AMERICAN JOURNAL OF PERINATOLOGY/VOLUME 8, NUMBER 4 July 1991
FIBROEPITHELIAL POLYPS OF THE VAGINA IN PREGNANCY Michael L. Pearl, M.D., William R. Crombleholme, M.D., James R. Green, M.D., and Kent Bottles, M.D.
A 38-year old pregnant woman presented with a polypoid tumor of the vagina. A biopsy revealed benign fibroepithelial polyps. Her pregnancy progressed normally, and she underwent an uncomplicated vaginal delivery. Once the benign nature of the lesion has been established, a spontaneous vaginal delivery is not contraindicated. However, operative vaginal delivery should be avoided to reduce the risk of trauma and hemorrhage. Local excision is curative and may be performed as an interval procedure when the vaginal vascularity has returned to normal.
Polypoid tumors of the vagina are uncommon. In infants and young girls, such lesions are suspicious for sarcoma botryoides. In adults, benign vaginal polyps with bizarre stromal cells may occur, leading to a misdiagnosis of sarcoma. The obstetrician is faced with additional decisions when these lesions occur during pregnancy, most notably the timing of excision and the route of delivery. This is the first report of a vaginal delivery occurring in the presence of fibroepithelial polyps of the vagina. A review of the literature is presented to emphasize the benign nature of this disorder.
A biopsy revealed benign fibroepithelial polyps with focal acute inflammation and decidualization. A Pap smear result was benign. Her pregnancy progressed normally, without any bleeding. Serial examinations failed to demonstrate any growth of the polyps. She had an uncomplicated spontaneous vaginal delivery at 42 weeks, delivering a 3100 gm female infant. Her bleeding intra- and postpartum was within normal limits. Careful examination of the lesion following delivery revealed some flattening of the polyps, but no significant trauma. The patient will be scheduled for excision of the polyps when she returns for her routine postpartum visit.
CASE REPORT
PATHOLOGY
A 38-year-old primagravid Filipino woman presented for prenatal care at 17 weeks of gestation. She reported that she had had 2 years of painless postcoital vaginal bleeding that continued to the present time. Her last pelvic examination had been several years previously and was reported to be normal. On prenatal pelvic examination, she had a 5 by 7 cm, firm irregular mass in the posterior vaginal fornix that was adjacent to, but not involving, the cervix. The mass consisted of multiple polypoid, grapelike structures protruding from the mucosa into the posterior vaginal vault (Fig. 1). The polyps were smooth and edematous and were friable but not spontaneously bleeding. The induration extended into the rectovaginal space but was free of the pelvic sidewall.
Grossly, the outer surface was pale gray with a smooth texture. On sectioning, the cut surfaces were soft, gelatinous, and pale gray. Microscopic examination revealed polypoid structures covered with benign squamous epithelium. The distal tips of several of the polyps showed focal ulceration with numerous acute inflammatory cells. At the base and midportion of the polyps, there was an increase in cellularity consisting of decidualized cells with an oval, vesicular nucleus containing a conspicuous nucleolus surrounded by a finely granular eosinophilic cytoplasm. The stroma was composed of loose fibrous connective tissue without any hypercellularity. No large atypical stromal cells were identified (Figs. 2, 3).
Departments of Obstetrics, Gynecology and Reproductive Sciences, and Pathology, University of California, San Francisco, San Francisco General Hospital, San Francisco, California Reprint requests: Dr. Crombleholme, San Francisco General Hospital, Ward 6D, 1001 Potrero Ave., San Francisco, CA 94110 236
Copyright © 1991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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ABSTRACT
VAGINAL POLYPS/Pearl, et al.
Figure 3. High-power photomicrograph shows decidual cells with vesicular nuclei, prominent nucleoli, and well-demarcated, eosinophilic cytoplasm. (H & E stain, original magnification x400.)
Figure 1. Multiple polyps in posterior vaginal vault.
Figure 2. Low-power photomicrograph shows a polyp covered by stratified squamous epithelium. (H & E stain, original magnification X40.)
