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CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 3  |  Page : 216-218

Diffuse multiple giant adenomyomatous endometrial polyps: A rare case report


1 Department of Pathology, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
2 Department of Gynecology, King George Hospital, Visakhapatnam, Andhra Pradesh, India

Date of Web Publication17-Sep-2018

Correspondence Address:
Dr. Atla Bhagyalakshmi
Department of Pathology, Andhra Medical College, Visakhapatnam, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_23_18

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  Abstract 


Endometrial polyps represent a limited focal, circumscribed overgrowth of the endometrium. They are often found in perimenopausal women. Here we present a case of a 25-year-old infertile lady admitted with chief complaint of frequent heavy prolonged menstrual bleeding. She underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. On gross examination of the uterus, there were multiple endometrial polyps filling the entire endometrial cavity. Histopathology revealed adenomyomatous endometrial polyps.

Keywords: Adenomyomatous, endometrium, polyps


How to cite this article:
Bhagyalakshmi A, Nagamani T, Kartheek B V, Balaji C. Diffuse multiple giant adenomyomatous endometrial polyps: A rare case report. J NTR Univ Health Sci 2018;7:216-8

How to cite this URL:
Bhagyalakshmi A, Nagamani T, Kartheek B V, Balaji C. Diffuse multiple giant adenomyomatous endometrial polyps: A rare case report. J NTR Univ Health Sci [serial online] 2018 [cited 2018 Dec 18];7:216-8. Available from: http://www.jdrntruhs.org/text.asp?2018/7/3/216/241281




  Introduction Top


Endometrial polyps are localized overgrowth of endometrial glands and stroma through the uterine cavity with prevalence of 25% of women.[1] Polyps are the common causes of vaginal bleeding in perimenopausal period. During the reproductive period, they are less common.[2] They are associated with postmenopausal bleeding, infertility, and menorrhagia. Their etiopathogenesis has not been completely explained yet. Endometrial polyps occur with increased frequency after tamoxifen exposure. Development of endometrial polyps is affected by unbalanced estrogen therapy, estrogen-like effect, and unbalanced estrogens and progestins. It may be pedunculated or sessile, single or multiple.[2] The most common size is <2 cm, and polyps >4 cm are called giant polyps.[3] The prevalence of malignancy with endometrial polyps is 1–3%. Adenomyomatous polyps of the endometrium are a rare subtype of endometrial polyps. In addition to the usual features of endometrial polyps, they also contain a smooth muscle component. Here we presented a case of diffuse multiple giant endometrial adenomyomatous polyps in a young nulliparous woman.


  Case Report Top


A 25-year-old nulligravida woman came with chief complaint of menorrhagia since 6 months. She had no other relevant medical, surgical, or family history. On physical examination pallor was present, and vaginal examination revealed 12 weeks anteverted uterus. Bleeding was present; bilateral fornices were free with no cervical motion tenderness. She underwent magnetic resonance imaging (MRI) in view of clinical suspicion of malignancy. MRI findings were suggestive of bulky uterus with endometrial carcinoma. Subsequently, she underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. On gross examination, cut section of uterus revealed multiple diffuse giant polyps filling the entire endometrial cavity [Figure 1]. On histopathological examination with hematoxylin and eosin stains revealed adenomyomatous polyps which showed proliferative endometrial glands, few cystically dilated surrounded by endometrial stroma, bordered by leiomyomatous smooth muscle [Figure 2] and [Figure 3]. There are also thickened blood vessels in the stroma [Figure 4]. No nuclear or cytological atypia were noted neither in the glands nor in the stroma.
Figure 1: Gross photograph showing bulky hysterectomy specimen with multiple large polyps filling the entire endometrial cavity extending upto the isthmus

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Figure 2: Photomicrograph showing proliferative endometrial gands with few dilated glands seen.(H&E,40X)

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Figure 3: Photomicrograph showing proliferative endometrial glands, surrounded by endometrial stroma, bordered by leiomyomatous smooth muscle. (H&E,100X)

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Figure 4: Photomicrograph showing thickened blood vessels.(H&E,100X)

