Atypical polypoid adenomyoma (APA) is a relatively rare group of focal, polypoid lesions in the uterine cavity, most often in women of childbearing age and, to a lesser extent, in postmenopausal patients. Currently, with the clinical application of hysteroscopy, most cases can be clearly diagnosed preoperatively, but because the clinical understanding of its biological characteristics is not yet sufficient, there is often under- and over-treatment in clinical treatment. In this study, we summarized the clinical data of 10 patients with uterine atypical polypoid adenomyoma treated in the Minimally Invasive Gynecology Center of Beijing Maternity Hospital from June 20056 to June 2008, and analyzed their clinical characteristics, treatment modalities and prognosis in order to summarize the clinical treatment experience, which is reported as follows. I. Clinical data 1. Source: A total of 10 patients with uterine atypical polypoid adenomyoma admitted to the Minimally Invasive Gynecology Center of Beijing Maternity Hospital from June 2005 to June 2008 had complete clinical data, and their clinical characteristics, treatment and prognosis were retrospectively analyzed. 2. General situation and clinical manifestations: The patients’ age of onset ranged from 27 to 60 years old, with a mean age of 41.5 years old, and 3 cases of menopausal patients. The main clinical manifestations in fertile women were irregular vaginal bleeding, increased menstrual flow, prolonged menstruation, intermenstrual vaginal bleeding, and infertility, etc. The postmenopausal patients mainly presented with postmenopausal vaginal bleeding, abnormal vaginal fluid discharge and lower abdominal pain. There were three infertility patients in this group, one of whom had failed IVF-ET. one patient took triamcinolone for 1.5 years after radical breast cancer surgery. The clinical data of the patients are detailed in Table 1. 3. Ultrasonography: 7 patients showed strong echogenicity in the uterine cavity, 3 lesions showed as cystic areas or small dark areas on ultrasound due to cystic changes in some areas, and 1 case did not show obvious occupancy in the uterine cavity on ultrasound. The blood flow index could show low or high obstructive blood flow signal (RI 0.35~0.52). 5 cases suggested myometrial echogenic heterogeneity, suggesting possible combined adenomyosis. 4. Hysteroscopic morphological changes: All cases were diagnosed by hysteroscopic examination of definitive histopathology. The hysteroscopic lesions were mostly seen in the lower segment of the uterine cavity or prolapsed at the cervical os, ranging from 1 to 4 cm in diameter, with smooth or lobulated surface and soft or hard texture. In one case, the hysteroscopic image and submucosal myoma were not easily distinguishable, and in two cases, the lesions of APA-H were seen with rich blood supply and heterogeneous vessels. Initial treatment: All patients underwent hysteroscopic “four-step diagnosis and treatment” for excision of uterine atypical polypoid adenomyoma and multi-point biopsy of the endometrium. The hysteroscopic “four-step approach” was performed as follows: (1) complete excision of the uterine atypical polypoid adenomyoma from the radicle (step1); (2) excision of the endometrial tissue around the radicle (step2); (3) excision of the myometrial tissue below the radicle at a depth of about 0.3 cm (step3); (4) excision of the endometrial tissue at a depth of about 0.3 cm (step4); and (5) excision of the endometrial tissue at a depth of about 0.5 cm (step5). (step3); ④, multi-point biopsy of the endometrial tissue in the rest of the uterine cavity (step4). Each of the above tissues was sent for pathological examination, and further treatment was decided according to the pathological results. Further surgical treatment: According to the pathological results of the hysteroscopic “four-step diagnosis and treatment method”, further surgical treatment was performed in 4 cases. 2 patients with a high architecture index (APA-H) and 1 patient with a low architecture index (APA-L) were treated. Two patients with high architecture index (APA-H) and one patient with low architecture index (APA-L) combined with mild endometrial atypical hyperplasia underwent laparoscopic total hysterectomy, and two of the menopausal patients had bilateral adnexa removed at the same time. 6. Adjuvant medication: 2 cases were treated with medication. 