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GIANT CERVICAL POLYPS: REPORT OF TWO CASES AND LITERATURE REVIEW

Wen-Yih Wu, Bor-Ching Sheu, Ho-Hsiung Lin* Department of Obstetrics and Gynecology, National Taiwan University College of Medicine and National Taiwan University Hospital, Taipei, Taiwan.

SUMMARY Objective: We report two patients with benign giant cervical polyps. Case Reports: A 47-year-old multiparous woman complained of a protruding mass from her for 6 months. On , there was a large cervical measuring 7 = 2.5 cm arising from the endocervix. The polyp was excised by electrocauterization at the base. The pathological report revealed no evidence of malignancy in the polyp. A 45-year-old nulligravid woman suffered from menorrhagia for 2 months and a mass protruding from the vagina was noted for 10 days. On pelvic examination, there were two cervical polyps. One was 5 = 2 cm and arose from the posterior lip of the and the other was 1 = 1 cm and arose from the right lateral lip. The polyps were excised by electrocauterization. The pathological report revealed benign cervical polyps. Conclusion: Giant cervical polyp is uncommon and malignancy has not been reported in the 11 cases in the literature. Excision was adequate for these lesions. [Taiwanese J Obstet Gynecol 2005;44(1):65–68]

Key Words: cervical disease, cervical polyp

Introduction are usually found at gynecologic pelvic examination. They are also found in women who present for evalua- Cervical polyps are relatively common lesions and most tion of intermenstrual or and for commonly present in perimenopausal and multigravid profuse . Polyps are painless and, un- women between the ages of 30 and 50 years [1]. The less a patient has a bleeding abnormality that necessi- incidence is 4–10% of all cervical lesions [2]. A cervical tates her to be evaluated by a physician, they go un- polyp is a growth protruding from the ectocervix or diagnosed until the next Pap smear is obtained. endocervical canal. Polyps that arise from the endo- Histologically, polyps are composed of endocervical are called endocervical polyps. If they epithelium with a fibrovascular stalk. Differential arise from the ectocervix, they are called cervical diagnoses include polypoid fragments of endocervical polyps. The polyps usually develop as a result of chronic carcinoma or carcinosarcoma protruding through the papillary endocervicitis. They are soft, spherical, glis- os, retained products of conception, grapelike swel- tening red masses and bleed easily when touched. lings of sarcoma botryoides that occasionally origi- Often, they are friable, and they may be associated with nate in the cervix, and prolapsing submucous fibroids or profuse secondary to the underlying endo- endometrial polyps [3]. . They are most commonly asymptomatic and Most cervical polyps can be grasped with a clamp and twisted free, and the base can be cauterized for hemostasis. During pregnancy, the cervix is highly *Correspondence to: Dr. Ho-Hsiung Lin, Department of Obstetrics vascularized. If the polyps are stable and benign-looking, and Gynecology, National Taiwan University Hospital, 7 Chung- they should just be observed during the pregnancy and Shan South Road, Taipei, Taiwan. removed only if they are causing bleeding. E-mail: [email protected] Although they are mostly benign, carcinomatous Received: March 5, 2004 Revised: March 23, 2004 change occurs in 1.7% of cervical polyps [2]. Some Accepted: March 23, 2004 cervical polyps are associated with malignant or pre-

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malignant lesions of the cervix or . Most without any communication with the endocervical ca- polyps are less than 1 cm in diameter; giant cervical nal. The other was 1.0 = 1.0 cm and originated from the polyps are rarely reported. In the literature, there is no right posterior lip of the ectocervix. There was no ex- clear definition of the size of a giant cervical polyp: the tension of the mass into the paracervix, paravagina, or smallest reported giant cervical polyp is 5 cm. We report . The , adnexa, and pelvic soft tissues two patients with giant cervical polyps. were freely movable without fixation. Pap smear showed inflammation but was negative for intraepithelial le- sion and malignancy. The cervical swab was negative Case Reports for human papilloma virus. There was no inguinal lymphadenopathy. The abdomen was free from palpable Case 1 masses. The two cervical masses were excised from the A 47-year-old gravida 2, para 2, woman complained of base by electrocauterization with minimal blood loss. a protruding mass from the vagina for 6 months. Her The specimen was sent for pathologic examination. was at the age of 14 and her menstrual Microscopically, both sections showed a cervical polyp interval was 30 days with a duration of 7 days. No dys- with focal squamous metaplasia. At the time of the 6- menorrhea or hypermenorrhea was noted. She had month follow-up, there was no recurrence. undergone tubal ligation 18 years earlier. Her family history was noncontributory. Pelvic examination revealed a 7.0 = 2.5 cm, pink, Discussion soft, pedunculated polypoid mass protruding from the vaginal introitus and extending beyond the vulva (Fig- Benign cervical polyps are encountered frequently but ure A). The pedicle originated from the endocervix. giant cervical polyps are rare. Only nine cases have There was no extension of the mass into the paracervix, previously been reported (Table 1) [4–12], although paravagina, or parametrium. A fixed egg-size mass was there is no clear definition about the size of a giant palpable in the uterus. The adnexa and the pelvic soft tis- cervical polyp. Patient ages range from 5 to 61 years sues were freely movable without fixation. There was no (mean, 32 years). Eight patients were nulliparous and inguinal lymphadenopathy. Transvaginal sonography three were multiparous. Two patients were postmeno- revealed a 4.0 = 4.0 cm intramural uterine myoma in pausal. Eight patients presented with an introital mass. the anterior uterine wall and both ovaries appeared nor- Additional symptoms included leukorrhea, abnormal mal. The mass was excised from the base by electro- bleeding, and vaginal discharge. In one pregnant patient, cauterization with minimal blood loss. The specimen the polyp protruded from the external os mimicking was sent for pathologic examination, which revealed a inevitable abortion [8]. Treatment included polypectomy polypoid, pink mass measuring 7.0 = 2.5 = 1.5 cm. Microscopically, it was a giant endocervical polyp with marked squamous metaplasia that exhibited marked hyperkeratosis and parakeratosis. Multiple surface AB erosions with acute and chronic inflammatory cell infiltration were also noted. The central core contained markedly ectatic congestive blood vessels.

