Challenges in Assessing Stromal Invasion and Staging Cervical Carcinomas Arising In or Confined to Endocervical Polyps

Abstract

The staging of cervical carcinomas that appear confined to endocervical polyps presents a rare but recurring diagnostic and reporting challenge. Current classification systems, including the International Federation of Gynecology and Obstetrics (FIGO) 2018 staging system, the American Joint Committee on Cancer (AJCC) eighth edition, and College of American Pathologists (CAP) protocols, do not provide specific guidance for this scenario. Endocervical polyps are typically benign lesions, but in rare instances they may harbor invasive carcinoma. When invasion appears limited to the polyp stroma, assessment of the depth of invasion and assignment of a pathologic stage becomes challenging due to the polyp's limited, distorted, or fragmented architecture. Importantly, it is often difficult in routine practice to distinguish a truly polyp-confined carcinoma from an exophytic cervical tumor involving a polyp. This review highlights the gaps in staging of cervical carcinomas arising in or confined to endocervical polyps and draws cautious conceptual parallels to staging approaches in other organ systems, not to propose guideline changes, but to highlight existing gaps and reporting ambiguities. Currently, for reporting and staging purposes, pathologists use the same approach as that for other exophytic tumors. Here, we emphasize standardized documentation and transparent reporting of staging limitations as a practical interim approach, while acknowledging the absence of evidence sufficient to support formal staging modifications. Until additional data are available, careful descriptive reporting may facilitate clinical decision-making and enable future data collection needed to inform evidence-based revisions.

Keywords

endocervical polyp cervical carcinoma staging FIGO gynecologic pathology

Introduction

Cervical carcinomas that appear confined to endocervical polyps pose a unique interpretive challenge for surgical pathologists, largely because this scenario is not clearly addressed in major staging systems, including the International Federation of Gynecology and Obstetrics (FIGO) 2018 staging system,^1–3 the American Joint Committee on Cancer (AJCC) eighth edition, or the College of American Pathologists (CAP) protocols.⁴ The definition of a carcinoma arising in a cervical polyp was first described in 1987 as “requiring the absence of disease in the base and remaining cervical tissue.”⁵ Although tumors involving polyps may appear circumscribed, it is often not possible to determine with certainty whether invasion is truly limited to the polyp or represents an exophytic growth pattern arising from the cervical wall.

This article is intended as a narrative review and interpretive perspective, based on published literature and professional experience, rather than a proposal for immediate staging revisions. The discussion covers human papillomavirus (HPV)-associated adenocarcinomas and squamous cell carcinomas (SCCs), which share a common HPV-driven pathogenesis, though they may differ in certain molecular and clinical characteristics^6,7 However, HPV-independent adenocarcinomas, particularly gastric-type adenocarcinoma (GAS), represent biologically distinct entities for which the considerations discussed here may not be applicable.⁸

Endocervical Polyps: Histologic and Clinical Considerations

Endocervical polyps are benign, often incidental, exophytic growths protruding from the surface of the cervical canal. They are composed of a fibrovascular core containing blood vessels of varying sizes, often including thick-walled arteries, lined by endocervical glandular epithelium with variable squamous metaplasia.^9–13 These common lesions typically arise in the endocervical canal of women aged 40 to 60 years.

Large retrospective studies demonstrate that premalignant and malignant lesions in endocervical polyps are uncommon but not negligible. Schnatz et al reported that approximately 2.7% of cervical polyps in women under age 50 may harbor premalignant or malignant lesions, while such findings are exceedingly rare in women under 20.^14–17 The overall prevalence of malignancy ranges from 0.1% to 0.3% across multiple large series, with dysplasia identified in 0.4% to 0.7% of patients.^12,14–16 Importantly, the prevalence of any abnormality (malignancy, dysplasia, or atypia) is significantly lower in postmenopausal women (1.4%) compared with premenopausal women (2.7%).¹⁴

Both SCC and adenocarcinoma can arise within endocervical polyps, though primary invasive carcinoma originating within a polyp is distinctly rare. Park et al identified high-grade squamous intraepithelial lesions (HSILs) in 1.1% and SCC in 0.1% of 1905 endocervical polyps over a 12-year period.¹² Squamous intraepithelial lesions (SILs) occurring in endocervical polyps are frequently HPV-associated, with HPV DNA detected in 88% of lesions by in situ hybridization.¹⁰ Importantly, in 8 of 9 patients with SILs arising in polyps, there was no evidence of dysplasia on colposcopic examination or biopsy of the remainder of the cervix, suggesting that these lesions can occur de novo within the polyp.¹⁰

Adenocarcinoma arising within endocervical polyps has also been documented, though most malignancies identified in polyps represent metastatic involvement from endometrial or other sources rather than primary cervical lesions.^15–17 The National Comprehensive Cancer Network (NCCN) Cervical Cancer Guidelines recognize that endocervical adenocarcinoma can demonstrate “stromal invasion and/or exophytic invasion,” acknowledging polyps or polyp-like lesions as distinct presentation patterns.^18,19 Most primary cervical adenocarcinomas are HPV-associated usual-type, which are caused almost exclusively by HPV-16, -18, and -45.²⁰ Rarer variants include endometrioid, clear cell, mesonephric, and gastric-type subtypes, with the latter being HPV-independent and associated with more aggressive behavior.²¹

Cervical SCCs account for approximately 75% of cervical carcinomas worldwide and arise on the ectocervix, with the majority (>90%) being HPV-associated, most commonly with high-risk HPV types 16 and 18.^22,23 Adenocarcinomas comprise 20% to 25% of cervical cancers and develop in the endocervical canal, with adenocarcinoma in situ (AIS) as the precursor lesion.^18,22,23 Unlike SILs, where invasion is not a concern for staging purposes, invasive carcinomas (whether squamous or glandular) require careful assessment of stromal invasion to assign stage and predict lymph node metastasis risk.^22,24

The development of invasive carcinoma within endocervical polyps may be linked to chronic inflammation, hormonal exposure, or underlying dysplasia. When invasion arises in a polyp, the altered stromal architecture of the fibrovascular core differs substantially from the underlying cervical wall stroma, complicating direct application of depth-based staging metrics and necessitating careful identification of the presumptive point of origin.²⁵ Correlation with imaging—particularly MRI to assess cervical stromal involvement and tumor extent—and multidisciplinary discussion become essential for accurate staging and treatment planning.²⁶

