Invasive squamous cell carcinoma on the mucosal surface of the leiomyomatous polyp, cervix - Report of an extremely rare occurrence

Hariharanadha Sarma Nandyala; Chaitanya Balekuduru; Jyothi Suchitra Mekala

doi:10.4103/jdrntruhs.jdrntruhs_44_21

CASE REPORT

Year : 2022 | Volume : 11 | Issue : 4 | Page : 386-388

Invasive squamous cell carcinoma on the mucosal surface of the leiomyomatous polyp, cervix - Report of an extremely rare occurrence

Hariharanadha Sarma Nandyala¹, Chaitanya Balekuduru¹, Jyothi Suchitra Mekala²
¹ Department of Pathology, RDT Hospital, Bathalapalli, Andhra Pradesh, India
² Department of Gynecology and Obstetrics, RDT Hospital, Bathalapalli, Andhra Pradesh, India

Date of Submission	09-Apr-2021
Date of Decision	20-Mar-2022
Date of Acceptance	26-Mar-2022
Date of Web Publication	17-Mar-2023

Correspondence Address:
Dr. Hariharanadha Sarma Nandyala
Department of Pathology, RDT Hospital, Bathalapalli - 515 661, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jdrntruhs.jdrntruhs_44_21

Abstract

Endocervical polyps constitute the most common new growths of the uterine cervix. They are most often found during the fourth to sixth decades and in multigravidas. The paucity of smooth muscles in the cervical stroma makes the leiomyomas uncommon in the cervix and accounts for less than 1% of all fibroids. Cervical leiomyomas or fibroids usually arise from the supravaginal portion of the cervix. Studies indicate that the prevalence of atypia, dysplasia, and malignancy in cervical polyps is none to very low. The occurrence of neoplastic change in the overlying mucosa of the leiomyomatous cervical polyp is extremely rare. There has been only a single case of squamous cell carcinoma (SCC) arising on the mucosal surface of a cervical leiomyomatous polyp. We are presenting a case of SCC arising from the mucosal surface of the cervical leiomyomatous polyp.

Keywords: Endocervical polyp, leiomyoma, squamous cell carcinoma

How to cite this article:
Nandyala HS, Balekuduru C, Mekala JS. Invasive squamous cell carcinoma on the mucosal surface of the leiomyomatous polyp, cervix - Report of an extremely rare occurrence. J NTR Univ Health Sci 2022;11:386-8

How to cite this URL:
Nandyala HS, Balekuduru C, Mekala JS. Invasive squamous cell carcinoma on the mucosal surface of the leiomyomatous polyp, cervix - Report of an extremely rare occurrence. J NTR Univ Health Sci [serial online] 2022 [cited 2023 Apr 1];11:386-8. Available from: https://www.jdrntruhs.org/text.asp?2022/11/4/386/371760

Introduction

Endocervical polyps constitute the most common new growths of the uterine cervix. They are most often found during the fourth to sixth decades and in multigravidas.^[1] The polyps typically arise within or above the cervical Os and range from a few millimeters to 4 cm in size with an average of 1 cm. Endocervical polyps are clinically relevant because approximately 40% are symptomatic and often present with bleeding.^[2] Cervical leiomyomas usually occur singly and arise from the supravaginal portion of the cervix. They produce unilateral enlargement of the cervical portion depending on the location. Leiomyoma of the cervix can present as a mass per vagina with ulceration and superficial necrosis.^[3]

The occurrence of neoplastic change on the mucosal surface of an endocervical polyp is extremely rare. Only one such case of squamous cell carcinoma (SCC) arising from the mucosal surface of a leiomyomatous polyp is on the record in the world literature.^[4] We present the second case of invasive SCC arising from the mucosal surface of a leiomyomatous endocervical polyp.

Case history

A 56-year-old lady presented to the gynecology outpatient clinic with the complaint of bleeding per vagina of 2 months duration. Physical examination in general did not reveal any significant findings. Gynecological examination revealed a small polypoidal lesion on the posterior lip of the cervix near the OS. No other significant findings were noted. A polypectomy was done and the tissue was sent for a histopathological examination.

