Endometrial polyps

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Endometrial polyps

• Dr Shaun Monagle
• MBBS 1991

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Definition

• Benign localised overgrowth of endometrial glands
  and stroma, covered by epithelium, projecting
  above the adjacent epithelium
• Clonal lesions
• chromosome 6

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Clinical features

• Prevalence 24
• More common in women gt 40
• Present with
• intermenstrual or post-menopausal bleeding
• Infertility
• Persistent bleeding following curettage
• Common association with Tamoxifen use

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Pathological findings

• Sessile or pedunculated
• Size 1mm and beyond may fill the endometrial
  cavity and project through the cervical os
• May be multiple
• May originate anywhere, but most commonly fundus

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polyp
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Histopathology

• Irregularly outlined glands that may be out of
  phase with endometrium
• Fibrovascular stalk or fibrous stroma with
  numerous thick walled vessels
• Metaplastic epithelium particularly squamous may
  be present
• Those in the lower uterine segment may contain
  endocervical glands
• Mesenchymal component contains endometrial
  stroma, fibrous tissue or smooth muscle.
• Absence of cytological atypia
• hyperplasia, carcinoma (any type) and
  carcinosarcoma may involve or be entirely
  confined to a polyp
• endometrial intraepithelial carcinoma may be
  identified in an atrophic polyp

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• Benign polyp in a hysterectomy specimen
• Note
• Endometrial epithelium on three surfaces
• Dilated glands
• Fibrotic stroma
• Scattered dilated thick walled blood vessels

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• Endometrial polyp
• Note
• Dilated thick-walled blood vessels
• Stromal fibrosis (less than previous image)
• Proliferative endometrial glands

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Endometrial polyp (low power)features cystically
dilated glands of various sizes and shapes
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Endometrial polyp (high power)characteristic
features of thick walled blood vessels in a
fibrous core
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Classification

• Morphologically diverse lesions that are
  difficult to subclassify.
• Most are either hyperplastic, atrophic or
  functional.
• Hyperplastic
• resemble diffuse non polypoid endometrial
  hyperplasia
• no evidence that these have the same significance
  as diffuse hyperplasia, so best to avoid the term
  hyperplastic in the diagnosis
• Atrophic
• low columnar or cuboidal cells lining cystically
  dilated glands
• typically in post-menopausal patients
• Functional
• resemble normal cycling endometrium
• relatively uncommon

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Tamoxifen related polyps

• Larger, sessile with a honeycomb appearance
• bizarre stellate shape of glands and frequent
  epithelial and stromal metaplasias
• often periglandular stromal condensation
• malignant transformation in up to 3
• interestingly the cytogenetic profile is similar
  to non-iatrogenic lesions

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Differential Diagnosis

• Endometrial hyperplasia
• diffuse process, majority of fragments in
  curettage, absence of thick walled vessels
• polypoid endometrial carcinoma
• malignant epithelial cells
• adenofibroma
• adenosarcoma
• stromal cells cytologically atypical and
  mitotically active
• stromal cells packed tightly around non malignant
  glands
• leaf like pattern

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Adenosarcoma
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Adenosarcomanote the cellular stroma
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Adenosarcomastromal cells condensing around
cytologically benign glands
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Clinical behavior and treatment

• At most 5 of polyps contain carcinoma
• polyps may represent a marker of increased cancer
  risk, but no evidence suggests they are more
  likely to become cancer than the adjacent
  endometium
• those containing atypical hyperplasia or
  carcinoma should be treated as per similar flat
  lesions

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References

• http//www.pathologyoutlines.com
• Blausteins Pathology of the Female Genital
  Tract. 5th Edition. RJ Kurman. Springer-Verlag
  New York. 2002.
• Differential Diagnosis in Surgical Pathology.
  Haber, Gattuso, Spitz and David. Saunders, 2002
• WHO Classification of Tumour. Pathology and
  Genetics. Tumours of the breast and female
  genital organs. Tavassoli and Devilee. IARC
  Press, 2003
• Sternbergs Diagnostic Surgical Pathology, 4th
  edition. SE Mills. Lippincott, Williams and
  Wilkins, 2004