DISCUSSION
Fibroepithelial polyps of the vagina are uncommon benign lesions that may have a bizarre histologic appearance. Consequently, they are of concern for their potential to be misdiagnosed as malignant tumors of the vaginal connective tissue. These lesions are most often found in adult
women, occasionally during pregnancy, and rarely in infancy.1 Although usually asymptomatic, patients may present with vaginal bleeding or sensation of a mass. The patient's age is an important indicator of the benign nature of these lesions, because sarcoma botryoides occurs almost exclusively in girls under the age of 8 years. Sarcoma botryoides may further be distinguished by the presence of a dense subepithelial zone (the "cambium layer"), rhabdomyoblasts containing cross-striations, undifferentiated mesenchymal cells, and invasion of adjacent structures.2 Rhabdomyosarcomas and mixed mesodermal tumors contain a diffusely malignant stroma, as opposed to the scattering of atypical stromal cells seen in fibroepithelial polyps.2 Additionally, mixed mesodermal tumors often contain malignant heterologous elements (cartilage, bone, or striated muscle) not seen in fibroepithelial polyps.2 The etiology of these polyps is unclear. Elliott and Elliott 3 described a 0.5 to 5.0 mm subepithelial myxoid stromal zone extending from vulva to endocervix in mature women. Approximately 25% of healthy women demonstrated anisonucleosis in this zone with bizarre nuclear features similar to those seen in fibroepithelial polyps. Norris and Taylor1 proposed that the presence of edematous polyps in newborn infants are a reflection of maternal or placental hormonal stimulation, similar to clitoral or breast enlargement and thickening of the vaginal mucosa. Elliott et al4 comment that the "bizarre overgrowth of the subepithelial mesenchyme may be . . . an excessive response of some Mullerian tissue to growth-provoking hormones." Burt et al5 reported that 3 of 5 patients had a history of hormone replacement, suggesting a possible contribution of hormonal stimulation to the development of stromal hypertrophy and polyp formation. Thus, it may be that the hormone-rich environment existing in pregnant women may stimulate excessive 237
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-
Table 1. Cases Reported in Pregnancy No.
Cases Pregnant
Reference 1
Norris and Taylor Elliot et al 4 Miettinen et al 6 Chirayil and Tobon7 Present case Totals
8/24 2/2 1/7
2/18 1
14/52
Atypical Stromal Cells
Treatment
Local excision Local excision Local excision Local excision Biopsy 9/14 (64%) 5/8 2/2 Yes 1/2 No
Table 2. Nonpregnant Cases Atypical Stromal No. Cases Cells
References 1
Norris and Taylor Burt et al 5 Miettinen et al 6 Chirayil and Tobon7 Totals
16 5 6 16 43
Treatment
Local Local Local Local 8/16 26/43 (60%) 7/16 5/5 6/6
excision excision excision excision
of fibroepithelial polyps, we believe that spontaneous vaginal delivery is not contraindicated if appropriate precautions are taken. In contrast, operative vaginal delivery should be avoided. Therapy consists of local excision. This may take place as an interval procedure to permit the normal postpartum decrease in vascularity. Only two recurrences have been reported, both in the same patient following biopsy.1 After excision, no further recurrences were noted. Even with transection of the tumor, the clinical course is benign.4 In summary, fibroepithelial polyps are uncommon benign vaginal lesions that raise the specter of sarcoma botryoides. Although they may occur in pregnancy, the pregnancy does not appear to have an influence on the degree of stromal atypia. Spontaneous vaginal delivery is not contraindicated. Local excision is curative, and the subsequent course is benign.
REFERENCES 1.
growth of the stromal zone described by Elliott and Elliott. Pregnancy does not appear to have an influence on the presence of atypical stromal cells. Of pregnant patients reported, 64% had atypical cells on histologic evaluation, compared with 60% of nonpregnant patients (Tables 1, 2). An additional concern in pregnancy is hemorrhage from birth trauma. Although there have been no other reports of vaginal delivery in the presence
238
Norris HJ, Taylor HB: Polyps of the vagina. Cancer 19:227232,1966 2. KurmanRJ (ed): Blaustein's Pathology ofthe Female Genital Tract. New York: Springer-Verlag, 1987, p 108 3. Elliott GB, Elliott JDA: Superficial stromal reactions of lower genital tract/Arch Pathol 95:100-101, 1973 4. Elliott GB, Reynolds HA, Fidler HK: Pseudosarcoma botryoides of cervix and vagina in pregnancy. J Obstet Gynaecol Br Commonw 74:728-733, 1967 5. Burt RL, Prichard RW, Kim BS: Fibroepithelial polyps of the vagina. Obstet Gyencol 47:52s—54s, 1976 6. Miettinen M, Wahlstrom T, Vesterinen E, Saksela E: Vaginal polyps with pseudosarcomatous features. Cancer 51: 1148-1151, 1983 7. ChirayilSJ, Tobon H: Polypsof the vagina: a clinicopathological study of 18 cases. Cancer 47:2904-2907, 1981
Downloaded by: Georgetown University Medical Center. Copyrighted material.