Grossly, the polyp measured 1 × 2 × 2.5 cm with a focal brownish rough surface of size 0.5 × 0.5 cm. The cut surface revealed grayish-white firm tissue. Microscopic examination revealed a poorly circumscribed spindle cell tumor partly replacing the stroma. The tumor cells are spindle-shaped, elongate with blunt ends, and have a round to oval nucleus. The cells are arranged in sweeping fascicles, sheets, and interlacing bundles. There was no pleomorphism, no atypia, or no increase in the mitoses. The mucosa overlying the tumorous area showed neoplastic change ranging from high-grade squamous intraepithelial neoplasia (H-SIL) to frank microinvasive SCC. The invasive areas of the neoplastic squamous epithelium are surrounded by extensive infiltration of lymphocytes, eosinophils, and occasional plasma cells [Figure 1] and [Figure 2].

Figure 1: Plump spindle shaped cells arranged in sheets and interlacing fascicles. The overlying squamous epithelium shows high grade squamous intraepithelial lesion (H&E × 10)

Click here to view

Figure 2: The squamous epithelium overlying the spindle cell growth shows pleomorphic cells with hyperchromatic nucleus. The neoplastic cells are invading the stroma. Moderate collection of lymphocytes and eosinophils are seen around the advancing tumor edges. Blue arrow squamous cell carcinoma and red arrows leiomyoma (H&E × 20)

Click here to view

A diagnosis of microinvasive non-keratinizing SCC over a leiomyomatous polyp of the cervix is made. Subsequent to the histopathology report, the patient underwent a total hysterectomy with bilateral salpingo-oophorectomy and regional lymphadenectomy.

This specimen was sent to the pathology department and the microscopic examination revealed a tiny remnant focus of leiomyoma with a small area of SCC overlying it [Figure 3]. Lymph nodes did not reveal any metastatic deposits.

Figure 3: Part of remnant spindle cell growth and invasive squamous cell carcinoma in the overlying mucosa (H&E × 20)

Click here to view

Discussion

Endocervical polyps are common and occur over a wide age range with a mean in the fifth decade. Cervical leiomyomatous polyp usually arises from the posterior lip of the ectocervix.^[3] The focal proliferation of endocervical stroma leads to polyp formation. Depending upon their stromal content, they may be either fibrous, angiomatous, edematous, or cellular. When these polyps protrude through the external OS, the external surface epithelium may be replaced by reserve cell hyperplasia, which can differentiate into squamous metaplasia and finally mature stratified squamous epithelium.^[5]

Although most cervical polyps are benign, several studies indicate that the prevalence of dysplasia and malignancy in the symptomatic cervical polyps is none to extremely low [Table 1].

Table 1: Prevalence of Dysplasia and Malignancy Changes in Polypectomy Specimens

Click here to view

^{[14],[15].[16],[17],[18]}

The occurrence of neoplastic change in the overlying squamous epithelium of a cervical polyp is extremely rare. Neno Chin et al.^[12] reported nine cases of squamous intraepithelial lesions (SIL) and two cases of SCC in 1500 cases of endocervical polyps. Women in the perimenopausal to postmenopausal years have a slightly higher likelihood of a malignancy associated with cervical polyps.^[13] Neoplastic change in the overlying mucosa of a cervical leiomyomatous polyp is much rarer with only one case reported in the world literature so far.^[5]

