Clinical History
A 69-year-old post-menopausal woman presented with abnormal vaginal bleeding for three months. A transvaginal ultrasound showed endometrial thickening. Endometrial biopsy was performed. Pathological result was compatible with endometrioid endometrial cancer, G1.
Imaging Findings
A magnetic resonance (MRI) protocol for staging endometrial cancer was performed which included: axial T2-weighted images (T2WI) and diffusion-weighted images (DWI) sequences of the abdomen; axial T1-weighted images (T1WI), T2WI and DWI of the pelvis; sagittal T2WI of the pelvis; axial oblique (perpendicular to the endometrial cavity) T2WI and DWI; axial oblique dynamic multiphase and late phase contrast-enhanced (perpendicular to cervix) sequences.
MRI depicted an endometrial tumour, with 12 cm, distending the endometrial cavity and protruding through the external cervical os into the vagina, invading >50% of the depth of the myometrium. There were no signs of cervical stroma invasion. Neither suspicious lymph nodes were identified nor peritoneal metastasis were recognised. There were no adnexal abnormalities.
Surgical staging was performed, determining stage II disease. The pathological result was confirmed (endometrioid, G1). An endocervical polyp was identified, invaded by carcinoma.
External radiation therapy and vaginal brachytherapy was proposed.
Discussion
Endometrial polyps are the most common benign cervical growth, with an estimated incidence of up to 4% in gynaecologic patients. [1] This entity occurs more frequently in perimenopausal women, especially in the 5th decade of life. [2] It is assumed that they are the pathologic result of focal hyperplasia of the glandular epithelium. A possible link to oestrogen exposure is proposed, as it is often seen in association with endometrial hyperplasia. [1] Nearly 25% of the cases have a coexisting endometrial polyp. [1] 0.2%–1.5% of the cases are affected by malignancy or dysplasia and this is most common in the perimenopausal age group. [1]
We describe a case of a cervical polyp associated with endometrial cancer, which was invaded by neoplastic cells.
Cervical polyps are symptomatic in approximately 40% of the cases. [2] The presenting symptoms include intermenstrual bleeding, metrorrhagia, menorrhagia, postmenopausal bleeding, contact bleeding or vaginal discharge. [1, 2]
The diagnosis is primarily done by hysteroscopy. [2]
At ultrasound, polyps are usually hyperechoic. At colour / spectral Doppler, a feeding vessel / vascular stalk may be identified. [1, 3] The polyp is often mobile at real-time imaging, with transducer pressure. [1]
MRI may show a smooth-walled hyperintensity on T2WI with a central area of low signal intensity, which corresponds to the fibrous core. [3]
This entity may undergo cystic changes and present with different imaging features. [1]
In our case, the presence of the endometrial cancer was a confusing factor, leading to the interpretation of a prolapsed endometrial cancer in the vagina. Moreover, the fibrous stalk was not clearly depicted. Although not assumed to be a cervical polyp, it was presumed to be of malignant nature.
The management of cervical polyps usually includes polypectomy. A conservative approach is also possible in asymptomatic women with no concerning history and normal cervical cytology. Only women who presented with symptoms of abnormal bleeding or who were being evaluated colposcopically for abnormal Pap smear results had premalignant or malignant disease. [4] In our case the cervical polyp was removed as a result of surgical staging of endometrial cancer.
The stalk arises from the endocervical mucosa and extends into the polyp, confirming the endocervical origin. It is fundamental to identify the origin of the endocervical polyp, as endocervical and endometrial polyps are different histologic entities. [1]
Differential Diagnosis List
Endocervical polyp with endometrial carcinoma invasion
Prolapsed endometrial tumour into the vagina
Prolapsed endometrial polyp
Prolapsed intra-cavitary leiomyoma
Final Diagnosis
Endocervical polyp with endometrial carcinoma invasion
