Fetal and Pediatric Pathology, 33:176–181, 2014 C Informa Healthcare USA, Inc. Copyright ISSN: 1551-3815 print / 1551-3823 online DOI: 10.3109/15513815.2014.890259
ORIGINAL ARTICLE
Fetal Pediatr Pathol Downloaded from informahealthcare.com by Yale Dermatologic Surgery on 09/30/14 For personal use only.
Giant Cervıcal Polyp with Mesonephric Duct Remnants: Unusual Cause of Vaginal Bleeding in an Adolescent Girl ¨ Demirdag, ˘ Safak Guc ¨ ¸ er, Diclehan Orhan, Tutku Soyer, Gul and Ibrahim Karnak Hacettepe University Faculty of Medicine, Pediatric Surgery, Ankara, Turkey
Background: Cervical polyps (CP) are quite common in adults, they are extremely rare in children and adolescents. CP containing mesonephric duct remnants (MDR) are few millimeters in size and seldom grossly visible. Case: A 14-year-old female admitted with massive vaginal bleeding with an intact wide hymeneal opening. Pelvic MRI revealed 47 mm × 25 mm × 35 mm polypoid mass originating from the endometrial cavity. During vaginoscopy, a polypoid mass was detected at 9 o’clock position of right lip of ectocervix and was totally excised. Light microscopy showed CP including small round or branched glands containing inspissated eosinophilic secretions and patchy chronic inflammatory infiltrate. The patient was diagnosed as gaint CP containing MDR. Conclusion: Giant CP is an uncommon variant of classical polyps and exhibit distinct clinical and pathologic features. However, MDR are benign lesions of cervix, detailed histopathological evaluation should be performed to all CP to differentiate malignant lesions. Keywords: cervical polyp, giant, mesonephric duct remnant, adolescent, children
INTRODUCTION Cervical polyp (CP) is a common benign lesion of cervix in adults and usually diagnosed as an incidental finding during investigation of dysfunctional uterine bleeding. The occurrence of polyps of uterine cervix is extremely rare in adolescents. The incidence of CP in adolescents with vaginal bleeding was reported as 1.5% [1]. The most common clinical presentation of a CP is vaginal bleeding with malodorous discharge [1]. Mesonephric duct remnants (MDR) are vestiges of mesonephric duct and may rarely present in CPs. It is typically located at 3 and 9 o’clock position of cervix within deep cervical stroma [2]. MDR are usually milimetric in size and seldom grossly visible. Giant CP is an uncommon variant of classical polyps and exhibit distinct clinical and pathologic features. Giant CPs containing MDR has not been reported in adolescents. These giant polyps should be carefully evaluated to exclude malignant cervical lesions. This 14-year-old female with a giant CP is reported to discuss the clinical features and differential diagnosis of giant CPs in adolescents.
Received 10 June 2013; Revised 27 January 2014; accepted 29 January 2014. Address correspondence to Dr Tutku Soyer Associate Professor, Hacettepe University, Medical Faculty, Pediatric Surgery, Ankara, Turkey. E-mail: [email protected]
Gıant Cervıcal Polyp wıth Mesonephrıc Duct Remnants
Fetal Pediatr Pathol Downloaded from informahealthcare.com by Yale Dermatologic Surgery on 09/30/14 For personal use only.
CASE REPORT A 14-year-old female was admitted to our department with a complaint of vaginal mass. She has been followed up for dysfunctional vaginal bleeding for the last two years. She received oral contraceptives for vaginal bleeding and had anemia in her control visits. Six months before admission, two units of erythrocyte transfusion were performed because of severe anemia (Hemoglobin; 5.6 g/dL). In her medical history, menarche occurred at age 12 and she had monthly menses lasting 8 days until 3 months when she began to have prolonged vaginal bleeding. She had no history of sexual intercourse, hematologic disease and previous gynecologic evaluation. Physical examination revealed adequate stage of pubertal development (Tanner stage: M4, P5), body weight and height (>75 percentile). Vital signs were within normal limits. She had slight uterine bleeding with an intact hymen. The hymeneal opening was 2 cm in diameter and wider than normal size (10 mm) in adolescents [3]. In rectal examination, a palpable mass was detected anterior to rectum. She had sense of protruding mass during straining.
Figure 1. Pelvic MRI showing polypoid mass in uterine cervix (arrow). The uterine cavity was distended with blood. C Informa Healthcare USA, Inc. Copyright
Fetal Pediatr Pathol Downloaded from informahealthcare.com by Yale Dermatologic Surgery on 09/30/14 For personal use only.
