Atypical polypoid adenomyoma follow-up and management

Abstract

Background: Atypical polypoid adenomyoma (APA) is a rare uterine tumor typically found in fertile age and associated with infertility. Among young nullipara women, conservative treatment is proposed despite the high recurrence rate and the association with endometrial cancer. Our aim was to assess the risk of recurrence with different conservative treatments in fertile ages and the prevalence of malignant or pre-malignant associated lesions to better address an adequate patient counselling when treatment modalities are discussed. Methods: This study is a systematic review and meta-analysis of case reports and case series about APA management and follow-up. A literature search was carried from Medline and Scopus for studies published from January 1, 1980 to December 31, 2018. Results: We included 46 observational studies and 296 cases in fertile women. The prevalence of APA relapse was 44% (CI.95 33–57%) and was lower in cases treated with operative hysteroscopy (22%; CI.95 11–39%) than in cases treated with blind curettage and polypectomy (38%; CI.95 15–67%). The prevalence of the concomitant or during the follow-up diagnosis of endometrial carcinoma was 16% (CI.95 9–29%). The risk of cancer development during follow-up was significantly less in cases treated with histeroscopy (10.56% new cumulative diagnosis at 5 years follow up; CI.95 0–23.7%) than blind curettage and polypectomy (35.5% new cumulative diagnosis at 5 years; CI.95 11.65–52.92%; P < .05). Medical treatment with medroxyprogesterone acetate after surgery does not reduce APA recurrence. Pregnancy was observed in 79% cases in which the desire was expressed. Conclusion: This review suggests that conservative treatment performed by operative hysteroscopy is the optimal choice because it lowers the risk of recurrence, improves the accuracy of concomitant carcinoma or hyperplasia diagnosis, and leaves the possibility of future pregnancies.

Utility of a PAX2, PTEN, and β-catenin Panel in the Diagnosis of Atypical Hyperplasia/Endometrioid Intraepithelial Neoplasia in Endometrial Polyps

“…44,45 APA is associated with an increased risk of progression to endometrioid adenocarcinoma. [46][47][48] APA have molecular features similar to AH and low-grade endometrioid adenocarcinoma 44 with frequent CTNNB1 (β-catenin) mutations. 49 PMP is another rare endometrial polypoid lesion composed of complex mucinous glands with characteristic intraluminal papillary tufts.…”

“…Morules are almost always present 44,45 . APA is associated with an increased risk of progression to endometrioid adenocarcinoma 46–48 . APA have molecular features similar to AH and low-grade endometrioid adenocarcinoma 44 with frequent CTNNB1 (β-catenin) mutations 49 .…”

Biomarkers in the Diagnosis of Endometrial Precancers. Molecular Characteristics, Candidate Immunohistochemical Markers, and Promising Results of Three-Marker Panel: Current Status and Future Directions

“…APA is characterized by atypical architecturally complex endometrial glands within benign myomatous or fibromyomatous stroma, often accompanied by morules [ 94 , 95 ]. Despite its initial classification as a benign lesion, subsequent research has revealed an association with an elevated risk of progressing to endometrial adenocarcinoma [ 96 , 97 , 98 ]. PMP consists of irregular or complex mucinous glands displaying distinctive intraluminal papillary tufts and the absence of nuclear atypia.…”

The typical polypoid adenomyoma is a special form of endometrial polyp: a case-controlled study with a large sample size

“…TPAs mainly involve normal endometrial glands with interwoven smooth muscle stroma [ 5 , 6 ]. In contrast, the APAs are lesions with unspecified malignant potential due to a crowded, irregular, and complex glandular epithelium along with abundant, chaotic, and lose smooth muscle stroma, which can resemble atypical endometrial hyperplasia [ 7 , 8 ].…”