Current Staging Systems and Their Limitations

For measurement purposes, the International Society of Gynecological Pathologists (ISGyP) recommends that depth of stromal invasion be measured from the basement membrane of the surface epithelium or the point of origin to the deepest point of invasion.²⁵ According to the CAP protocol for examination of resection specimens from patients with primary carcinoma of the uterine cervix,⁴ accurate measurement of stromal invasion is essential for FIGO and AJCC staging for both SCC and HPV-associated adenocarcinoma.^{18,22,24,25,27} FIGO stage IA is defined as invasive carcinoma diagnosed only by microscopy with maximum depth of invasion ≤5 mm, subdivided into IA1 (stromal invasion ≤3 mm) and IA2 (stromal invasion >3 mm and ≤5 mm).^18,22,27 For stage IB and beyond, both depth of invasion and tumor size (maximum diameter) become critical staging parameters.^25,28 In SCC, the depth of invasion is a particularly important risk factor for recurrence, while in cervical adenocarcinoma, tumor size becomes more pronounced as a risk factor, especially in the presence of lymphovascular space invasion (LVSI).¹⁸ The Gynecologic Oncology Group (GOG)/Sedlis criteria for adjuvant radiation after radical hysterectomy stratify risk based on the combination of LVSI, depth of stromal invasion (superficial, middle, or deep third), and tumor size, reflecting the clinical importance of accurate depth measurement.^29–31

In addition, tumors that are predominantly or entirely exophytic—where there is little or no invasion into the underlying stroma—should not be regarded as in situ. Instead, the tumor thickness should be measured from the surface of the tumor to the deepest point of invasion. Furthermore, the depth of invasion should not be reported relative to the epithelial origin, as this may not truly reflect the biological potential of these tumors.^4,32

The Silva pattern-based classification system provides a complementary approach for risk stratification of HPV-associated endocervical adenocarcinomas based on the destructiveness of stromal invasion rather than absolute depth.¹⁸ Pattern A tumors demonstrate non-destructive invasion with well-demarcated rounded glands without solid growth, single stromal cells, desmoplastic stromal response, or LVSI, and have excellent survival without lymph node metastases or recurrences.^18,33,34 Pattern B shows localized (early) destructive stromal invasion arising from well-demarcated glands, while Pattern C demonstrates diffuse destructive stromal invasion or solid growth.¹⁸ Recent studies suggest combining pattern A and pattern B without LVSI into a low-risk group and pattern B with LVSI and pattern C into a high-risk group, as this binary classification demonstrates improved interobserver agreement and superior prognostic stratification.^18,33–36

However, handling lesions where tumors appear to arise from within an endocervical polyp presents unique challenges that differ from tumors that are predominantly or entirely exophytic. Both the 2018 FIGO staging system¹ and the 2020 AJCC system²⁸ address exophytic tumors but do not provide specific guidance for carcinomas arising within polyps.^19,25,28

The endocervical stroma refers to the supporting tissue of the endocervix beneath the epithelium, composed of dense fibro-muscular tissue containing vessels, lymphatic systems, and nerves.³⁷ Although endocervical polyps also possess a surface epithelium and an underlying stroma like the adjacent or underlying (deep to the polyp) endocervical tissue, the stromal architecture differs substantially. The fibrovascular core of endocervical polyps contains blood vessels of varying sizes, often including thick-walled arteries, embedded within a stromal framework that is distinct from the native cervical wall stroma.^13,15,38 This altered architecture complicates the assessment of depth of invasion in polyp-based lesions.

The ambiguity in assigning a stage to lesions arising within endocervical polyps potentially leads to inconsistent reporting and management strategies. When invasion arises in a polyp, pathologists must carefully identify the presumptive point of origin within the altered stromal architecture and measure to the deepest invasive focus, but the biological significance of invasion depth measured within the polyp's fibrovascular core versus invasion into the underlying cervical wall stroma remains unclear.²⁵ This uncertainty is compounded by the fact that the fibrovascular stroma of polyps may have different immunophenotypic characteristics compared to native endocervical stroma, with studies demonstrating differential expression of CD34 and CD10 between endocervical and endometrial stromal cells.³⁹ Furthermore, the pattern-based Silva classification system for HPV-associated endocervical adenocarcinomas, which stratifies tumors based on the destructiveness of stromal invasion rather than absolute depth, may offer complementary prognostic information in polyp-based lesions.⁴⁰ However, its application to tumors arising within polyps has not been systematically studied, and the distinction between non-destructive invasion (Pattern A) and AIS can be particularly challenging in the context of a polyp's altered architecture.^40,41

Lessons From Other Organ Systems

The challenge of staging carcinomas arising within polyps has been addressed in other organ systems, providing conceptual frameworks that may inform approaches to cervical carcinomas confined to endocervical polyps. However, it is important to acknowledge that these analogies are drawn from tumor types with substantially larger evidence bases and distinct biological behaviors, and their direct applicability to cervical carcinomas in polyps (currently supported by only limited case reports) requires cautious interpretation and prospective validation.

Endometrial Carcinoma

The 2023 FIGO staging system for endometrial cancer explicitly addresses carcinomas confined to polyps, defining stage IA1 as non-aggressive histological type (ie, low-grade endometrial endometrioid carcinomas) limited to an endometrial polyp or confined to the endometrium, whereas stage IC includes aggressive histological types (serous, high-grade endometrioid, clear cell, mesonephric-like, carcinosarcoma, undifferentiated, gastrointestinal-type mucinous, and mixed) within a polyp or confined to the endometrium without myometrial invasion.^42,43 This staging framework is evidence-based and supported by studies demonstrating that endometrial carcinomas confined to polyps or restricted to the endometrium are associated with favorable prognosis regardless of the histologic subtype.^44–47

