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Primary vaginal carcinoma is a rare gynaecological tumour representing 1%–3% of all gynaecologic cancers. Several studies report increased vaginal cancer risk associated with genital prolapse following the occurrence of inflammatory lesions or decubitus ulcers.
Case
We report the rare case of an 82-year-old woman with primary squamous cell carcinoma arising from vaginal wall prolapse. Vaginal carcinoma was suspected during gynaecological examination for vulvar bleeding. A wide local excision was performed and pathologic examination revealed a primary squamous cell carcinoma of the vagina.
Conclusion
Persistent genital prolapse may be at risk for vaginal carcinoma, and cytological and a colposcopic assessments are essential to identify patients who require diagnostic biopsy.
Résumé
Contexte
Le carcinome vaginal primitif est une tumeur gynécologique rare qui représente de 1 % à 3 % de tous les cancers gynécologiques. Plusieurs études font état d'un risque accru de cancer du vagin associé au prolapsus génital à la suite de l'apparition de lésions inflammatoires ou d'escarres de décubitus.
Cas
Nous rapportons le cas rare d'une femme de 82 ans atteinte d'un carcinome épidermoïde primitif résultant d'une colpocèle. L'examen gynécologique pour des saignements vulvaires a éveillé un soupçon de carcinome vaginal. Une exérèse locale large a été pratiquée; l'examen anatomopathologique a révélé un carcinome épidermoïde vaginal primitif.
Conclusion
Le prolapsus génital persistant est susceptible de mener à un carcinome vaginal; ainsi, les évaluations cytologique et colposcopique sont essentielles pour déterminer si une patiente requiert une biopsie diagnostique.
Primary vaginal carcinoma is a rare gynaecological tumour comprising 1% to 3% of all gynaecological cancers and with an inclination to metastasize to the cervix, vulva, endometrium, ovary, kidney, thyroid, and breast.
It typically occurs in older patients (aged 60–70 y) and is commonly located in the upper rear third of the vagina. Squamous cell carcinoma (SCC) accounts for about 85% of new cases of vaginal cancer, whereas 5% to 10% are adenocarcinoma.
We report an unusual case of an SCC located on the prolapsed anterior vaginal wall (cystocele) and mimicking a vulvar cancer.
CASE REPORT
An 82-year-old woman was referred to our gynaecology unit with a diagnosis of large vulvar cancer. The patient did not report any history of relevant gynaecological disease, apart from an abdominal hysterectomy about 30 years earlier for uterine fibroids and, more recently, a vaginal bleeding mass. Pelvic examination revealed negative inguinal lymph nodes and a 3-cm lesion arising on the prolapsed anterior vaginal wall (cystocele; Figure 1). A biopsy was performed, and pathology examination revealed a primary SCC. Computed axial tomography was negative for distant metastatic disease, and cystoscopy revealed no bladder wall infiltration. A wide vaginal excision with bilateral groin lymph nodes dissection was performed, and pathology revealed a primary vaginal SCC with clear margins. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. Subsequently, external beam radiotherapy followed by vaginal brachytherapy was administered. The patient died from a complication of preexisting cardiopathy in association with a recurrence of cancer in the bladder during the 2-year postoperative follow-up period. All procedures performed in this study were in accordance with the Declaration of Helsinki as revised in 2013. The patient was provided with a description of the study and was formally invited to participate in it. The patient agreed to participate in the study and gave informed consent.
Cervical carcinoma combined with uterine prolapse is a rare condition, and a primary vaginal carcinoma arising in the setting of vaginal wall prolapse after hysterectomy is even more exceptional.
There is no clear explanation for the etiology of this rare association. In young patients, the disease appears to be related to human papillomavirus, whereas in older patients it may be associated with chronic inflammation due to prolapse and hormonal factors.
Clinical symptoms of vaginal cancer include loss of blood by external genitalia, foul-smelling leukorrhea, pelvic pain, and, in more advanced stages, urinary retention and bilateral hydroureteronephritis.
When tumours arise from vaginal wall prolapse, the lesion is detected on objective examination and accompanied by ulcer and edema of the surrounding tissues. For this reason, it is important to note that vaginal colposcopic patterns do not have the same specificity as cervical colposcopic evaluation.
Therefore, in the case of a suspected vaginal lesion, biopsy under colposcopic guidance is indicated to check the histology and make a definitive diagnosis.
The occurrence of inflammatory lesions or decubitus ulcers in patients with genital prolapse is quite common. Lesion histopathology reports showed chronic cervicitis in 97.9% of cases, cervical decubitus ulcers in 13.6%, and carcinoma in situ in 1%.
These findings support the need for diagnostic biopsy in all cervical or vaginal lesions located in uterine and/or vaginal prolapse to exclude a neoplastic transformation.
Therefore, persistent genital prolapse may be considered a risk factor for vaginal carcinoma, in which case, cytological and colposcopic assessments are essential to evaluate those patients who will need a diagnostic biopsy.
Consent: The woman whose story is told in this case report provided signed permission for its publication.
Dislosures: This research project was supported in part by the Apulian Regional Project “Medicina di precisione.” This work was also supported by a grant (5 £ 1000) from the IRCCS Istituto Tumori Giovanni Paolo II in Bari, Italy (no. 332/2019) in the context of a scientific program exploring ovarian stem cell development to prevent infertility in oncology patients. The APC will be funded by IRCCS Istituto Tumori Giovanni Paolo II in Bari, Italy.
All authors have indicated that they meet the journal's requirements for authorship.
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