1 case was a primary infertility patient with APA-L and moderate atypical hyperplasia of the endometrium, treated with high potency progesterone for 6 months after surgery, and currently under ovulation treatment; 1 case was a primary infertility patient with APA-L and simple hyperplasia of the endometrium, who was pregnant after ovulation treatment after surgery. The other four patients with APA-L had no abnormal endometrial pathology and were referred directly to follow-up without any adjuvant treatment after hysteroscopic “four-step diagnosis and treatment”. One patient with moderate atypical hyperplasia in the endometrium of primary infertility was referred to ovulation treatment after hysteroscopy and endometrial biopsy after high potency progesterone treatment; the rest of the patients were followed up with regular post-operative B consultation for 6 to 34 months, with no evidence of recurrence. According to the 2002 WHO classification criteria, APA is a mixed tumor of epithelial and mesenchymal origin with unclear pathogenesis. The incidence of APA is significantly higher in patients with Turner’s syndrome undergoing long-term hormone replacement and in patients on long-term triamcinolone acetonide. Clinical and pathological characteristics (1) Age of onset: The literature reports that APA occurs in women of childbearing age, with a mean age of 39 years (25-73 years) and 96% of premenopausal patients, of whom 55% are younger than 40 years. In our group, the proportion of menopausal patients was higher, while premenopausal patients accounted for only 70%, and the mean age was 41.5 years, which was higher than the average, probably related to the higher proportion of menopausal patients. (2) Clinical manifestations: The most common clinical manifestations of APA are various types of irregular vaginal bleeding, such as vaginal dripping bleeding, increased menstrual flow, prolonged menstruation, intermenstrual vaginal bleeding, etc. Postmenopausal patients most often present with postmenopausal vaginal bleeding; another significant clinical feature of APA is infertility. Another significant clinical feature of APA is infertility. Some of the infertility may be due to anovulation, often accompanied by endometrial proliferative changes, such as simple hyperplasia, complex hyperplasia, atypical hyperplasia, etc. Another part of infertility may be due to the presence of APA disturbing the intrauterine environment; other clinical manifestations of APA include abnormal vaginal discharge and lower abdominal pain, which may be related to the infection and necrosis of the lesion coming out of the surface of the cervical opening and stimulating abnormal contraction of the uterus. (3) Ultrasound: Polypoid adenomyoma may show the following features on ultrasound, mainly including: (1) cystic areas or small dark areas in about 30% of the lesions. These cystic areas or small dark areas are mostly small hemorrhagic foci on the gross specimen, which may be caused by exfoliation and bleeding of the endometrium lining the lesion site under the influence of ovarian hormones; (2) the lesion is often accompanied by posterior acoustic shadowing. The lesions are often associated with posterior acoustic shadowing due to hyperplasia and hypertrophy of muscle bundles in the lesion tissue, which may appear similar to the posterior acoustic shadowing of some uterine fibroids; (3) the boundaries of the lesions are clear, but the bases are not clearly demarcated from the myometrium, and the echogenicity is similar to that of the myometrium; (4) the presence of adenomyosis changes such as uneven echogenicity of the myometrium is often demonstrated, suggesting that polypoid adenomyoma and adenomyosis are correlated in terms of tissue origin. The above ultrasound image characteristics of polypoid adenomyoma are not specific in distinguishing APA from typical polypoid adenomyoma lesions. (4) Morphologic changes in hysteroscopic lesions: Hysteroscopic APA lesions are also nonspecific. Most of them are polypoid with soft texture and smooth surface, while a few of them are hard and not easily distinguishable from submucosal fibroids. The blood supply of the lesions should be paid special attention under hysteroscopy. Both cases of APA-H lesions in this group were rich in blood supply and showed vascular heterotypes. In addition, because APA is often combined with endometrial lesions, the endometrium should be carefully observed under hysteroscopy, and the diagnosis of APA and combined endometrial lesions can only be clarified by hysteroscopic localization of tissue biopsy. (5) Pathology: Histopathologically, APA consists of two components: endometrial glands and smooth muscle tissue, and the so-called “atypicality” refers to the heterogeneity of the endometrial glandular epithelial cells and the heterogeneity of the glandular tissue structure. If the lesion contains ≥ 30% of complex structural glands such as branches and sprouts, it is APA-H. Conversely, if the glandular structural heterogeneity is < 30%, it is APA-L. If APA-H has a tendency to infiltrate the myometrium, it is APA with low malignant