Vulvar Squamous Cell Carcinoma

In vulvar carcinoma, tumor thickness and depth of invasion are measured separately,⁴⁸ with tumor thickness excluded from staging because vulvar carcinomas can have significant exophytic components.⁴⁹ The 2021 FIGO staging system adopted an alternative method to measure depth of invasion: the distance from the basement membrane of the deepest, adjacent, dysplastic, tumor-free rete ridge (or nearest dysplastic rete peg) to the deepest point of invasion, rather than the previous method measuring from the epithelial-stromal junction of the adjacent most superficial dermal papilla.^24,49–51 This prompts down-staging some conventional stage IB (tumor size greater than 2 cm or stromal invasion greater than 1 mm) tumors to IA (tumor size less than or equal to 2 cm and stromal invasion less than or equal to 1 mm). Patients who are down-staged using this approach experience fewer inguinal recurrences, improved disease-specific survival, and lower risk of inguinal lymph node involvement at diagnosis compared to those with conventional stage IB disease, suggesting that lymphadenectomy may be avoidable in this down-staged group.^48,50,51 Several studies assessed this alternative measurement method and demonstrated its prognostic superiority, findings that have been subsequently validated.^52,53

Colorectal Carcinoma

In colorectal pathology, the management of carcinomas arising in polyps has been extensively studied because the depth of submucosal invasion is a critical determinant of lymph node metastasis risk and guides the necessity for additional surgical intervention.^54–57 The Haggitt classification, proposed in 1985, stratifies pedunculated polyps into levels based on the extent of invasion: level 1 (invasion into the head of the polyp), level 2 (invasion into the neck), level 3 (invasion into the stalk), and level 4 (invasion beyond the stalk into the submucosa).^58–60 In Haggitt's original study of 129 patients, when invasion was limited to the head, neck, or stalk (levels 1-3), there were no lymph node metastases and only 1 of 101 patients died with colorectal cancer; in contrast, 7 of 28 patients (25%) with level 4 invasion were diagnosed with lymph node or systemic metastasis.⁶⁰ For sessile polyps and poorly oriented or fragmented specimens, the Kikuchi classification may be used to assess the depth of submucosal invasion, where submucosal involvement is divided into superficial (SM1), mid (SM2), and deep (SM3) levels, with lymph node metastasis rates of 3.4%, 8.5%, and 22.6%, respectively.^61–63

Implications for Cervical Carcinoma in Endocervical Polyps

These data from endometrial, vulvar, and colorectal tumor systems highlight the importance of potentially integrating scenarios of carcinoma arising in endocervical polyps into the FIGO and AJCC staging systems. However, several critical differences must be acknowledged. The endometrial polyp staging categories emerged from substantial outcome data demonstrating favorable prognosis for polyp-confined disease. The vulvar depth of invasion methodology was validated in studies with clinical outcome correlation. The colorectal Haggitt and Kikuchi classifications are supported by decades of accumulated evidence from thousands of patients with lymph node metastasis data.

In contrast, the current discussion of cervical carcinomas confined to endocervical polyps is based on extremely limited case reports, representing a completely different tumor type with distinct biology, HPV association patterns, and metastatic behavior. The extrapolation of frameworks from these other organ systems, while conceptually logical, requires prospective data collection and validation before any staging recommendations can be made. The primary value of these analogies lies in demonstrating that other staging systems have successfully addressed the challenge of carcinomas arising in polyps, providing a rationale for developing similar approaches for cervical carcinomas, but not in directly applying their specific criteria to cervical lesions without supporting evidence.

Future efforts should focus on systematic documentation of cervical carcinomas arising in endocervical polyps, including detailed pathologic parameters (depth of invasion within the polyp, invasion into underlying cervical stroma, tumor size, LVSI, Silva pattern for adenocarcinomas), clinical outcomes, and lymph node status, to establish an evidence base that could eventually inform staging recommendations specific to this rare presentation.

Histopathologic Challenges in Endocervical Polyp-Confined Carcinomas

The classification systems discussed above—including the Haggitt and Kikuchi classifications for colorectal carcinomas and the alternative depth measurement methods for vulvar SCC—cannot be directly applied to endocervical polyps. Unlike colorectal polyps, endocervical polyps lack a submucosa and may not always have a histologically identifiable stalk.^19,64 The fibrovascular core of endocervical polyps, while containing stromal tissue, differs fundamentally from the layered architecture of the colorectal wall that underlies the Haggitt and Kikuchi systems.

Furthermore, the nature of the specimen received significantly impacts the ability to assess invasion. Specimens may be received fragmented and unoriented (Figure 1) depending on the procedure performed: resection versus polypectomy versus excisional biopsy (cone, LEEP, LLETZ) versus curettage.^4,32,64 The NCCN Guidelines emphasize that the intent of a cone biopsy is to remove the ectocervix and endocervical canal en bloc using a scalpel, providing the pathologist with an intact, non-fragmented specimen without electrosurgical artifact, which facilitates margin status evaluation. When a LEEP is chosen for treatment, the specimen should not be fragmented, and care must be undertaken to minimize electrosurgical artifact at the margins.

Figure 1.

Invasive endocervical adenocarcinoma, HPV-associated, arising in and confined to an endocervical polyp. Hematoxylin and eosin (H&E)-stained sections of endocervical curettage specimen examined at 40× (A) objective, and surgical resection specimen examined at 20× (B) and 200× (C) objectives. Positive high-risk HPV RNA in situ hybridization, DAB staining examined at 200× objective (D). The schematic was created in BioRender (2025) https://BioRender.com/cnxoveb.

However, in practice, specimens are frequently suboptimal.¹⁹

Studies have demonstrated that biopsy specimens frequently underrepresent the presence and extent of stromal invasion. Djordjevic and Parra-Herran found that while the pattern of invasion on cone/LEEP specimens correlated with the overall pattern on hysterectomy in 92.8% of tumors, agreement between patterns in biopsy and the overall tumor was only 37.5%.⁶⁴ In all discrepant instances, biopsy failed to reveal destructive invasion that was evident on excision.⁶⁴ Similarly, Spasić et al reported that in papillary SCC (an exophytic variant), 94% of presurgical biopsies showed no evidence of stromal invasion, yet 76.5% of subsequent excision specimens demonstrated invasive carcinoma.⁶⁵ Besides, Rivera-Colon et al found that the pattern of invasion could be classified in only 50% of cervical biopsies for adenocarcinoma, compared with 100% of resection specimens.⁶⁶

When specimens are fragmented, poorly oriented, or limited to biopsy or curettage material, it is often inappropriate to assign a definitive pathologic stage due to the inability to accurately assess invasion. In such scenarios, the pathology report should clearly state the limitations and defer staging. The Association of Directors of Anatomic and Surgical Pathology recommends that the maximum depth of invasion by tumor into the cervical stroma, in millimeters or the proportion of the wall involved, should be recorded, with the depth of invasion measured from the base of the epithelium of the presumptive point of origin, whether squamous or glandular.^24,67 However, when this measurement cannot be reliably performed, the report should explicitly acknowledge this limitation.