T. Soyer et al.
Laboratory findings including blood counts were; Hemoglobin 9,1 g/dL (N: 13.6–17.2 g/dL), hematocrit 27,2% (N: 39.5–50.3%), white blood cells 6.6 × 103 /μL (N: 4.3–10.3 × 103 /μL), platelets 270 × 103 /μL (N: 156–373 × 103 /μL). Prothrombin time, international normalized ratio (INR) and bleeding time were in normal range and bleeding disorders were excluded. Liver and renal functional tests and thyroid hormone levels were also normal. FSH (6.4mIU/mL) and LH (12.74uIU/mL) levels were normal. Other hormone levels including estradiol, total testosterone and dihydroepiandrostenedion levels were within normal limits. Also, beta HCG was negative at admission. Ultrasonographic evaluation of the pelvis showed a polypoid mass protruding from the cervical channel. Oncologic evaluation was performed to exclude vaginal rhabdomyosarcoma. Pelvic magnetic resonance imaging (MRI) revealed a 47 mm × 25 mm × 35 mm polypoid mass originating from the distal end of endometrial cavity and protruding into the vagina (Figure 1). The patient underwent cystocopy and vaginoscopy with a presumptive diagnosis of a malignant cervical lesion. Cystoscopic evaluation did not reveal a pathologic finding. During vaginoscopy, a 3.5 × 3 cm polypoid mass was detected at the 9 o’clock position of right lip of ectocervix. The mass was pedinculated and had no communication with endocervix. The mass was totally excised with electrocoagulation after transfixing suturing of the base the pedicle. Postoperative course was uneventful. Gross evaluation of polyp revealed a rubbery yellowish mass with a smooth surface (Figure 2). Light microscopy showed a CP including small round or branched glands containing inspissated eosinophilic secretions and patchy chronic inflammatory infiltrate (Figure 3). They were lined with a layer of cubic epithelium without any atypia or metaplasia. Stromal arteries showed intimal and medial thickening. Immunohistochemistry revealed positive Bcl-2 staining epithelium of the cystic remnants while normal endocervical glands were negative. Myogenin and CEA staining of mesonephric remnants were negative and a low proliferation index was found with Ki67 marker (
ORIGINAL ARTICLE
Fetal Pediatr Pathol Downloaded from informahealthcare.com by Yale Dermatologic Surgery on 09/30/14 For personal use only.
Giant Cervıcal Polyp with Mesonephric Duct Remnants: Unusual Cause of Vaginal Bleeding in an Adolescent Girl ¨ Demirdag, ˘ Safak Guc ¨ ¸ er, Diclehan Orhan, Tutku Soyer, Gul and Ibrahim Karnak Hacettepe University Faculty of Medicine, Pediatric Surgery, Ankara, Turkey
Background: Cervical polyps (CP) are quite common in adults, they are extremely rare in children and adolescents. CP containing mesonephric duct remnants (MDR) are few millimeters in size and seldom grossly visible. Case: A 14-year-old female admitted with massive vaginal bleeding with an intact wide hymeneal opening. Pelvic MRI revealed 47 mm × 25 mm × 35 mm polypoid mass originating from the endometrial cavity. During vaginoscopy, a polypoid mass was detected at 9 o’clock position of right lip of ectocervix and was totally excised. Light microscopy showed CP including small round or branched glands containing inspissated eosinophilic secretions and patchy chronic inflammatory infiltrate. The patient was diagnosed as gaint CP containing MDR. Conclusion: Giant CP is an uncommon variant of classical polyps and exhibit distinct clinical and pathologic features. However, MDR are benign lesions of cervix, detailed histopathological evaluation should be performed to all CP to differentiate malignant lesions. Keywords: cervical polyp, giant, mesonephric duct remnant, adolescent, children
INTRODUCTION Cervical polyp (CP) is a common benign lesion of cervix in adults and usually diagnosed as an incidental finding during investigation of dysfunctional uterine bleeding. The occurrence of polyps of uterine cervix is extremely rare in adolescents. The incidence of CP in adolescents with vaginal bleeding was reported as 1.5% [1]. The most common clinical presentation of a CP is vaginal bleeding with malodorous discharge [1]. Mesonephric duct remnants (MDR) are vestiges of mesonephric duct and may rarely present in CPs. It is typically located at 3 and 9 o’clock position of cervix within deep cervical stroma [2]. MDR are usually milimetric in size and seldom grossly visible. Giant CP is an uncommon variant of classical polyps and exhibit distinct clinical and pathologic features. Giant CPs containing MDR has not been reported in adolescents. These giant polyps should be carefully evaluated to exclude malignant cervical lesions. This 14-year-old female with a giant CP is reported to discuss the clinical features and differential diagnosis of giant CPs in adolescents.
