Florid polypoid endometriosis of the cervix with left ureteric obstruction: a mimic of cervical malignancy

Abstract

Polypoid endometriosis, in contrast to typical (nonpolypoid) CASE REPORTA 48-year-old nulliparous Chinese woman, who had undergone subtotal hysterectomy and left salpingooophorectomy for uterine adenomyosis and left ovarian endometriotic cyst 4 years previously, presented with heavy vaginal bleeding. Clinical examination showed an enlarged cervix. A cervical (Papanicolaou) smear was performed and was normal.Ultrasound examination showed a 4.0-cm heterogeneous cervical mass with internal vascularity and irregular polypoid extension into the left parametrium and causing left hydroureter, suspicious for cervical tumor (Figure 1a). Magnetic resonance imaging (MRI) of the pelvis revealed a 4.0 × 3.5 × 5.5-cm polypoid mass in the endocervical canal, isointense on T1-weighted imaging and heterogeneously hyperintense on T2-weighted imaging, with delayed contrast enhancement (Figure 1b). Polypoid extension into the left parametrium was noted, involving the distal left ureter and resulting in severe hydronephrosis with marked thinning of the left renal cortex. There was no invasion into the rectal lumen or urinary bladder.Examination under anesthesia showed a 3.5-cm mass in the cervical canal. Tru-cut needle biopsy of the mass showed focally ulcerated polypoid endocervical mucosa with dilated glands, granulation and thick-walled vessels but no evidence of malignancy. There was also induration of the parametria, although not involving the pelvic sidewalls. Cystoscopy and sigmoidoscopy were negative for malignancy. The patient was advised to undergo removal of the endocervical mass for symptom control.At laparotomy, an enlarged cervical stump was found with a polypoid mass in the cervical canal. There were dense fibrotic adhesions to the rectum, urinary bladder and left ureter, resulting in left hydronephrosis with pyuria. After adhesionolysis, the cervical stump was excised with the endocervical polypoid mass. Left ureterolysis and antegrade stenting were performed. The patient made an uneventful recovery and was discharged in good health.The excised cervix measured 5.0 × 3.5 × 5.5 cm and contained a 4.0 × 3.0 × 5.0-cm polypoid lesion with histological features of polypoid endometriosis. The cervical stroma was expanded by irregularly distributed islands of endometrial glands and stroma involving the entire thickness of the cervical wall, extending into the left parametrium. In some of these islands, the glands were cystically dilated and some contained intraluminal polypoid masses of endometrial tissue with features resembling endometrial polyps. The stromal component was transmural and displayed 'pseudoinfiltrative' growth but the cells showed very little mitotic activity and no features of invasion were identified. On histology, samples from around the left ureter showed dense fibrous tissue with florid endometriosis. The right ovary showed features of burnt-out endometriosis.

Fine Needle Aspiration Cytology: A Tool to Diagnose Cervical and Vaginal Endometriosis in Low-Income Places

“…Cases of florid polypoid lesions, sometimes with an Arias-Stella reaction, have been described [20]. In all of our cases, cervical and vaginal endometriosis was identified during colposcopy.…”

“…Coelomic metaplasia and vascular dissemination are two other theories for the pathogenesis of cervical endometriosis [19]. Some unusual cases of florid polypoid endometriosis have been described in the cervix [20]. …”

Vaginal Polypoid Endometriosis Simulating Neoplasia in a Young Woman

“…Another case of bladder polypoid endometriosis mimicking cancer in a pregnant woman and a case of cervical polypoid endometriosis involving parametria and 1 ureter mimicking cancer has also been reported [8,9].…”

US of the Nongravid Cervix with Multimodality Imaging Correlation: Normal Appearance, Pathologic Conditions, and Diagnostic Pitfalls

“…The pathogenesis of cervical endometriosis is unclear, but it is hypothesized to be the result of traumatic disruption of the mucosa, permitting implantation of cast-off endometrial fragments (84,85). Superficial cervical endometriosis may be an incidentally detected histologic finding in asymptomatic women (84,86), but cervical endometriosis also may manifest as a cervical mass, with symptoms of pelvic pain or abnormal vaginal bleeding (87). A variety of mani- festations of cervical endometriosis have been reported at US, ranging from a complex cystic mass to a solid-appearing lesion with extension into the paracervical tissues, potentially producing a US appearance that is similar to that of other entities, including leiomyomas, polyps, and carcinoma (84,87,88).…”

“…Superficial cervical endometriosis may be an incidentally detected histologic finding in asymptomatic women (84,86), but cervical endometriosis also may manifest as a cervical mass, with symptoms of pelvic pain or abnormal vaginal bleeding (87). A variety of mani- festations of cervical endometriosis have been reported at US, ranging from a complex cystic mass to a solid-appearing lesion with extension into the paracervical tissues, potentially producing a US appearance that is similar to that of other entities, including leiomyomas, polyps, and carcinoma (84,87,88). Clinical history and speculum examination may allow establishment of the correct diagnosis; however, sometimes cervical endometriosis is recognized only at histopathologic examination.…”