The presence of invasive carcinoma confined to a polyp, without stromal invasion beyond or deep to the polyp into the underlying endocervical tissue, complicates staging even further. No published guidelines explicitly address this scenario or incorporate it into any staging system or classification. The literature contains only a limited number of published case reports with adequate follow-up or prognostic data describing carcinomas confined to endocervical polyps. Berzolla et al reported that in a series of 2246 cervical polyps, malignancy was diagnosed in only 0.1% of specimens, and because no tumors represented primary malignancies arising de novo within polyps, the authors concluded that progression of cervical polyps to malignancy appears unlikely.¹⁵

To support the relevance of this diagnostic challenge, we compiled previously published reports (Table 1) and briefly reviewed available outcomes, where reported. These data, though limited, suggest that some of these carcinomas may exhibit indolent behavior when confined to polyps. However, the small number of reported tumors and the heterogeneity of follow-up intervals preclude definitive conclusions about prognosis. For HPV-associated adenocarcinomas, the Silva pattern-based classification may provide complementary prognostic information, as Pattern A tumors have demonstrated excellent survival without lymph node metastasis or recurrence. Whether this favorable prognosis extends to Pattern A tumors arising within polyps remains to be determined. For SCC, the stage-for-stage prognosis is not dissimilar to that for adenocarcinoma, though adenosquamous and clear cell histologies may have inferior recurrence-free survival.^22,71

Table 1.

Three Case Reports of Invasive Cervical Carcinoma Arising In and Confined to Endocervical Polyp Reported in Literature.

Authors (Year)	Patient Age	Presentation	Polyp Size	Cytology	Histologic Type	Associated Findings	Nodal Status	Management	Residual Disease
Fındık and Görkemli (2017) ⁶⁸	41 years	3-Month abnormal vaginal bleeding	1 cm	Not reported	VGA	HSIL	No nodal dissection	Polypectomy + HBS	No residual tumor
Hasegawa-Nakajima et al (2020) ⁶⁹	63 years	Asymptomatic	0.5 cm	Negative pap smear	VGA	HSIL	No nodal dissection	Polypectomy + cone biopsy + HBSO	No residual tumor
Gupta et al (2024) ⁷⁰	38 years	Secondary infertility and 5-year abnormal uterine bleeding; background endometriosis and adenomyosis	3 cm	Negative pap smear	Usual-type invasive adenocarcinoma	Chronic cervicitis	No nodal dissection	Polypectomy + HBSO	No residual tumor

HBS: hysterectomy with bilateral salpingectomy; HBSO: hysterectomy with bilateral salpingo-oophorectomy; HSIL: high-grade squamous intraepithelial lesion; VGA: villoglandular papillary adenocarcinoma.

Considerations for Documentation and Reporting

Given the histopathologic challenges outlined above, standardized documentation is essential for carcinomas arising in endocervical polyps. Pathology reports should include: (a) tumor size (maximum diameter), histologic type, and HPV status; (b) whether invasion is confined to the polyp or extends into underlying cervical stroma; (c) depth of invasion within the polyp (if measurable); (d) presence or absence of LVSI; (e) margin status; (f) Silva pattern for HPV-associated adenocarcinomas; and (g) explicit acknowledgment of any limitations in staging due to specimen fragmentation, orientation, or the unique architecture of polyp-based lesions. This standardized documentation will facilitate future data collection and enable the development of evidence-based staging recommendations for this rare but clinically important presentation. To address these issues, we suggest the following considerations.

Histopathological Assessment

Pathologists are advised to meticulously evaluate the polyp to determine the extent of stromal invasion within or beyond the polyp. The depth of invasion should be measured from the base of the epithelium—whether squamous epithelial surface or an endocervical gland at the surface—that is involved by invasive adenocarcinoma to the deepest point of invasion.^42,43 This approach aligns with the FIGO and AJCC staging systems, which measure depth from the base of the epithelium of the presumptive point of origin.^42,43,46

If the invasive focus or foci are not in continuity with the surface epithelium, the depth of invasion should be measured from the deepest focus of tumor invasion to the base of the nearest surface epithelium or endocervical gland at the surface that is involved by invasive adenocarcinoma. If the invasive carcinoma is exclusively or predominantly exophytic and confined to the polyp, this should not be regarded as in situ lesion and the tumor thickness (from the surface of the tumor to the deepest point of invasion) should be measured, consistent with CAP protocol recommendations for exophytic tumors.⁴⁷

When measurement of the depth of invasion is not feasible, for example, in specimens with multiple invasive foci or significant fragmentation, the greatest linear dimension (maximum tumor diameter) should be measured microscopically and clearly stated on the pathology report. The pathology report should also clearly document the reason the depth of invasion cannot be assessed and explain why only the greatest linear dimension is provided. Whether the invasion is confined within the polyp stroma or extends beyond and deep to the polyp into the underlying cervical stroma should be clearly documented. This distinction is critical because the biological behavior of carcinomas confined to polyps may differ from those with cervical stromal invasion, though data remain limited.

To facilitate systematic data collection, we propose that the CAP protocol be extended to include documentation of polyp involvement. Under the “TUMOR” heading, the section “+Tumor Site (select all that apply)” can be extended to include “___ Endocervical Polyp.” Additionally, besides documenting “Depth of Stromal Invasion,” “+Extent of Depth of Stromal Invasion,” “+Horizontal Extent of Stromal Invasion,” and “+Silva System for Invasion,” an additional section could indicate whether the invasive carcinoma arose and is confined to a polyp or not. Gathering data on this opens the door for future research and enables prediction of tumor behavior in such scenarios. This approach provides critical insights into whether the scenario of carcinoma arising within a polyp should be incorporated into staging systems based on its prognostic significance or distinct tumor behavior.