Received 10 June 2013; Revised 27 January 2014; accepted 29 January 2014. Address correspondence to Dr Tutku Soyer Associate Professor, Hacettepe University, Medical Faculty, Pediatric Surgery, Ankara, Turkey. E-mail: [email protected]
Gıant Cervıcal Polyp wıth Mesonephrıc Duct Remnants
Fetal Pediatr Pathol Downloaded from informahealthcare.com by Yale Dermatologic Surgery on 09/30/14 For personal use only.
CASE REPORT A 14-year-old female was admitted to our department with a complaint of vaginal mass. She has been followed up for dysfunctional vaginal bleeding for the last two years. She received oral contraceptives for vaginal bleeding and had anemia in her control visits. Six months before admission, two units of erythrocyte transfusion were performed because of severe anemia (Hemoglobin; 5.6 g/dL). In her medical history, menarche occurred at age 12 and she had monthly menses lasting 8 days until 3 months when she began to have prolonged vaginal bleeding. She had no history of sexual intercourse, hematologic disease and previous gynecologic evaluation. Physical examination revealed adequate stage of pubertal development (Tanner stage: M4, P5), body weight and height (>75 percentile). Vital signs were within normal limits. She had slight uterine bleeding with an intact hymen. The hymeneal opening was 2 cm in diameter and wider than normal size (10 mm) in adolescents [3]. In rectal examination, a palpable mass was detected anterior to rectum. She had sense of protruding mass during straining.
Figure 1. Pelvic MRI showing polypoid mass in uterine cervix (arrow). The uterine cavity was distended with blood. C Informa Healthcare USA, Inc. Copyright
Fetal Pediatr Pathol Downloaded from informahealthcare.com by Yale Dermatologic Surgery on 09/30/14 For personal use only.
T. Soyer et al.
Laboratory findings including blood counts were; Hemoglobin 9,1 g/dL (N: 13.6–17.2 g/dL), hematocrit 27,2% (N: 39.5–50.3%), white blood cells 6.6 × 103 /μL (N: 4.3–10.3 × 103 /μL), platelets 270 × 103 /μL (N: 156–373 × 103 /μL). Prothrombin time, international normalized ratio (INR) and bleeding time were in normal range and bleeding disorders were excluded. Liver and renal functional tests and thyroid hormone levels were also normal. FSH (6.4mIU/mL) and LH (12.74uIU/mL) levels were normal. Other hormone levels including estradiol, total testosterone and dihydroepiandrostenedion levels were within normal limits. Also, beta HCG was negative at admission. Ultrasonographic evaluation of the pelvis showed a polypoid mass protruding from the cervical channel. Oncologic evaluation was performed to exclude vaginal rhabdomyosarcoma. Pelvic magnetic resonance imaging (MRI) revealed a 47 mm × 25 mm × 35 mm polypoid mass originating from the distal end of endometrial cavity and protruding into the vagina (Figure 1). The patient underwent cystocopy and vaginoscopy with a presumptive diagnosis of a malignant cervical lesion. Cystoscopic evaluation did not reveal a pathologic finding. During vaginoscopy, a 3.5 × 3 cm polypoid mass was detected at the 9 o’clock position of right lip of ectocervix. The mass was pedinculated and had no communication with endocervix. The mass was totally excised with electrocoagulation after transfixing suturing of the base the pedicle. Postoperative course was uneventful. Gross evaluation of polyp revealed a rubbery yellowish mass with a smooth surface (Figure 2). Light microscopy showed a CP including small round or branched glands containing inspissated eosinophilic secretions and patchy chronic inflammatory infiltrate (Figure 3). They were lined with a layer of cubic epithelium without any atypia or metaplasia. Stromal arteries showed intimal and medial thickening. Immunohistochemistry revealed positive Bcl-2 staining epithelium of the cystic remnants while normal endocervical glands were negative. Myogenin and CEA staining of mesonephric remnants were negative and a low proliferation index was found with Ki67 marker (
