Case Report
Veterinarni Medicina, 53, 2008 (11): 636640
Incidental finding of uterine adenomyosis in a bitch
with reproductive disorders: a case report
C.C. Perez-Marin, L. Molina, J.M. Dominguez, Y. Millan,
J. Martin de las Mulas
Veterinary Faculty, University of Cordoba, Spain
ABSTRACT: Uterine adenomyosis, a disease not widely addressed in dogs, is characterised by the progressive
penetration of endometrial glands and stroma into the myometrium, together with smooth-muscle hyperplasia.
This report describes a case of adenomyosis in an 8-year-old German Shepherd bitch with mammary tumours,
concomitant with cystic ovarian disease and endometrial cystic hyperplasia. Clinical signs included presence of
small nodules and enlargement of mammary glands, and bloody uterine discharge. Ultrasonography confirmed the
uterine and ovarian abnormalities, while the diagnosis was later confirmed by histopathological examination. The
findings are discussed as possibly related to the reproductive disorders observed, and a hypothetical participation
of hormonal factors, as has been described in woman, is suggested. However, further studies must be realized.
Keywords: adenomyosis; ovarian cysts; mammary tumour; infertility
Uterine adenomyosis is a non-neoplastic lesion
resulting from the abnormal down-growth of the
endometrial glands and endometrial stroma into
the myometrium (Kennedy et al., 1998). Although
it is a rare, sporadic disorder in dogs (Tamada et al.,
2005), it is much more common in women.
Uterine adenomyosis results in no symptoms during
much of its development, and is usually diagnosed in
adult dogs. Since it is generally found as an incidental
lesion in pathological changes of the uterus including endometritis, pyometra and glandular-cystic hyperplasia it tends to be investigated as a histological
finding rather than a clinical disorder. Adenomyosis
has recently been associated with infertility in humans (Barrier et al., 2004; Matalliotakis et al., 2005),
although little is known of the precise mechanisms
involved. Possible causes of adenomyosis in women
include defects in the formation of the myometrium
(Parrott et al., 2001), an abnormal immune response
in the endometrium (Ota et al., 1998), surgery and
hormone manipulation (Mori and Nagasawa, 1989,
Baskin et al., 2002), and age (Barrier et al., 2004).
Diagnosis of adenomyosis in animals is always
post-surgical, since the diagnostic techniques
used in humans, such as the measurement of serum cancer antigen 125 (CA 125) levels (Halila et
al., 1987), hysterosalpingography (Marshak and
Eliasoph, 1955) and magnetic resonance imaging
(Bazot et al., 2001) are not used in canine veterinary practice.
This paper reports a case of adenomyosis diagnosed from a tissue specimen taken from a bitch
with cystic endometrial hyperplasia, ovarian cysts
and ovarian papillary cystadenoma, together with a
previously-diagnosed mammary carcinosarcoma.
Case history
An 8-year-old nulliparous German Shepherd bitch
was admitted to the University of Cordoba, Veterinary
Clinic after the owner noticed a number of mammary
nodules. Vital signs were normal except for a mild
increase in temperature (39.2C). Blood biochemistry
and metabolic tests were normal, with the exception
of mild leukocytosis (Table1). Physical examination
revealed bilateral mammary tumours, involving the
caudal abdominal (enlarged) and inguinal mammary
Supported by the Consejeria de Innovacion, Ciencia y Empresa, Junta de Andalucia, Spain (Research Group Project
BIO287).
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Veterinarni Medicina, 53, 2008 (11): 636640
Case Report
Table1.Biochemical and haematological parameters
Parameter
Values
Reference values
WBC
13.8103l
612103l
RBC
7.53106l
5.08.0106l
HGB
18g/dl
1117g/dl
HCT
49%
3750%
MCV
69.2fl
6077fl
MCH
23.9pg
2025pg
34.5g/dl
3236g/dl
MCHC
PLT
16710 l
200400103l
Urea
32mg/dl
2040mg/dl
Creatinin
1.2mg/dl
0.51.3mg/dl
7.6g/dl
6.07.5g/dl
Fibrinogen
200 mg/dl
100400 mg/dl
Glucose
91 mg/dl
60115 mg/dl
Total proteins
WBC = white blood cells; RBC = red blood cells; HGB = hemoglobin; HCT = hematocrit; MCV, mean corpuscular volume;
MCH = mean corpuscular hemoglobin; MCHC = mean corpuscular hemoglobin concentration; PLT = platelets
glands of the right chain, and the abdominal and
inguinal mammary glands of the left chain (smaller
tumour masses). Laterolateral thoracic radiographs
revealed no pulmonary metastases and surgical resection of both mammary chains was decided upon
as the course of action. Histological examination of
the right mammary chain, the first to be removed,
confirmed malignant disease; one tumour was diagnosed as a carcinosarcoma (Figure1 and 2).
Bloody vulvar discharge which the owner associated with the heat period was observed one
month later, one day prior to the second operation
(resection of the left mammary chain). The vaginal
smear comprised mainly intermediate and superficial cells showing signs of keratinization with occasional endometrial cells. Vaginal disorders were
not considered during the clinical exploration.