AMERICAN JOURNAL OF PERINATOLOGY/VOLUME 8, NUMBER 4 July 1991
FIBROEPITHELIAL POLYPS OF THE VAGINA IN PREGNANCY Michael L. Pearl, M.D., William R. Crombleholme, M.D., James R. Green, M.D., and Kent Bottles, M.D.
A 38-year old pregnant woman presented with a polypoid tumor of the vagina. A biopsy revealed benign fibroepithelial polyps. Her pregnancy progressed normally, and she underwent an uncomplicated vaginal delivery. Once the benign nature of the lesion has been established, a spontaneous vaginal delivery is not contraindicated. However, operative vaginal delivery should be avoided to reduce the risk of trauma and hemorrhage. Local excision is curative and may be performed as an interval procedure when the vaginal vascularity has returned to normal.
Polypoid tumors of the vagina are uncommon. In infants and young girls, such lesions are suspicious for sarcoma botryoides. In adults, benign vaginal polyps with bizarre stromal cells may occur, leading to a misdiagnosis of sarcoma. The obstetrician is faced with additional decisions when these lesions occur during pregnancy, most notably the timing of excision and the route of delivery. This is the first report of a vaginal delivery occurring in the presence of fibroepithelial polyps of the vagina. A review of the literature is presented to emphasize the benign nature of this disorder.
A biopsy revealed benign fibroepithelial polyps with focal acute inflammation and decidualization. A Pap smear result was benign. Her pregnancy progressed normally, without any bleeding. Serial examinations failed to demonstrate any growth of the polyps. She had an uncomplicated spontaneous vaginal delivery at 42 weeks, delivering a 3100 gm female infant. Her bleeding intra- and postpartum was within normal limits. Careful examination of the lesion following delivery revealed some flattening of the polyps, but no significant trauma. The patient will be scheduled for excision of the polyps when she returns for her routine postpartum visit.
CASE REPORT
PATHOLOGY
A 38-year-old primagravid Filipino woman presented for prenatal care at 17 weeks of gestation. She reported that she had had 2 years of painless postcoital vaginal bleeding that continued to the present time. Her last pelvic examination had been several years previously and was reported to be normal. On prenatal pelvic examination, she had a 5 by 7 cm, firm irregular mass in the posterior vaginal fornix that was adjacent to, but not involving, the cervix. The mass consisted of multiple polypoid, grapelike structures protruding from the mucosa into the posterior vaginal vault (Fig. 1). The polyps were smooth and edematous and were friable but not spontaneously bleeding. The induration extended into the rectovaginal space but was free of the pelvic sidewall.
Grossly, the outer surface was pale gray with a smooth texture. On sectioning, the cut surfaces were soft, gelatinous, and pale gray. Microscopic examination revealed polypoid structures covered with benign squamous epithelium. The distal tips of several of the polyps showed focal ulceration with numerous acute inflammatory cells. At the base and midportion of the polyps, there was an increase in cellularity consisting of decidualized cells with an oval, vesicular nucleus containing a conspicuous nucleolus surrounded by a finely granular eosinophilic cytoplasm. The stroma was composed of loose fibrous connective tissue without any hypercellularity. No large atypical stromal cells were identified (Figs. 2, 3).
Departments of Obstetrics, Gynecology and Reproductive Sciences, and Pathology, University of California, San Francisco, San Francisco General Hospital, San Francisco, California Reprint requests: Dr. Crombleholme, San Francisco General Hospital, Ward 6D, 1001 Potrero Ave., San Francisco, CA 94110 236
Copyright © 1991 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
Downloaded by: Georgetown University Medical Center. Copyrighted material.
ABSTRACT
VAGINAL POLYPS/Pearl, et al.
Figure 3. High-power photomicrograph shows decidual cells with vesicular nuclei, prominent nucleoli, and well-demarcated, eosinophilic cytoplasm. (H & E stain, original magnification x400.)
Figure 1. Multiple polyps in posterior vaginal vault.
Figure 2. Low-power photomicrograph shows a polyp covered by stratified squamous epithelium. (H & E stain, original magnification X40.)
