1 Squamous cell carcinoma 18 2 20 Leiomyosarcoma 4 0 4 Adenocarcinoma 4 2 6 Choriocarcinoma 2 1 3 Stromal sarcoma 1 0 1 Granulosa cell tumour 3 0 3 Subtotal 245 35 280 Total 303 90 393 153 Modupeola et al. European Journal of General Medicine leading indication for hysterectomy in Black African Women (8-11,13). Cervical intraepithelial neoplasia (CIN), a pre-neo - plastic disease which early detection impacts posi- tively on the incidence of cervical cancer was the second commonest clinically and histologically. Over 70% of the cases were high grade lesions histologi- cally. All the women with CIN as clinical indication were identified from prior cervical smear cytology. We thus, recorded a high degree of correlation with subsequent tissue specimen. Unfortunately, the cervi- cal cytology is not widely employed in our setting due to lack of awareness and socioeconomic factors (14,15). 5 incidental CIN lesions were recorded. Vaginal bleeding ranked a poor third in the clinical indication. Histology of these cases revealed cervical SCC in 6, endometrial cystic hyperplasia in 2, chronic cervicitis -5 and CIN- 2. All six SCC were advanced stage disease. Patients in our setting more often present late in the course of their disease (14). Of the 143 patients with neoplastic clinical indication, 11.9% was malignant. 5 of the women with malignant clinical indication had previous histological diagnosis. Incidental pathological findings ranged from seeming- ly innocuous chronic cervicitis, squamous metaplasia and hydatidiform mole to malignant diseases compris- ing, squamous cell carcinoma and choriocarcinoma. Clinical accuracy of 95.6% was observed. Of the 14 clinical indications at variance with histology, 12 (86%) did not require hysterectomy as the treatment of choice. In conclusion, the leading clinical indication for hys- terectomy and histological finding was leiomyomata. Over 90% of clinical indications compared well with histopathological outcome.

1. Harris WJ. Early complications of abdominal and vag- inal hysterectomy (Review). Obstet Gynaecol Survey 1995;50:795-805. 2. Bachmann GA. Hysterectomy: A critical review. J Reprod Med 1990;35:839-62. 3. Mayonda I. Total or subtotal abdominal hysterec- tomy for benign gynaecological disease. Review in Gynaecological practice 2003;3:26-31. 4. Campbell S, Monga A. Gynaecology by Ten Teachers. Campbell S, Monga A (edrs) ELST 17 th pg 53. 5. Ezem BU, Otubu JA. Hysterectomy in the Hausa/fulani population in Nigeria. Int J Gynecol Obstet 1981;19:145-9. 6. Carlson KJ. Outcomes of hysterectomy. Clin Obstet Gymaecol 1997;40:939-46. 7. Loft A, Anderson TF, Bronnum-Hansen H, Rocpstorff C, Madsen M. Early postoperative mortality following hysterectomy. A Danish population based study (1977- 1981). Br J Obstet Gynaecol 1991;98:147-54. 8. Emembolu JO. Uterine fibromyomata. Presentation and management in Northern Nigeria. Int J Gynaecol Obstet 1987;25:414-6. 9. Seffah JD, Adanu RMK. Hysterectomy for Uterine Fibroids in Nullipara at Korle Bu Teaching Hospital, Ghana. Trop J Obstet Gynaecol 2005;22:125. 10. Orji EO, Ndububa VI, Ajenifuja KO. Elective Hysterectomy in Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife. Sahel Med J 2002;5:125-8. 11. Roberts OA, Okunlola MA. Abdominal Hysterectomy for Benign Gynaecological Conditions at Ibadan, Nigeria. Trop J Obstet Gynaecol 2001;18:19-23. 12. Mackenzie I.Z. Reducing Hospital Stay after abdominal hysterectomy. Br J Obstet Gynaecol 1996;103:175-8. 13. Onwuhafua PI, Oguntayo A, Adesiyun G, Obineche I, Akuse JT. Audit of Hysterectomies in a Group of Private Hospitals in kaduna City, Northern Nigeria. Trop J Obstet 2005;22:16-20. 14. Anorlo RI, Banjo AA, Odomelun C, Egagle ME, Abudu OO. Cervical cancer screening, level of awareness in women attending a primary health care facility in Lagos. Nig Med J 2000;7:25-8. 15. Ayinde OA, Omigbodun AO. Knowledge, attitude and practices related to prevention of cancer of the cer - vix among female health workers in Ibadan. J Obstet Gynaecol 2003;23:59-62.