Case 2 A 45-year-old nulligravid woman complained of menorrhagia for 2 months. Her menarche was at the age of 14 and her menstrual interval was around 30 days. She denied a history of surgery. She had noted a mass protruding from the vaginal introitus for 10 days. The mass bled easily without pain. Her family history was noncontributory. Pelvic examination revealed a pink, soft, polypoid mass protruding from the vaginal introitus and extending beyond the vulva (Figure B). There were two polyps originating from the ectocervix. A mass measuring 5.0 = Figure. Giant cervical polyp protruding from the vaginal 2.0 cm arose from the posterior lip of the ectocervix introitus: (A) Case 1; (B) Case 2.

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Table 1. Clinical features of patients with giant cervical polyps Age Introital mass Author Parity Additional symptoms Treatment (yr) (duration) Saier et al [4] 61 0 + (2 yr) Leukorrhea, PMB Polypectomy Lippert et al [5] 26 0 + Leukorrhea, urinary retention ARH+BSO+PLND Duckman et al [6] 56 3 + PMB Polypectomy, D&C, TAH+BSO Aridogan et al [7] 17 0 + (3 yr) Bleeding, discharge Polypectomy Adinma [8] 30 1 – 1st trimester bleeding for 2 wk Polypectomy Branger et al [9] 22 0 – None Polypectomy Gogus et al [10] 5 0 – Leukorrhea for 1 yr, Exploratory laparotomy, bloody discharge for 1 wk polyp resection Khalil et al [11] 27 0 + (2 d) Malodorous discharge for 2 yr Polypectomy, D&C Amesse et al [12] 12 0 + (1 mo) None Polypectomy Present case 47 2 + (6 mo) None Polypectomy Present case 45 0 + (10 d) Bleeding Polypectomy PMB = postmenopausal bleeding; ARH = abdominal radical hysterectomy; BSO = bilateral salpingo-oophorectomy; PLND = pelvic lymph node dissection; D&C = dilatation and curettage; TAH = total abdominal hysterectomy.

Table 2. Histopathologic features of giant cervical polyps Author Polyp location Size (cm) Microscopic description Diagnosis Saier et al [4] Ectocervix, 13 = 6 Endocervical mucosa with squamous Cervical polyp right anterior lip metaplasia Lippert et al [5] Ectocervix 17 = 12 = 4 Endocervical mucosa with squamous Endocervical polyp metaplasia Duckman et al [6] Ectocervix, 10 = 3.5 = 1.8 Squamous mucosa with ulceration Cervical polyp right posterior lip Aridogan et al [7] Ectocervix 14 = 4 = 3.5 Squamous mucosa with ulceration Cervical polyp Adinma [8] External cervical os 5 = 1 = 0.5 Not reported Cervical Polyp Branger et al [9] Not reported 15 Squamous mucosa with pseudo-papillary Cervical polyp proliferations; chronic inflammation Gogus et al [10] Endocervix, 5 = 4 = 1.5 Endocervical mucosa with squamous Multiloculated posterior midline metaplasia endocervical polyp Khalil et al [11] Endocervix, 17 = 10 = 5 Fibrovascular tissue with endocervical Giant cervical polyp anterior lip glands Amesse et al [12] Ectocervix, 5.2 = 2.2 = 1.4 Squamous mucosa admixed with Cervical polyp right anterior lip endocervical mucosa Present case Endocervix, 7 = 2.5 = 1.5 Endocervical mucosa with squamous Endocervical polyp posterior midline metaplasia Present case Ectocervix, 5 = 2 = 0.7 Endocervical mucosa with focal Cervical polyp posterior lip squamous metaplasia in nine patients and polyp resection in one. Radical The histopathologic features of the reported cases hysterectomy, bilateral salpingo-oophorectomy, and of giant cervical polyp are summarized in Table 2. pelvic lymphadenectomy were performed in one patient Polyps originated from the ectocervix in eight cases and because the clinician’s impression was cervical ma- from the endocervix in two. The location of the giant lignancy [5]. One patient underwent total abdominal cervical polyp was not reported in one case. The size of hysterectomy and bilateral salpingo-oophorectomy due the polyps ranged from 5 to 17 cm. Usually, the gross to [6]. Another patient un- morphology was a polypoid pink mass with a long derwent exploratory laparotomy and polyp resection pedicle originating from the ectocervix. Microscopi- through an incision in the lower uterine segment be- cally, the most common description of the surface was cause the polyp extended into the endometrial cavity squamous mucosa or endocervical epithelium with with subsequent uterine enlargement and the clinical squamous metaplasia. Chronic inflammatory cells impression was rhabdomyosarcoma [10]. infiltrated the fibrous stroma and prominent vessels