potential (atypical polypoid adenomyoma with low Compared with APA-L, APA-H is prone to recurrence after treatment, but there is no statistical difference, while APA-LMP is characterized by recurrent recurrence and myometrial infiltration, and some cases may develop into endometrial cancer. APA has the following significant biological characteristics: ① most APA is benign and can be cured by simple lesion excision; ② after conservative treatment (curettage or resection) of APA, the overall recurrence rate is 30.1 %. The overall recurrence rate is 30.1%, while the recurrence rate of APA-H is up to 60%, and repeated recurrence is prone to myometrial infiltration; (3) some APA cases can be combined with endometrial lesions, and the chance of APA co-existence or development of endometrial cancer is 8.8%, which is much higher than the risk of endometrial cancer in endometrial polyps (0.8%). The above characteristics show that most APA has a good clinical prognosis, because APA occurs in young or infertile patients, most of whom have fertility aspirations or require preservation of the uterus; therefore, for most young patients, the use of hysterectomy is overtreatment, and performing hysterectomy not only destroys the normal anatomy of the pelvic floor, but also causes great psychological stress and mental trauma to the patient; however, given that However, given that some APAs are prone to recurrence and secondary or combined carcinoma, and that APAs cannot be considered entirely benign, the treatment of scraping or simple excision of the lesion in some cases is inadequate and delays the disease. Based on the pathophysiological characteristics of APA, we have applied the "four-step hysteroscopic diagnosis and treatment method" to fully evaluate and treat APA with satisfactory results in recent years. The advantages of the "four-step hysteroscopic approach" are: Step1: complete hysteroscopic excision of APA from the radicle, which avoids the disadvantage of recurrence of the disease after treatment by traditional scraping methods, especially the residual lesion at the radicle, and the complete excision of the lesion facilitates comprehensive histological examination. Step2: endometrial resection around the lesion to clarify whether the endometrium around the lesion exists or combined with endometrial lesions, and to further clarify whether APA is completely excised without residual; Step3: myomectomy at the base of the lesion to clarify whether there is myometrial infiltration; Step4: multi-point biopsy of endometrial tissue in the rest of the uterine cavity to clarify through a comprehensive examination of the endometrial condition The presence of coexisting endometrial lesions will be clarified. The "four-step approach" is essential to guide the clinical selection of treatment: first, the need for further surgical treatment is determined according to the "four-step approach". If the pathology suggests the presence of high-risk factors such as myometrial infiltration or endometrial lesions in APA-H or Step 2-4 pathology, hysterectomy should be performed in patients who have no desire to preserve the uterus; conversely, if no such high-risk factors are present, the uterus and reproductive function can be preserved in young patients. Two of our three hysterectomized patients had APA-H and one had APA-L combined with endometrial atypical hyperplasia, while all patients who had hysterectomies with risk factors excluded had no recurrence at clinical follow-up. Thus, the "four-step diagnosis and treatment method" is the basis for clinical decision on the scope of surgery. Secondly, according to the "four-step diagnosis and treatment method", it is important to determine whether further medication is needed, especially for the treatment of infertility patients. In our three infertility patients, one of them had early secretory endometrium on endometrial biopsy and conceived spontaneously with postoperative guidance only; one case had simple hyperplasia on endometrial biopsy and became pregnant with adjuvant ovulation treatment; one case had moderate atypical hyperplasia on endometrial biopsy and was treated with high potency progesterone for 6 months, and hysteroscopy again suggested endometrial metaplastic changes and is currently under ovulation treatment. In conclusion, in view of the pathophysiological characteristics of APA, although most cases have a good clinical prognosis, there are still some cases with high-risk factors, and a comprehensive assessment of the lesion and endometrial condition by applying the "four-step diagnosis and treatment method" under hysteroscopy in close collaboration with clinicians and pathologists is the basis for guiding the clinical selection of an appropriate treatment plan.