Staging Assignment

In occasions where invasive carcinoma is confined to the polyp stroma and there is no evidence of underlying cervical stromal invasion (beyond and deep to the polyp), it is reasonable, for the time being, to consider staging by measuring the tumor depth of invasion—when possible—and sub-staging based on the 2018 FIGO staging system¹ and the 2020 AJCC system.^28,42,43,46 This approach would essentially only include pT1 tumors (FIGO stage I), as carcinomas confined to polyps without cervical stromal invasion would by definition be limited to the cervix. The 2018 FIGO staging system defines stage IA as invasive carcinoma diagnosed only by microscopy with maximum depth of invasion ≤5 mm (IA1: ≤3 mm; IA2: >3 mm and ≤5 mm), while stage IB includes tumors with depth >5 mm or visible lesions, further subdivided by greatest dimension (IB1: ≤2 cm; IB2: >2 cm and ≤4 cm; IB3: >4 cm).^42,43

However, this approach should be applied cautiously, acknowledging the lack of explicit guidelines addressing carcinomas arising in polyps. The ISGyP has provided recommendations for tumor staging of endocervical adenocarcinoma, emphasizing that pathologic findings are crucial in determining stage for early-stage disease, which in turn determines treatment and prognosis.⁷² Yet these recommendations do not specifically address the unique scenario of polyp-confined carcinomas.

If a stage cannot be assigned due to specimen limitations or the unique architecture of polyp-based lesions, the pathology report may include a comment on the staging ambiguity due to current guideline limitations. For example: “Note: Most of the invasive component is confined to an endocervical polyp. The depth of invasion within the polyp measures [X] mm. The area of invasion shows focal destructive invasion (Silva pattern C). No invasion into the underlying cervical stroma is identified. Current staging guidelines do not explicitly address carcinomas confined to endocervical polyps; therefore, definitive staging cannot be assigned. Clinical correlation and multidisciplinary discussion are recommended.” This transparency aids in proper clinical decision-making and helps with future risk stratification and assessment.

Need for Guideline Updates

Rather than proposing immediate changes to staging protocols, professional societies such as FIGO, CAP, and ISGyP are encouraged to advocate for broader documentation and study of carcinomas confined to polyps. The International Collaboration on Cancer Reporting (ICCR) (an alliance formed by the Royal Colleges of Pathologists of Australasia and the United Kingdom, the CAP, the Canadian Partnership Against Cancer, and the European Society of Pathology) has developed standardized, evidence-based reporting data sets for cervical carcinomas.⁷³ This collaborative framework provides an ideal mechanism for incorporating polyp-specific documentation elements.

This initiative may, in the future, support formal revisions to existing guidelines. It could eventually lead to updates in the staging guidelines and reporting protocols to explicitly address tumors confined to endocervical polyps. Incorporating such criteria would enhance the accuracy of staging and treatment planning. The revised 2018 FIGO staging system was developed through review of literature and consensus view of the FIGO Gynecologic Oncology Committee and related societies, with the explicit conclusion that “data collection and publication will inform future revisions.” Systematic documentation of polyp-confined carcinomas represents an opportunity to generate the evidence base necessary for such future revisions.⁴⁶

Until formal guidelines are established, pathologists are encouraged to document all relevant histopathologic parameters in detail, clinicians should review these tumors in multidisciplinary tumor board discussions, and institutions should contribute data to registries or structured case series that may ultimately inform evidence-based staging recommendations for this rare but clinically important presentation.

Conclusions

The staging of invasive cervical carcinomas—both SCC and adenocarcinoma—confined to endocervical polyps remains a significant diagnostic challenge due to the absence of clear guidance in current staging systems, including the FIGO, AJCC, and CAP protocols. The unique histologic architecture of endocervical polyps, characterized by a fibrovascular core that differs fundamentally from native cervical stroma, complicates the direct application of depth-based staging metrics designed for conventional cervical carcinomas. Furthermore, the frequent receipt of fragmented or poorly oriented specimens compounds the difficulty in accurately assessing the extent of invasion within the polyp.

This narrative review highlights the need for updated staging guidance to better address tumors arising in endocervical polyps. However, until formal guidelines are established, pathologists—particularly gynecologic pathologists—are advised to provide comprehensive pathology reports detailing the criteria outlined above: tumor size (maximum diameter), histologic type, HPV status, whether invasion is confined to the polyp or extends into underlying cervical stroma, depth of invasion within the polyp (when measurable), presence or absence of LVSI, margin status, Silva pattern for HPV-associated adenocarcinomas, and explicit acknowledgment of any limitations in staging due to specimen quality or the unique architecture of polyp-based lesions. This standardized documentation could improve staging accuracy, clinical decision-making, and prognostication.

Future research, ideally involving international collaborations among pathologists, gynecologic oncologists, and professional societies, is needed to validate whether carcinomas arising within endocervical polyps exhibit distinct biological behavior that merits unique staging criteria. Systematic data collection through registries and multi-institutional case series will be essential to generate the evidence base necessary for future guideline revisions. Ultimately, clear and standardized criteria will facilitate more precise treatment strategies and potentially improve outcomes for patients with these rare but clinically important presentations.

Footnotes

Acknowledgments

Figure 1 was created with BioRender.com (accessed in October 2025). All rights and ownership of BioRender content are reserved by BioRender. BioRender content included in the completed graphic is not licensed for any commercial uses beyond publication in a journal. For any commercial use of this figure, users may, if allowed, recreate it in BioRender under an Industry BioRender Plan.

ORCID iD

Hisham F. Bahmad

Ethical Approval

This work is mostly a narrative review without any new patient-level data generated. All images were derived from archival material used solely for illustrative purposes. Ethical approval is not applicable (No outright data included).

Institutional Review Board Statement

Not Applicable.

Informed Consent Statement

Not applicable.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The original contributions presented in this review are included in the article. Further inquiries can be directed to the senior author.

References

Bhatla

Berek

Cuello Fredes

, et al. Revised FIGO staging for carcinoma of the cervix uteri. Int J Gynaecol Obstet. 2019;145(1):129–135. doi:10.1002/ijgo.12749

Bhatla

Aoki

Sharma

Sankaranarayanan

. Cancer of the cervix uteri: 2021 update. Int J Gynaecol Obstet. 2021;155(S1):28–44. doi:10.1002/ijgo.13865

Corrigendum to “revised FIGO staging for carcinoma of the cervix uteri” [Int J Gynecol Obstet 145(2019) 129-135]. Int J Gynaecol Obstet. 2019;147(2):279–280. doi:10.1002/ijgo.12969

Krishnamurti

Crothers

Birdsong

Klepeis

Movahedi-Lankarani

Otis

CN.