Subsequent abdominal ultrasonography showed
Figure 1. Mammary carcinosarcoma (hematoxylin-eosin, 40) showing rounded neoplastic
epithelial cells with rounded-to-ovoid, vesicular nuclei, marked nucleoli and high-grade
atypia. Myoepithelial cells with high-grade
atypia
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Case Report
Veterinarni Medicina, 53, 2008 (11): 636640
Figure 2. Resected mammary chain
Figure 3. Left: ultrasonograph of cystic ovary (anechoic);
right: kidney for purposes of comparison
that both ovaries were abnormal in size, with
large anechoic structures; ovarian cystic disease
was diagnosed (Figure 3). Uterine ultrasonography
findings were consistent with endometrial cystic
hyperplasia (Figure 4). In the light of these findings,
ovariohysterectomy was performed in addition to
the programmed mastectomy. At gross examination, numerous cysts were visible on the ovaries.
One ovary displayed a brownish-black, morulalike multilobar lesion, measuring 3.5 2.5 2cm
and containing solid, chocolate-coloured material (Figure 5). A bleeding cyst was also observed,
comprising several thin-walled cavities containing
a translucent fluid. A large, thin-walled, multilobar
cyst containing amber-coloured material was observed. The cervix was slightly enlarged (approx.
50 mm).
Microscopic examination disclosed a highly-edematous endometrial mucosa, which hindered interpretation of possible hyperplasia; endometrial cysts with
fluid retention were also observed. The cervical mucosa
lamina propria displayed chronic inflammatory infiltrate and cystic glandular dilation; evidence of fibrosis
among muscle-fiber bundles suggested a possible cause
of enlargement. Glandular structures surrounded by
endometrial stroma were visible in the cornual and
cervical myometrium (Figure 6). This finding enabled
diagnosis of adenomyosis.
Figure. 4. Echoic uterus containing anechoic cysts,
indicative of endometrial cystic hyperplasia
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DISCUSSION
In the present case, uterine adenomyosis was an incidental finding in a bitch with mammary tumours and
Figure 5. Ovary showing brownish-black multilobar lesion
containing solid, chocolate-coloured material, with a thinwalled, bleeding cyst containing translucent fluid
Veterinarni Medicina, 53, 2008 (11): 636640
Case Report
Figure 6. Cervix. Mild chronic inflammatory infiltrate in mucosal lamina propria;
cystic glandular dilation; fibrosis among
smooth-muscle-fiber bundles (hematoxylin-eosin, 4)
ovarian cystic disease. In studies with mice, Nagasawa
et al. (1987) and Nagasawa and Kusakawa (2001) suggested a possible link between mammary tumours
and uterine adenomyosis: the two disorders develop
simultaneously pointing to a powerful genetic, as well
as environmental, influence. The joint presence of the
two disorders here indicates that the clinical signs as
a whole may have a hormonal aetiology.
The literature contains three reports of canine adenomyosis, in which clinical signs were only apparent
at an advanced stage (Stocklin-Gautschi et al., 2001;
Tamada et al., 2005) (Table 2). Although adenomyosis
is certainly found in numerous cases of uterine pathology, the present case study suggests a link among
adenomyosis, mammary tumour and ovarian cystic
disease, perhaps mediated by the influence of oestrogen hormone associated with polycystic ovaries.
Although the mechanism responsible for uterine
adenomyosis is not known, research in women has
suggested a link between changes in the endometrium and in ovarian hormones, and increased local production of oestrogen (Leyendecker, 2006).
Oestrogen-related hyperperistalsis together with
a progesterone-induced increase in intrauterine
pressure might result in myometrial dehiscencies
that are infiltrated by basal endometrium with the
secondary development of peristromal muscular
tissue. This would lead to diffuse or focal adenomyosis of varying extent, and local aromatase production would contribute to the proliferation of lesions
through local oestrogen synthesis (Ferenczy, 1998;
Leyendecker, 2006). This is why adenomyosis may
constitute a progressive disease. With regard to the
impact of adenomyosis on fertility, the most likely
explanation is the impairment of uterine mechanisms of rapid and sustained sperm transport as a
consequence of the destruction of normal uterine
architecture (Leyendecker, 2006).
Table 2. Findings in the present case study, compared with reports of canine uterine adenomyosis in the literature
Reference
Hormone Cervix involvetreatment
ment
Other
pathologies
Vaginal
discharge
yes
OCD
CEH
purulent
no
yes
OCD
cervical
enlargment*
bloody,
milky,
mucosa
no
yes
no
uterine torsion
no, tense
abdomen
Age
Breed
Weight
Litters
Tamada et al., 2005
13
Shiba-inu
5.9
no
Stocklin-Gautschi et
al., 2001
10
Crossbred
41
no
Stocklin-Gautschi et
al., 2001
12
Toy Poodle
4.5
no
*the remainder of the uterus was normal
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Case Report
Here, the joint presentation of endometrial hyperplasia with cysts suggested that adenomyosis may
perhaps be due to an endocrine impairment. Ovarian
hormones are known to favour the development of
mammary tumours; thus, early ovariectomy has been
found to limit tumour development (Schneider et al.,
1969). However, the aetiology of uterine adenomyosis
remains unclear, and the disorder is rarely addressed
in the literature. Reported symptoms vary widely,
which is suggestive of a multifactorial aetiology.
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Received: 20080813
Accepted: 20081123
Corresponding Author:
Carlos C. Perez Marin, University of Cordoba, Veterinary Faculty, Department of Animal Medicine and Surgery,
140-14 Cordoba, Spain
Tel. +34 957 218 716, fax +34 957 211 093, e-mail: pv2pemac@uco.es
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