DISCUSSION
Fibroepithelial polyps of the vagina are uncommon benign lesions that may have a bizarre histologic appearance. Consequently, they are of concern for their potential to be misdiagnosed as malignant tumors of the vaginal connective tissue. These lesions are most often found in adult
women, occasionally during pregnancy, and rarely in infancy.1 Although usually asymptomatic, patients may present with vaginal bleeding or sensation of a mass. The patient's age is an important indicator of the benign nature of these lesions, because sarcoma botryoides occurs almost exclusively in girls under the age of 8 years. Sarcoma botryoides may further be distinguished by the presence of a dense subepithelial zone (the "cambium layer"), rhabdomyoblasts containing cross-striations, undifferentiated mesenchymal cells, and invasion of adjacent structures.2 Rhabdomyosarcomas and mixed mesodermal tumors contain a diffusely malignant stroma, as opposed to the scattering of atypical stromal cells seen in fibroepithelial polyps.2 Additionally, mixed mesodermal tumors often contain malignant heterologous elements (cartilage, bone, or striated muscle) not seen in fibroepithelial polyps.2 The etiology of these polyps is unclear. Elliott and Elliott 3 described a 0.5 to 5.0 mm subepithelial myxoid stromal zone extending from vulva to endocervix in mature women. Approximately 25% of healthy women demonstrated anisonucleosis in this zone with bizarre nuclear features similar to those seen in fibroepithelial polyps. Norris and Taylor1 proposed that the presence of edematous polyps in newborn infants are a reflection of maternal or placental hormonal stimulation, similar to clitoral or breast enlargement and thickening of the vaginal mucosa. Elliott et al4 comment that the "bizarre overgrowth of the subepithelial mesenchyme may be . . . an excessive response of some Mullerian tissue to growth-provoking hormones." Burt et al5 reported that 3 of 5 patients had a history of hormone replacement, suggesting a possible contribution of hormonal stimulation to the development of stromal hypertrophy and polyp formation. Thus, it may be that the hormone-rich environment existing in pregnant women may stimulate excessive 237
Downloaded by: Georgetown University Medical Center. Copyrighted material.
-
Table 1. Cases Reported in Pregnancy No.
Cases Pregnant
Reference 1
Norris and Taylor Elliot et al 4 Miettinen et al 6 Chirayil and Tobon7 Present case Totals
8/24 2/2 1/7
2/18 1
14/52
Atypical Stromal Cells
Treatment
Local excision Local excision Local excision Local excision Biopsy 9/14 (64%) 5/8 2/2 Yes 1/2 No
Table 2. Nonpregnant Cases Atypical Stromal No. Cases Cells
References 1
Norris and Taylor Burt et al 5 Miettinen et al 6 Chirayil and Tobon7 Totals
16 5 6 16 43
Treatment
Local Local Local Local 8/16 26/43 (60%) 7/16 5/5 6/6
excision excision excision excision
of fibroepithelial polyps, we believe that spontaneous vaginal delivery is not contraindicated if appropriate precautions are taken. In contrast, operative vaginal delivery should be avoided. Therapy consists of local excision. This may take place as an interval procedure to permit the normal postpartum decrease in vascularity. Only two recurrences have been reported, both in the same patient following biopsy.1 After excision, no further recurrences were noted. Even with transection of the tumor, the clinical course is benign.4 In summary, fibroepithelial polyps are uncommon benign vaginal lesions that raise the specter of sarcoma botryoides. Although they may occur in pregnancy, the pregnancy does not appear to have an influence on the degree of stromal atypia. Spontaneous vaginal delivery is not contraindicated. Local excision is curative, and the subsequent course is benign.
REFERENCES 1.
growth of the stromal zone described by Elliott and Elliott. Pregnancy does not appear to have an influence on the presence of atypical stromal cells. Of pregnant patients reported, 64% had atypical cells on histologic evaluation, compared with 60% of nonpregnant patients (Tables 1, 2). An additional concern in pregnancy is hemorrhage from birth trauma. Although there have been no other reports of vaginal delivery in the presence
238
Norris HJ, Taylor HB: Polyps of the vagina. Cancer 19:227232,1966 2. KurmanRJ (ed): Blaustein's Pathology ofthe Female Genital Tract. New York: Springer-Verlag, 1987, p 108 3. Elliott GB, Elliott JDA: Superficial stromal reactions of lower genital tract/Arch Pathol 95:100-101, 1973 4. Elliott GB, Reynolds HA, Fidler HK: Pseudosarcoma botryoides of cervix and vagina in pregnancy. J Obstet Gynaecol Br Commonw 74:728-733, 1967 5. Burt RL, Prichard RW, Kim BS: Fibroepithelial polyps of the vagina. Obstet Gyencol 47:52s—54s, 1976 6. Miettinen M, Wahlstrom T, Vesterinen E, Saksela E: Vaginal polyps with pseudosarcomatous features. Cancer 51: 1148-1151, 1983 7. ChirayilSJ, Tobon H: Polypsof the vagina: a clinicopathological study of 18 cases. Cancer 47:2904-2907, 1981
Downloaded by: Georgetown University Medical Center. Copyrighted material.
AMERICAN JOURNAL OF PERINATOLOGY/VOLUME 8, NUMBER 4 July 1991