Protocol for the examination of resection specimens from patients with primary carcinoma of the uterine cervix; 2023. https://documents.cap.org/documents/Cervix_5.1.1.0.REL_CAPCP.pdf?_gl=1*u6vrvc*_ga*MTQxNzQyNzI2Ni4xNzEzODE0NTg1*_ga_97ZFJSQQ0X*MTc0NTI3NTc0MC4xNS4wLjE3NDUyNzYxMTQuMC4wLjA

Ferenczy

Winkler

. Benign diseases of the cervix. In: Kurman

, ed. Blaustein’s pathology of the female genital tract. 3rd ed. Springer-Verlag; 1987:158–176.

Stolnicu

Hoang

Chiu

, et al. Clinical outcomes of HPV-associated and unassociated endocervical adenocarcinomas categorized by the International Endocervical Adenocarcinoma Criteria and Classification (IECC). Am J Surg Pathol. 2019;43(4):466–474. doi:10.1097/pas.0000000000001224

Stolnicu

Hoang

Soslow

. Recent advances in invasive adenocarcinoma of the cervix. Virchows Arch. Nov 2019;475(5):537–549. doi:10.1007/s00428-019-02601-0

Nishio

Matsuda

Iwata

Yamagami

. Gastric-type adenocarcinoma of the uterine cervix: clinical features and future directions. Jpn J Clin Oncol. 2024;54(5):516–520. doi:10.1093/jjco/hyae019

Alkilani

Apodaca-Ramos

10.

Chin

Platt

Nuovo

. Squamous intraepithelial lesions arising in benign endocervical polyps: a report of 9 cases with correlation to the Pap smears, HPV analysis, and immunoprofile. Int J Gynecol Pathol. 2008;27(4):582–590. doi:10.1097/PGP.0b013e31817e0928

11.

Angra

McCluggage

. Endocervical polyp with florid “epidermal metaplasia”: report of a previously undescribed phenomenon. Int J Gynecol Pathol. 2016;35(5):478–481. doi:10.1097/pgp.0000000000000288

12.

Park

Kim

Koh

Yoon

Bae

Kim

. Clinicopathological characteristics of squamous cell carcinoma and high-grade squamous intraepithelial lesions involving endocervical polyps. In Vivo. 2020;34(5):2613–2621. doi:10.21873/invivo.12079

13.

Wheeler

Kurman

. The relationship of glands to thick-wall blood vessels as a marker of invasion in endocervical adenocarcinoma. Int J Gynecol Pathol. 2005;24(2):125–130. doi:10.1097/01.pgp.0000152025.45106.6d

14.

Schnatz

Ricci

O'Sullivan

. Cervical polyps in postmenopausal women: is there a difference in risk? Menopause. 2009;16(3):524–528. doi:10.1097/gme.0b013e3181927286

15.

Berzolla

Schnatz

O’Sullivan

Bansal

Mandavilli

Sorosky

. Dysplasia and malignancy in endocervical polyps. J Womens Health (Larchmt). 2007;16(9):1317–1321. doi:10.1089/jwh.2007.0408

16.

Esim Buyukbayrak

Karageyim Karsidag

Kars

, et al.Cervical polyps: evaluation of routine removal and need for accompanying D&C. Arch Gynecol Obstet. 2011;283(3):581–584. doi:10.1007/s00404-010-1405-5

17.

Levy

Kumarapeli

Spencer

Quick

. Cervical polyps: is histologic evaluation necessary? Pathol Res Pract. 2016;212(9):800–803. doi:10.1016/j.prp.2016.06.010

18.

Abu-Rustum

Campos

Amarnath

, et al. Cervical cancer, version 2.2026, NCCN clinical practice guidelines in oncology. J Natl Compr Cancer Network. 2025;23(12):549–573.

19.

National Comprehensive Cancer Network. Cervical Cancer (Version 2.2026). 2026. NCCN Clinical Practice Guidelines in Oncology. Accessed 01/26/2026. https://www.nccn.org/professionals/physician_gls/pdf/cervical.pdf

20.

Perkins

Wentzensen

Guido

Schiffman

. Cervical cancer screening: a review. JAMA. 2023;330(6):547–558. doi:10.1001/jama.2023.13174

21.

McCluggage

. New developments in endocervical glandular lesions. Histopathology. 2013;62(1):138–160. doi:10.1111/his.12012

22.

Tewari

. Cervical cancer. N Engl J Med. 2025;392(1):56–71. doi:10.1056/NEJMra2404457

23.

Arafah

Rashid

Tulbah

Akhtar

. Carcinomas of the uterine cervix: comprehensive review with an update on pathogenesis, nomenclature of precursor and invasive lesions, and differential diagnostic considerations. Adv Anat Pathol. 2021;28(3):150–170. doi:10.1097/pap.0000000000000300

24.

Darragh

Colgan

Thomas Cox

, et al. The lower anogenital squamous terminology standardization project for HPV-associated lesions: background and consensus recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology. Int J Gynecol Pathol. 2013;32(1):76–115. doi:10.1097/PGP.0b013e31826916c7

25.

Park

Roma

Singh

, et al. Tumor staging of endocervical adenocarcinoma: recommendations from the international society of gynecological pathologists. Int J Gynecol Pathol. 2021;40(Suppl. 1):S92–s101. doi:10.1097/pgp.0000000000000758

26.

Halle

Bozickovic

Forsse

, et al. Clinicopathological and radiological stratification within FIGO 2018 stages improves risk-prediction in cervical cancer. Gynecol Oncol. 2024;181:110–117. doi:10.1016/j.ygyno.2023.12.014

27.

Zhou

Beavis

Lin

, et al. Embracing and implementing the WHO cervical cancer elimination campaign goals: a consensus statement by SGO, ACOG, ASCCP, ASTRO, and ABS on minimum quality care standards for cervical cancer patients in the U.S. Gynecol Oncol. 2025;200:193–202. doi:10.1016/j.ygyno.2025.08.007

28.

Olawaiye

Baker

Washington

Mutch

. The new (version 9) American Joint Committee on Cancer tumor, node, metastasis staging for cervical cancer. CA Cancer J Clin. 2021;71(4):287–298. doi:10.3322/caac.21663

29.