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were often noted. Eight cases were diagnosed as cervical less the pathologic examination indicates malignancy. polyps and three as endocervical polyps. They were all histologically benign in spite of their grossly malignant appearance. References Cervical polyps are relatively common lesions. They are thought to be the result of reactive changes from 1. Danakas GT. Cervical polyps. In: Ferri FF. Ferri's Clinical long-standing chronic inflammation. Other suggested Advisor. Instant Diagnosis and Treatment. St. Louis: Mosby Inc, 2003:195. factors include multiparity and foreign bodies [7]. 2. Israel SL. A study of cervical polyps. Am J Obstet Gynecol 1940; Amesse et al pointed out that giant cervical polyps exhi- 39:45–50. bit distinct clinical and pathologic features, suggesting 3. Sheets EE. The cervix. In: Ryan KJ, Berkowitz RS, Barbieri RL, that they may represent an uncommon variant of the Dunaif A. Kistner's Gynecology & Women's Health, 7th edition. classical cervical polyp [12]. Most cervical polyps are St. Louis: Mosby Inc, 1999:98–9. incidental findings, but giant cervical polyps often 4. Saier FL, Hovadhanakul P, Ostapowicz F. Giant cervical present as a protruding introital mass with vaginal polyp. Obstet Gynecol 1973;41:94–7. bleeding. Their site of origin is usually the ectocervix, in 5. Lippert LJ, Richart RM, Ferenczy A. Giant benign endocervi- cal polyp: report of a case. Am J Obstet Gynecol 1974;118: contrast to the endocervical location of most cervical 1140–1. polyps. Their relatively large size and grossly polypoid 6. Duckman S, Suarez JR, Sese LO. Giant cervical polyp. Am J appearance may mimic a malignant . Khalil Obstet Gynecol 1988;159:852–4. et al noted that giant cervical polyps tend to occur in 7. Aridogan N, Cetin MT, Kadayifci O, Atay Y, Bisak U. Giant nulligravid rather than multiparous women because of cervical polyp due to a foreign body in a “virgin”. Aust NZ J a possible delay in seeking medical attention [11]. Obstet Gynaecol 1988;28:146–7. Aridogan et al reported the longest duration (3 years) 8. Adinma JI. Cervical polyp presenting as inevitable abortion. Trop Doct 1989;19:181. among the reported cases and the final diagnosis was 9. Branger C, Dreher E, Burkhardt A, Schmuckle U. Giant polyp still benign cervical polyp [7]. In the 11 reported cases, of the cervix. Geburtshilfe Frauenheilkd 1991;51:148–9. [In all giant cervical polyps were histologically benign. German] Duckman et al suggested that primary treatment of 10. Gogus S, Senocak ME, Arda IS, Buyukpamukcu N, Akcoren this tumor should be excision unless the pathology Z. Multilocular endocervical polyp in a five-year-old girl. report of the excised specimen indicates malignancy Pediatr Pathol 1993;13:415–9. [6]. Khalil et al stated that biopsy of these tumors prior 11. Khalil AM, Azar GB, Kaspar HG, Abu-Musa AA, Chararah IR, to excision may not be necessary [12]. Seoud MA. Giant cervical polyp. A case report. J Reprod Med 1996;41:619–21. In summary, giant cervical polyps usually present 12. Amesse LS, Taneja A, Broxson E, Pfaff-Amesse T. Protruding as protruding introital masses with giant cervical polyp in a young adolescent with a previous in nulligravidas. They commonly originate from the rhabdomyosarcoma. J Pediatr Adolesc Gynecol 2002;15: ectocervix. Primary treatment should be excision un- 271–7.

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