What is the management for a female patient of reproductive age with an endocervical polyp and chronic inflammation with reactive cells?

Management of Endocervical Polyp with Chronic Inflammation and Reactive Cells

Simple polypectomy with histologic examination is the definitive management for an endocervical polyp with chronic inflammation and reactive cells in a reproductive-age woman, followed by routine cervical cancer screening. 1, 2

Immediate Management

Polyp Removal and Histologic Evaluation

• All endocervical polyps should be removed and sent for histologic examination, as approximately 3.7% harbor clinically significant pathology including dysplasia (0.5%), malignancy (0.1%), or atypical features. 1, 2

• Polypectomy can be performed via simple excision or hysteroscopic removal depending on polyp size and location. 3

• The finding of chronic inflammation and reactive cells on initial pathology is common (inflammatory changes occur in 27.7% of polyps) and typically represents benign reactive changes rather than neoplasia. 2

Post-Polypectomy Evaluation

Cervical Cytology Assessment

• If a Pap smear was not performed within the past year or shows atypical cells, obtain cervical cytology after polyp removal. 1, 4

• Women with benign polyps showing reactive changes have an increased incidence of ASCUS (12.7%) and AGC-NOS (6.1%) on Pap smears due to inflammatory changes, which typically resolve after polyp removal. 1

• If the Pap smear shows ASCUS or AGC-NOS in the setting of a benign polyp with inflammation, repeat cytology in 6-12 months rather than immediate colposcopy, as these findings are usually reactive. 1

HPV Testing Considerations

• HPV testing is not routinely indicated for benign endocervical polyps with only chronic inflammation and reactive cells unless cervical cytology shows abnormalities. 4

• However, if dysplasia is found on polyp histology, HPV testing should be performed as 88% of polyps with squamous intraepithelial lesions harbor HPV DNA. 4

Critical Pathology Review

What to Look For on Final Histology

• Squamous dysplasia (CIN I, II, or III): Found in approximately 0.5% of cervical polyps and may not be evident on concurrent Pap smears because polyps arise in the endocervical canal where sampling is less effective. 4, 2

• Malignancy or atypical features: Includes adenosarcoma, adenocarcinoma in situ, or invasive carcinoma, occurring in 0.1-0.6% of cases. 1, 2

• Benign findings: Chronic inflammation (27.7%), metaplasia (13.6%), and microglandular hyperplasia (6.8%) are common benign findings requiring no additional intervention. 2

Management Based on Final Histology

If Benign Polyp Confirmed

• Return to routine cervical cancer screening appropriate for age (typically co-testing every 5 years or cytology every 3 years for women 30-65 years). 5

• Counsel patient about 6.2% recurrence rate and need to report any abnormal bleeding. 2

• No additional colposcopy or endocervical sampling is needed if histology shows only chronic inflammation and reactive changes. 2

If Dysplasia Identified

• CIN I: Manage according to standard CIN guidelines with repeat cytology and HPV testing at 12 months. 5

• CIN II/III: Requires treatment with excisional procedure (LEEP or cold knife conization) and subsequent surveillance. 6, 5

• Perform colposcopy with endocervical assessment to evaluate the remainder of the cervix, as 88% of cases show no evidence of SIL elsewhere on the cervix. 4

If Glandular Neoplasia or Malignancy Found

• Diagnostic excisional procedure is mandatory, preferably cold knife conization over LEEP to obtain intact specimen with interpretable margins. 5

• Immediate colposcopy with endocervical sampling and endometrial assessment if patient is ≥35 years or has risk factors for endometrial pathology. 5, 7

Common Pitfalls to Avoid

• Do not assume all cervical polyps are benign without histologic confirmation, as 3.7% harbor significant pathology that may not be detected on Pap smear alone. 1

• Do not perform aggressive workup for ASCUS or AGC-NOS Pap results in the setting of a benign inflammatory polyp, as these findings are typically reactive and resolve after polyp removal. 1

• Do not miss dysplasia arising within the polyp itself, as squamous intraepithelial lesions can occur de novo in endocervical polyps and may not be evident on colposcopic examination of the ectocervix. 4

• Do not forget to counsel about recurrence, as 6.2% of patients will develop another polyp requiring surveillance for abnormal bleeding. 2