Teaching Case

An elderly G1P1 woman with a history of subtotal hysterectomy and right oophorectomy after a cesarean section at 38 years of age, resected colon carcinoma over 20 years ago, hypertension presented with severe vaginal bleeding with discharge of clots and "cerebroid" material, hypotension, mental confusion and anaemia.

Transvaginal ultrasound (Fig.1) showed an enlarged uterine cervix stump after hysterectomy due to an egg-shaped echogenic mass, absence of adnexal masses and free fluid.
Immediately after stabilization including blood transfusions, multidetector CT (Fig.2) confirmed enlarged uterine cervix including a solid portion with early, progressive contrast enhancement, and nonenhancing dorsal hyperattenuation interpreted as intravaginal blood. Active bleeding and peritoneal effusion were excluded.
Further investigation with MRI confirmed a 6.5x4x3.5 cm cervical mass with heterogeneous intermediate-to-high T2 signal intensity, a central protruding portion, unspecific solid-type intermediate T1 signal intensity, and heterogeneous enhancement after intravenous gadolinium. The lesion did not show restricted diffusion similar to cervical carcinomas on high b-value (600 sec/mm2) diffusion-weighted acquisition, with mean apparent diffusion coefficient (ADC) value 1.62 × 10-3 mm2/sec. Surrounding inflammatory changes and adenopathies were absent.
Hysteroscopy confirmed a reddish endocervical polypoid mass, which was resected. Histopathology reported lobulated proliferation with colloidal content consistent with giant fibroglandular polyp.

Polypoid lesions of the uterine cervix represent a not-uncommon finding in adult women, and one of the main causes of vaginal bleeding. Patients are commonly perimenopausal (mean age 48 years), and may complain of associated symptoms such as abnormal discharge, dyspareunia, lower abdominal discomfort. Cervical polyps may be sessile or pedunculated, and display variable histological features, most usually (almost 30% of cases) inflammation, metaplasia or microglandular hyperplasia. Dysplasia, atypia and malignancy are very rare (<1% of cases) [1, 2].
The giant fibroepithelial polyp (GFEP) represents a rare pathological entity characterized by an unusually large (sometimes fist-like) size, which often grows to occupy most of the vaginal cavity. After surgical excision, histopathology is necessary to confirm absence of malignancy [1, 3].
Albeit extensively performed in the emergency setting to investigate abdomino-pelvic complaints, CT is not the ideal imaging technique for female pelvic disorders, mostly because of the poor tissue contrast compared to MRI between normal and neoplastic tissue. However, routine review studies along MRI-like sagittal and coronal planes provide an improved visualization of the normal anatomy of the vagina, uterus and adnexa thus improving the diagnostic accuracy of CT in the evaluation of the female genital organs [4-6].
Currently, MRI is the established modality of choice for characterization, pre-treatment staging and follow-up of most genital diseases, including uterine cervix carcinoma which is recognized due to its intermediate-to-high T2-signal intensity compared to the hypointense cervical stroma. MRI provides local staging, assessment of endophytic versus exophytic growth, and differentiation from non-epithelial neoplasms and non-neoplastic lesions. Among these, polyps are usually seen as masses with or without cysts filling the cervical or vaginal canal [7, 8].
Furthermore, diffusion-weighted imaging (DWI) is now being incorporated into pelvic MRI protocols. Restricted water diffusion may result from cytotoxic oedema, tissue hypercellu¬larity, or highly viscous fluid as in abscesses. With estimation of apparent diffusion coefficients (ADCs), DWI provides both qualitative and quantitative information regarding microscopic water motion, which may even prove more accurate compared to contrast-enhanced acquisitions. The ADCs of cervical cancer (median 1.09 ± 0.20×10−3 mm2/sec) are significantly lower than those of normal cervical tissue (average 1.79-2.09×10−3 mm2/sec) and of benign cervical lesions. Furthermore, well- or moderately differentiated tumours show lower mean ADC values compared to those of poorly differentiated carcinomas. Therefore, as this case demonstrates DWI has the potential to differentiate between normal cervix, benign and malignant proliferations [8-12].