Should All Asymptomatic Endocervical Polyps Be Removed: Two Case Reports

Abstract

Endocervical polyps are benign, pedunculated growths from the cervix. They are usually an incidental finding on examination of the cervix, though sometimes they can cause intermenstrual or postcoital bleeding. We present two case reports of asymptomatic endocervical polyps. In the first case, the endocervical polyp was noted in the colposcopy clinic. The woman had been referred with a mild dyskaryotic smear. Histology of the polyp showed CIN 2 and 3. In the second case, the polyp showed severe dysplasia. Hysteroscopy was performed to rule out endometrial carcinoma. CIN 3 can progress to invasive cancer in 12 % of cases. Atypical endometrial hyperplasia is an ominous finding on histology. 10-20% of all cases with atypia will have an underlying carcinoma. Invasive cancer develops in up to 50% of cases. As far as we are aware, these are the first case reports of CIN 3 and severe dysplasia reported in endocervical polyps. We recommend that all asymptomatic endocervical polyps be removed and sent for histological examination. CASE REPORT 1 A 46 year old, P0+0, was referred to the colposcopy clinic with a mildly dyskaryotic smear. She had no intermenstrual or postcoital bleeding or any other symptoms. She had regular menstrual cycles. She was on the combined contraceptive pill. She had no significant past medical or surgical history and was a non-smoker. On colposcopy, the entire squamocolumnar junction was seen. Colposcopy was complete with a type 1, small transformation zone. There were no acetowhite or iodine negative areas. There was a small 1 cm by 1 cm long endocervical polyp, which was removed and sent for histology. Histology of the polyp showed extensive squamous metaplasia. Squamous epithelium on the surface and the lining crypts showed cytological atypia indicating CIN 2 and focal CIN 3. The patient was recalled to the colposcopy clinic. She had a large loop excision of the transformation zone (LLETZ) under local anaesthetic. The histology of the loop specimen showed CIN 3 with complete excision. CASE REPORT 2 A 57-year-old woman, P2+0, was referred by to the gynaecology clinic with an endocervical polyp. The polyp had been noted by her GP while taking a routine cervical smear. She had no symptoms. She was postmenopausal with no significant past medical or surgical history. She was not on HRT. The polyp was removed in the gynaecology outpatient clinic and sent for histological examination. Histology reported the polyp as an endometrial polyp in which a few glands showed severe dysplasia with severe cytological atypia. The patient was recalled to the clinic. She had a hysteroscopy examination, which showed multiple endometrial polyps. The polyps were removed. Histology showed benign endometrial polyps. DISCUSSION Endocervical polyps are small, pedunculated growths of the endocervix. It is the most common cervical growth especially in the multigravids. It is usually asymptomatic and found incidentally. Occasionally the polyp may cause Should All Asymptomatic Endocervical Polyps Be Removed: Two Case Reports 2 of 3 intermenstrual, postcoital or postmenopausal bleeding. On histology, the polyp is characterised by overgrowth of benign stroma covered by epithelium. Endocervical polyps are covered by endocervical, squamocolumnar or squamous metaplastic epithelium. The clinical behaviour is essentially benign. In the first case, the histology of the endocervical polyp showed CIN 2 to CIN 3. The colposcopy was normal and did not show any acetowhite changes. The UK guidelines for colposcopy suggest a colposcopy and punch biopsy for mild dyskaryosis but a ‘see and treat' policy for higher-grade abnormal cervical smears.1 CIN 3 can progress to invasive cancer in 12 % of cases. Regression rates without treatment are only 32% and persistence rates about 56%.2 The CIN 3 would have been missed had the polyp not been removed. In the second case, histology of the endocervical polyp was reported as an endometrial polyp with severe dysplasia with atypia. Atypical endometrial hyperplasia is an ominous finding on histology. 10-20% of all cases with atypia will have an underlying carcinoma. Invasive cancer develops in up to 50% of cases.3 Hysteroscopy was performed to rule out adenocarcinoma. Hysteroscopy showed presence of multiple, benign endometrial polyps. We recommend that all asymptomatic endocervical polyps should be removed and sent for histological examination.