Alonso-Espías

Gorostidi

Gracia

, et al. Role of adjuvant radiotherapy in patients with cervical cancer undergoing radical hysterectomy. J Pers Med. 2023;13(10). doi:10.3390/jpm13101486

30.

Sedlis

Bundy

Rotman

Lentz

Muderspach

Zaino

. A randomized trial of pelvic radiation therapy versus no further therapy in selected patients with stage IB carcinoma of the cervix after radical hysterectomy and pelvic lymphadenectomy: a gynecologic oncology group study. Gynecol Oncol. 1999;73(2):177–183. doi:10.1006/gyno.1999.5387

31.

da Silva

Molino

GOG

Dias

MMF

, et al. Adjuvant radiotherapy for intermediate-risk early-stage cervical cancer post radical hysterectomy: a systematic review and meta-analysis. J Clin Med. 2025;14(11). doi:10.3390/jcm14114002

32.

Crothers

Krishnamurti

Birdsong

Klepeis

Movahedi-Lankarani

Otis

. Protocol for the Examination of Excision Specimens From Patients With Primary Carcinoma of the Uterine Cervix 2023. https://documents.cap.org/documents/Cervix.Bx_4.4.2.0.REL_CAPCP.pdf?_gl=1*2so820*_ga*MTQxNzQyNzI2Ni4xNzEzODE0NTg1*_ga_97ZFJSQQ0X*MTc0NTI5MDc1Mi4xOC4wLjE3NDUyOTA3NTUuMC4wLjA.

33.

Powell

Hodgson

Cohen

, et al. Improved risk prediction in human papillomavirus-associated endocervical adenocarcinoma through assessment of binary silva pattern-based classification: an international multicenter retrospective observational study led by the International Society of Gynecological Pathologists (ISGyP). Int J Gynecol Pathol. 2024;43(5):436–446. doi:10.1097/pgp.0000000000001033

34.

Matsubara

Otani

Kawakami

, et al. Cervical adenocarcinoma risk stratification using histotype and invasion pattern: a multicenter retrospective study by the KAMOGAWA Study Group. Gynecol Oncol. 2025;200:112–121. doi:10.1016/j.ygyno.2025.07.017

35.

Zyla

Dodington

Pakbaz

, et al. Assessment of interobserver agreement among gynecologic pathologists between three-tier versus binary pattern-based classification systems for HPV-associated endocervical adenocarcinoma. Am J Surg Pathol. 2024;48(12):1522–1529. doi:10.1097/pas.0000000000002289

36.

Sharma

Hodgson

Howitt

, et al. Molecular correlates of invasion pattern in HPV-associated endocervical adenocarcinoma: emergence of two distinct risk-stratified tiers. Histopathology. 2023;82(7):1067–1078. doi:10.1111/his.14893

37.

Prendiville

Sankaranarayanan

. Colposcopy and treatment of cervical precancer. IARC Technical Report, No. 45. ed. International Agency for Research on Cancer, World Health Organization; 2017:chap 2.

38.

Spaans

Scheunhage

Barzaghi

, et al. Independent validation of the prognostic significance of invasion patterns in endocervical adenocarcinoma: pattern A predicts excellent survival. Gynecol Oncol. 2018;151(2):196–201. doi:10.1016/j.ygyno.2018.09.013

39.

Barroeta

Pasha

Acs

Zhang

. Immunoprofile of endocervical and endometrial stromal cells and its potential application in localization of tumor involvement. Int J Gynecol Pathol. 2007;26(1):76–82. doi:10.1097/01.pgp.0000225852.74868.0c

40.

Parra-Herran

Taljaard

Djordjevic

, et al. Pattern-based classification of invasive endocervical adenocarcinoma, depth of invasion measurement and distinction from adenocarcinoma in situ: interobserver variation among gynecologic pathologists. Mod Pathol. 2016;29(8):879–892. doi:10.1038/modpathol.2016.86

41.

Ronnett

. Endocervical adenocarcinoma: selected diagnostic challenges. Mod Pathol. 2016;29(Suppl. 1):S12–S28. doi:10.1038/modpathol.2015.131

42.

Berek

Matias-Guiu

Creutzberg

, et al. FIGO Staging of endometrial cancer: 2023. J Gynecol Oncol. 2023;34(5):e85. doi:10.3802/jgo.2023.34.e85

43.

Gaffney

Matias-Guiu

Mutch

, et al. 2023 FIGO staging system for endometrial cancer: the evolution of the revolution. Gynecol Oncol. 2024;184:245–253. doi:10.1016/j.ygyno.2024.02.002

44.

Ouyang

Frimer

Hou

Wang

Goldberg

Hou

. Malignant endometrial polyps in uterine serous carcinoma: the prognostic value of polyp size and lymphovascular invasion. Int J Gynecol Cancer. 2018;28(3):524–528. doi:10.1097/igc.0000000000001213

45.

Assem

Rottmann

Finkelstein

, et al. Minimal uterine serous carcinoma and endometrial polyp: a close clinicopathological relationship. Hum Pathol. 2021;118:1–8. doi:10.1016/j.humpath.2021.09.001

46.

Bakshi

Modi

Arya

, et al. Molecular classification-driven stage migration and prognostic risk stratification in endometrial cancers: FIGO 2023 vs FIGO 2009. Virchows Arch. 2025. doi:10.1007/s00428-025-04366-1

47.

Schwameis

Fanfani

Ebner

, et al. Verification of the prognostic precision of the new 2023 FIGO staging system in endometrial cancer patients—an international pooled analysis of three ESGO accredited centres. Eur J Cancer. 2023;193:113317. doi:10.1016/j.ejca.2023.113317

48.

Turashvili

Krishnamurti

Crothers

, et al. Protocol for the Examination of Specimens From Patients With Primary Carcinoma of the Vulva . 2024. https://documents.cap.org/protocols/Vulva_5.1.0.0.REL_CAPCP.pdf?_gl=1*109zk16*_ga*MTQxNzQyNzI2Ni4xNzEzODE0NTg1*_ga_97ZFJSQQ0X*MTc0NTg4MTQ0Ni4yMy4xLjE3NDU4ODIyMDguMC4wLjA .

49.