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  Discussion Top


Polyps are biphasic benign endometrial lesions that have been defined classically as benign nodular protrusions above the endometrial surface, consisting of irregularly distributed endometrial glands and stroma. Larger polyps are associated with a higher risk of malignancy.[2] Lee et al. reported in a meta-analysis the prevalence rate of premalignancy and malignancy in endometrial polyps of 3.57%. They have also been implicated as a possible cause of infertility, either by physically interfering with blastocyst implantation or by altering the development of secretory phase endometrium, making it less receptive to the implanting embryo.[4] Endometrial polyps are divided into three basic groups according to their response to ovarian hormones. These types include mature functioning polyps, immature nonfunctioning polyps and nonfunctioning adenomyomatous polyps.[3] Polyps >4 cm are called giant polyps, and most giant endometrial polyps described in the literature were associated with postmenopausal tamoxifen treatment.[3]

Ours is an interesting case where a young 25-year-old woman developed endometrial polyp with no history of usage of tamoxifen or other drugs-like hormonal treatment.

Noninvasive techniques such as transvaginal ultrasonography, with or without the use of three-dimensional ultrasonography and contrast techniques, remain as first-line treatment.[3] The clinical findings and transvaginal sonographic examination suggested an endometrial carcinoma. On MRI examination, the distinction between the early noninvasive endometrial carcinoma from the endometrial polyp and hyperplasia is difficult to distinguish.[5] For the treatment and histologic diagnosis of endometrial polyps, hysteroscopic resection is the most effective method, while blind biopsy and curettage have low diagnostic accuracy and should not be performed. In our case in view of suspicion of endometrial carcinoma based on MRI findings, the patient underwent hysterectomy with bilateral salpingo-oophorectomy. The main histopathological differential diagnoses for adenomyomatous polyps are atypical polypoid adenomyoma and adenosarcoma. In atypical polypoid adenomyoma, the smooth muscle is arranged in short interlacing fascicles that contrast with the elongate bundles of smooth muscle found in adenomyomatous polyps, and even endometrial stroma is largely absent. Adenosarcoma, unlike benign polyps, has a more cellular stroma with increased mitotic activity that aggregates in cuffs around the glands. Large polyps typically have thick-walled vessels, which are lacking in adenosarcoma.[6]


  Conclusion Top


Endometrial polyp development is dependent on estrogen stimulation and unbalanced estrogen. Multiple diffuse giant endometrial adenomyomatous polyps, especially in a premenopausal woman, are rare. In this case there is no history of either tamoxifen usage or hormone replacement therapy. The definitive diagnosis is to be confirmed by histopathologic evaluation, although the MRI and hysteroscopic examination are helpful in the differential diagnosis of the polyps.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ünal B, Doğan S, Karaveli FŞ, Şimşek T, Erdoğan G, Candaner I. Giant endometrial polyp in a postmenopausal woman without hormone/drug use and vaginal bleeding. Case Rep Obstet Gynecol 2014;2014:1-4.  Back to cited text no. 1
    
2.
Kumar D, Singh LS, Devi SR, Pritamkumar C. A rare case of global multiple adenomyomatous endometrial polyps: Developed just after menarche, with giant polyp protruding through cervix. IOSR J Dent Med Sci 2016;15:5-8.  Back to cited text no. 2
    
3.
Çil AS, Bozkurt M, Kara D, Guler B. Giant endometrial polyp protruding from the external cervical os in a postmenopausal woman: Magnetic resonance imaging and hysteroscopic findings. Proc Obstet Gynecol 2013;3:2.  Back to cited text no. 3
    
4.
Lee SC, Kaunitz AM, Ramos LS, Rhatigan RM. The oncogenic potential of endometrial polyps. A systematic review and meta-analysis. Obstet Gynecol 2010;116:1197-205.  Back to cited text no. 4
    
5.
Grasel RP, Outwater EK, Siegelman ES, Capuzzi D, Parker L, Hussain SM. Endometrial polyps: MR imaging features and distinction from endometrial carcinoma. Radiology 2000;214:47-52.  Back to cited text no. 5
    
6.
Mazur MT, Kurman RJ. Polyps. In: Diagnosis of endometrial biopsies and curettings: A practical approach. 2nd ed. New York: Springer Science; 2005. pp 163-76.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case Report
Discussion
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