An Unusually Large Fibroepithelial Polyp of Uterine Cervix: Case Report and Review of Literature.

BACKGROUND: Fibroepithelial cervical polyps (FEPs) are benign growths protruding from the inner surface of the cervix. They are typically asymptomatic, but a very small minority can undergo malignant change. Giant cervical polyps with a size greater than 4 cm are rare entities with only 23 reported cases in the literature. Cervical polyps develop as a result of focal hyperplasia of the columnar epithelium of the endocervix. CASE
PRESENTATION: We present the case of a giant fibroepithelial polyp measuring approximately 11 x 6 x 4 cm which was protruding from the anterior lip of the uterine cervix in a 51-year-old woman who clinically presented vaginal bleeding. She was nulligravida and doesn't have a child. The speculum examination revealed a soft, mobile, painless irregular cerebriform mass on the cervix, protruding through the vagina. The polyp was excised using a scalpel, and the pedicle was sutured using the Vicryl 1-0 under short-term intravenous anaesthesia. Histopathological examination revealed a polypoidal tumour mass composed of cellular fibrovascular stroma covered with stratified squamous epithelium. Three months after the initial surgery, there was no recurrence seen.
CONCLUSION: Cervical giant polyps are rare entities and occur mostly in perimenopausal women. Transvaginal polypectomy, as performed for this patient followed by histopathological examination is an adequate procedure for these lesions.

Introduction

Fibroepithelial cervical polyps are polypoid growths projecting into the cervical canal. They can be one of the most common causes of intermenstrual vaginal bleeding. Polyps are almost always benign. The sparse literature available suggests rates of 0.0 – 1.7% malignant change in cervical polyps [1]. Although fibroepithelial stromal polyps of the lower female genital tract have been well-recognised since their initial description, they still pose diagnostic difficulties mainly owing to their variable histological appearances and rarity [2]. The incidence is about 4 to 10% of all cervical lesions. The polyps usually develop as a result of chronic papillary endocervicitis. They are soft, spherical, glistening red masses and bleed easily when touched. Often, they are friable, and they may be associated with profuse leukorrhea secondary to the underlying endocervicitis [3]. They are most present as an asymptomatic finding upon pelvic examination. They are also found in women who present for intermenstrual or postcoital bleeding, dyspareunia, lower abdominal discomfort and profuse vaginal discharge [4]. Most polyps measure < 1 cm in diameter. Giant cervical polyps measuring > 4 cm are rare, and to date, only 23 cases have been reported [5], [6]. They occur in adult women, rarely are in adolescents and frequently interpreted as malignant neoplasm at the time of the presentation [6]. In this study, we present a case of a giant fibroepithelial polyp of the uterine cervix in a premenopausal woman.

Case Presentation

A 51-year-old nulligravida woman presented with three months history of large, soft, painless, pedunculated mass measuring 11 x 6 x 4 cm protruding from the vagina (Figure 1).

Figure 1

Cystiform polyp protruding from the vagina

The pedicle originated from the endocervix. The mass was non-pulsatile, non-reducible, with not prolapsing upon coughing. There was no increase in the size of the mass with Valsalva manoeuvre. There were no signs of ulceration or inflammation. The patient described a menstrual cycle not related to the cycle, and the vaginal bleeding sometimes appeared suddenly. Her menarche was at the age of 13, and the duration of her menstrual cycle was 28 days with 6-days mensis. She never used hormonal therapy and had no past medical or surgical history. She never had been pregnant and had not a child. She is married, sexually active, and her last menstrual period was 5 months before. Medical history and laboratory results were unremarkable. Examination of her breasts, vulva and vagina did not reveal any abnormalities. There was no inguinal lymphadenopathy. The trans-abdominal sonography upon admission, showed an anteverted uterus, with normal age features and thin endometrium. Both ovaries were of normal anatomy. A cytological smear of the cervix showed normal endocervical and ectocervical cells with chronic inflammation. Polypectomy was performed under short intravenous general anaesthesia with the informed consent of the patient and with the procedure details. A Kelly clamp was placed to the tumour base, and the mass was excised (Figure 2).

Figure 2

The polyp after excision

The basis of the removed tumour was ligated with 1-0 Vicryl suture and hemostasis was achieved. Endometrial curettage was also done. The tumour was sent for pathologic examination, which revealed a polypoid pink mass measuring 11 x 6 x 4 cm. with a macroscopic appearance of three coupled cystic formations of which one was perforated (Figure 3).

Figure 3

Three coupled cystic formations

On the dissection of the tumour, it was seen that the tumour wall was thin and composed of several cavities of different sizes filled with a thick sticky mass (Figure 4).

Figure 4

The dissection of the tumour

Microscopically, the most characteristic feature of the fibroepithelial polyp was present. The histopathologic examination revealed a fibro-collagenous tissue in the stroma, thickened blood vessels, fibroblasts, and chronic inflammatory perivascular infiltrate covered with columnar cervical. All cavities were distended with Nabothian cysts, coated with columnar much-secretory epithelium (Figure 5, A and B).

Figure 5

A) HE x 20. Fibrocollagenous stroma covered; B) He x 40. The stroma of the polyp with a cystic cavity by stratified squamous epithelium

Uterine curettage confirmed simple columnar epithelium without malignant changes. The patient’s postoperative recovery was uneventful, with vaginal bleeding ceasing.

Discussion

Polyps are benign lesions and may represent a reactive hyperplastic process of subepithelial myxoid stroma and misdiagnosed as malignant. Polyps are usually small, soft, spherical and asymptomatic lesions [7], but large polyps can present with a lot of discomfort symptoms like a lower abdominal pain, abnormal vaginal discharge, intermittent bleeding and introitus mass [8]. We present the case of a giant cervical polyp was the first case in our centre in the past 20 years; thus, confirming its rarity. The symptoms of a painless mass protruding through the vagina with discharge and bleeding in our case was consistent with that reported in the literature [9], [10]. Only 22 cases of giant cervical polyps have been reported so far [11], and there is no case reported from North Macedonia. All the reported cases of giant cervical polyps were benign and thought to be the result of reactive changes from long-standing chronic inflammation [5], which corresponds with our case. Thus, it has been suggested that biopsy of these tumours before excision may not be necessary [9].

Previous reports indicate that giant cervical polyps originate more often from the ectocervix and rarely from the endocervix [11]. In our patient, the base of the polyp extended from the endocervix and protruding from the vaginal introitus. Most of the reported cases were nulliparous [6], [12] ranging between age 5-61 years old. In our case, the woman was nulliparous, in premenopausal with 5 months period of menstrual missing and above 51 years age.

The treatment of choice is surgical excision of the polyp with carefully obtained hemostasis. Some authors reported undertaking vaginal or abdominal hysterectomy because of endometrial hyperplasia and clinical suspicion of malignancy [5,13]. At histologic analysis, the tumour was diagnosed as a fibroepithelial cystic polyp.

In conclusion, giant cervical fibroepithelial polyps are rare benign tumours, presenting as protruding introital masses with vaginal bleeding in perimenopausal women. Thus, a wide range of morphological appearance of FEPs needs expert pathological interpretation to exclude atypical tumours and malignant pathology. The treatment is surgical and definitive diagnosis is verified by histological analysis.