National Comprehensive Cancer Network. Vulvar Cancer (Version 2.2026). 2026. NCCN Clinical Practice Guidelines in Oncology. Accessed 01/26/2026. https://www.nccn.org/professionals/physician_gls/pdf/vulvar.pdf

50.

van den Einden

Massuger

Jonkman

Bult

de Hullu

Bulten

. An alternative way to measure the depth of invasion of vulvar squamous cell carcinoma in relation to prognosis. Mod Pathol. 2015;28(2):295–302. doi:10.1038/modpathol.2014.103

51.

Skala

Ebott

Zhao

Lieberman

. Predictive value of an alternative strategy for measuring depth and size of stage 1 vulvar squamous cell carcinoma. J Low Genit Tract Dis. 2020;24(3):265–271. doi:10.1097/lgt.0000000000000544

52.

Khorsandi

Samghabadi

Gasper

. Comparison of the conventional and alternative methods of measuring depth of invasion of vulvar squamous cell carcinoma using whole-slide digital pathology images. Pathology. 2025;57(7):838–842. doi:10.1016/j.pathol.2025.05.011

53.

Bleeker

MCG

Bosse

van de Vijver

, et al. Does “one size fits all”? Rethinking FIGO depth of invasion measurements in vulvar cancer. Int J Gynecol Pathol. 2024;43(5):457–463. doi:10.1097/pgp.0000000000001009

54.

Williams

Pullan

Hill

, et al. Management of the malignant colorectal polyp: ACPGBI position statement. Colorectal Dis. 2013;15(Suppl. 2):1–38. doi:10.1111/codi.12262

55.

Shaukat

Kaltenbach

Dominitz

, et al. Endoscopic recognition and management strategies for malignant colorectal polyps: recommendations of the US multi-society task force on colorectal cancer. Am J Gastroenterol. 2020;115(11):1751–1767. doi:10.14309/ajg.0000000000001013

56.

National Comprehensive Cancer Network. Rectal Cancer (Version 4.2025). 2026. NCCN Clinical Practice Guidelines in Oncology. Accessed 01/26/2026. https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf

57.

National Comprehensive Cancer Network. Colon Cancer (Version 5.2025). 2026. NCCN Clinical Practice Guidelines in Oncology. Accessed 01/26/2026. https://www.nccn.org/professionals/physician_gls/pdf/colon.pdf

58.

Vogel

Felder

Bhama

, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of colon cancer. Dis Colon Rectum. 2022;65(2):148–177. doi:10.1097/dcr.0000000000002323

59.

Resch

Langner

. Risk assessment in early colorectal cancer: histological and molecular markers. Dig Dis. 2015;33(1):77–85. doi:10.1159/000366036

60.

Haggitt

Glotzbach

Soffer

Wruble

. Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. Gastroenterology. 1985;89(2):328–336. doi:10.1016/0016-5085(85)90333-6

61.

Nascimbeni

Burgart

Nivatvongs

Larson

. Risk of lymph node metastasis in T1 carcinoma of the colon and rectum. Dis Colon Rectum. 2002;45(2):200–206. doi:10.1007/s10350-004-6147-7

62.

Bosch

Teerenstra

de Wilt

Cunningham

Nagtegaal

. Predicting lymph node metastasis in pT1 colorectal cancer: a systematic review of risk factors providing rationale for therapy decisions. Endoscopy. 2013;45(10):827–834. doi:10.1055/s-0033-1344238

63.

Kikuchi

Takano

Takagi

, et al. Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines. Dis Colon Rectum. 1995;38(12):1286–1295. doi:10.1007/bf02049154

64.

Djordjevic

Parra-Herran

. Application of a pattern-based classification system for invasive endocervical adenocarcinoma in cervical biopsy, cone and loop electrosurgical excision (LEEP) material: pattern on cone and LEEP is predictive of pattern in the overall tumor. Int J Gynecol Pathol. 2016;35(5):456–466. doi:10.1097/pgp.0000000000000264

65.

Spasić

Ordobazari

Nadji

Huang

Pinto

. Papillary squamous cell carcinoma of the uterine cervix: biopsy samples frequently underrepresent the presence of stromal invasion. Int J Gynecol Pathol. 2021;40(4):408–412. doi:10.1097/pgp.0000000000000728

66.

Rivera-Colon

Chen

Niu

, et al. Cervical adenocarcinoma: histopathologic features from biopsies to predict tumor behavior. Am J Surg Pathol. 2020;44(2):247–254. doi:10.1097/pas.0000000000001379

67.

Recommendations for the reporting of surgical specimens containing uterine cervical neoplasms. Mod Pathol. 2000;13(9):1029–1033. doi:10.1038/modpathol.3880186

68.

Fındık

Görkemli

. Villoglandulary papillary adenocarcinoma co-existing with high-grade squamous intraepitelial lesion; arising from an endocervical polyp. Eur J Gen Med. 2017;14(4):119–121. doi:10.29333/ejgm/81745

69.

Hasegawa-Nakajima

Kiseki

Ikeda

. Villoglandular papillary adenocarcinoma with cervical intraepithelial neoplasia 3 of the cervix in a woman with a misdiagnosis of a cervical polyp. J Med Cases. 2020;11(12):407–410. doi:10.14740/jmc3589

70.

Gupta

Chadha

Kalwaniya

Dhir

. Rare occurrence of adenocarcinoma in an endocervical polyp: diagnostic and clinical challenges. Int J Reprod Contracept Obstet Gynecol. 2024;13(11):3371–3373. doi:10.18203/2320-1770.ijrcog20243210

71.

Grisaru

Covens

Chapman

, et al.

Does histology influence prognosis in patients with early-stage cervical carcinoma?

Cancer. 2001;92(12):2999–3004. doi:10.1002/1097-0142(20011215)92:12<2999::aid-cncr10145>3.0.co;2-1

72.

Palmieri

Mariani

Coleman

, et al. The new 2023 endometrial cancer FIGO staging system: balancing innovation with complexity. Int J Gynecol Cancer. 2025;35(8):101823. doi:10.1016/j.ijgc.2025.101823

73.

Park

Selinger

Alvarado-Cabrero

, et al. Dataset for the reporting of carcinoma of the cervix: recommendations from the international collaboration on cancer reporting (ICCR). Int J Gynecol Pathol. 2022;41(Suppl. 1):S64–s89. doi:10.1097/pgp.0000000000000909