We have reported a second such case of invasive SCC developing in the overlying mucosa of the leiomyomatous polyp. We want to emphasize the importance of histopathological examination of all the cervical polyps, so that we may not miss any important pathology underlying these polyps, which can radically change the management protocols.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Wright TC, Ronnett BM, Ferenczy A. Benign diseases of the cervix. In: Kurman RJ, Ellenson LH, Ronnet BM, editors. Blaustein's Pathology of the Female Genital Tract. 6^th ed. New York, Springer; 2011. p. 182-3.
2.	Nucci MR, Crum CP. Neuroendocrine carcinoma, mixed epithelial/mesenchymal and mesenchymal tumors, and miscellaneous tumors of the cervix. In: Crum CP, Nucci MR, Lee KR, editors. Diagnostic Gynecologic and Obstetric pathology. 2^nd ed. Philadelphia: Elsevier Saunders; 2006. p. 398-9.
3.	Tiltman AJ. Leiomyomas of the uterine cervix: A study of frequency. Int J Gynecol Pathol 1998;17:231-4.
4.	Nam HR, Huh SJ, Park CT, Kim B, Ahn G. A case of invasive squamous cell carcinoma on the surface of pedunculated cervical leiomyoma presenting an exophytic cervical cancer. Gynecol Oncol 2005;97:253-5.
5.	Dallenbauch-Hellweg G, Knebel Doeberitz MV, Trunk MJ. Color Atlas of Histopathology of the Cervix Uteri. 2^nd ed. Chapter 6. Springer Heidelberg; 2006. p. 42-56.
6.	Mackenzie IK, Naish C, Rees CM, Manek S. Why remove all cervical polyps and examine them histologically? BJOG 2009;116:1127-9.
7.	Tirlapur SA, Adeyemo A, O'Gorman N, Selo-Ojeme D. Clinico-pathological study of cervical polyps. Arch Gynecol Obstet 2010;282:535-8.
8.	Senturk MB, Budak MS, Durukan OB, Cakmak Y, Yildirim A, Polat M. Clinicopathological evaluations of cervical polyps. Zeynep Kamil Tip Bulteni 2015;46:98-101.
9.	Umadevi G, Sathiyakala R, Ranganathan K. Clinicopathological analysis of cervical polyps. Int J Reprod Contracept Obstet Gynecol 2017;6:1526-9.
10.	Younis MT, Iram S, Anwar B, Ewies AA. Women with asymptomatic cervical polyps may not need to see a gynaecologist or have them removed: An observational retrospective study of 1126 cases. Eur J Obstet Gynecol Reprod Biol 2010;150:190-4.
11.	Budak A,Kanmaz AG. Role of endometrial sampling in cases with asymptomatic cervical polyps. J Gynecol Obstet Hum Reprod 2019;48: 207-11.
12.	Chin N, Platt AB, Nuovo GJ. Squamous intraepithelial lesions arising in benign endocervical polyps: A report of 9 cases with correlation to the Pap smears, HPV analysis, and immunoprofile. Int J Gynecol Pathol 2008;27:582-90.
13.	Park CK, Kim YW, Kow HH, Yoon N, Bae GE, Kim HS. Clinicopathological Characteristics of squamous cell carcinoma and High grade squamous intraepithelial lesions involving endocervical polyps. In Vivo 2020;34:2613-21.
14.	Golan A, Ber A, Wolman I, David MP. Cervical polyp: Evaluation of current treatment. Gynecol Obstet Invest 1994;37:56-8.
15.	Schnatz PF, Ricci S, O'sullivan DM. Cervical polyps in post menopausal women: Is there a difference in risk?. Menopause 2009;16:524-8.
16.	Buyukbayrak EE, Karageyim Karsidag AY, Kars B, Sakin O, Alper AG, Pirimoglu M, et al. Cervical polyps: Evaluation of routine removal and need for accompanying D&C. Arch Gynecol Obstet 2011;283:581-4.
17.	Levy RA, Kumarapeli AR, Spencer HJ, Quick CM. Cervical polyps: Is histological evaluation necessary? Histologic findings in asymptomatic Israili jewish women. J Low Genit Tract Dis 2011;15:259-62.
18.	Pegu B, Srinivas BH, Saranya ST, Murugesan R, Priyadarshini Thippeswamy S, Gaur BP. Cervical polyp: Evaluating the need of routine surgical intervention and it's correlation with cervical smear cytology and endometrial pathology: A retrospective study. Obstet Gynecol Sci 2020;63:735-42.