Vaginal leiomyoma is a rare solid tumor with unknown exact etiology. These tumors generally are asymptomatic and the treatment of choice is surgical excision. The diagnosis of vaginal leiomyoma is made by histopathology. In this article, we have reported a 39-year-old woman with a solid regular homogenous mass measuring approximately 3x4 cm and reaching to the hymenal ring in the area of the anterior wall of vesicovaginal septum.
Vaginal leiomyoma is a benign smooth muscle tumor (1,2,3). In 1733, it was first reported by Denys de Leyden (3). These tumours which are seen in women between the ages of 35-50 years are extremely rare and the exact etiology is unknown (2,3,4,5). Although rare, the vaginal leiomyoma is the most common mesenchymal tumor of the vagina (6,7). These rare tumors can show variable clinical symptoms such as vaginal bleeding, dyspareunia, protrusion of mass from vagina, constipation, difficulty in micturation or abdominal pain(8), but are usually asymptomatic in the early stages.
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These tumors are more frequently seen in the midline anterior vaginal wall and are usually under 6 cm in size. But, rarely unusual presentations are reported (9). The treatment of choice for vaginal leiomyoma is usually surgical via a transvaginal approach and the recurrence rate after removal is very low (10). Sarcomatous change of the vaginal leiomyoma is negligible. (8). But, careful histological examination is necessary to exclude malignancy. In diagnosis of these tumors histological examination is essential.
In this report, our purpose is to report an unusual case of vaginal leiomyoma.
A 39 year old woman gravida 2, para 2 was admitted to clinic for outpatients with a complaint of dyspareunia. Her previous menstrual cycles were regular and her last menstrual period was 13 days ago. There was no history of oral contraceptive use. Her past medical history and physical examination was not remarkable. Her vital signs were also stable. The gynecology speculum examination showed a solid homogenous mass in anterior of the vaginal wall measuring about 3x4 cm and reaching the hymenal ring (Figure 1). When the upper limit of the mass with finger examination was reached, it was realised that the mass was not related to the cervix or any part of the bladder wall. On transvaginal ultrasonography examination, it was shown that the patient had a large hypoechoic mass within the vagina. In addition, the endometrial thickness was 8 mm and there was not such a pathological finding in the uterus. All routine preoperative laboratory studies were normal. Preoperatively, because there was concern about the risk of urethral injury, a urethral catheter was placed. Then, a midline vertical incision with a transvaginal approach was made over the vaginal mass, it was enucleated from the paravaginal tissues by sharp and blunt dissection and was completely removed. Per-operatively it was also seen that the mass was a primary vaginal tumor. Surgical duration was about 25 minutes, and blood loss was less than 50 mL. Gross examination of the tumor tissue obtained showed a histologic appearance of leiomyoma with a 3 g weight, 3x4 cm oval lobulated nodule. On cut section it was firm, grey-yellow coloured, and showed no areas of hemorrhage, necrosis, or hydropic degeneration (FigÃ¼re 2). The mass was reported as benign on frozen-section examination. There were no intraoperative or postoperative complications. The patient was discharged 2 days after surgery. Six weeks after surgery, the patient was asymptomatic. Pelvic examination findings were normal.
Histologic examination showed that the tumor was well-circumscribed, but not encapsulated. Histology revealed a benign smooth spindle cell tumor. The tumor cells were fusiform and had eosinophilic cytoplasm. The cytoplasmic membrane was distinct. Hypercellularity, mitotic activity, or nuclear atypia were not present. There were islands of hyaline degeneration in the tumor where necrosis was not seen. The rich collagenous matrix noted in the vaginal tumor was present. On microscopic examination, the lesion appeared to consist of subperitoneal smooth muscle proliferations. On immunohistochemical examination, the tumor cells were painted as positive for desmin and smooth muscle actin (SMA) and as negative for muscle specific actin (MSA). In the nuclei of the tumor cells, progesterone and estrogen receptors were positive.
Vaginal leiomyoma which is a benign smooth muscle tumour is a very rare tumor of the vagina. They usually have no relation with the uterus. In 1733, they were first described by Denys de Leyden (3). Up to now, rare cases of a few hundred have been reported in the world (11). Bennett and Erlich found only nine cases in 50,000 surgical specimens (12) while in 15,000 autopsies reviewed at the Johns Hopkins Hospital was found only one case (10). When we revise the cases in our hospital, this is the first case in the last 20 years.
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Though leiomyoma of the vagina begins at a much earlier age, it is seen frequently between the ages of 35 and 50 years because of slow growth characteristic of the tumor (13). Unlike uterine leiomyomas, vaginal leiomyoma predominates in white women (12). Although it is a common condition in women, men have also been reported (14). The tumor usually arises from the anterior vaginal wall (15) or rarely from the lateral vaginal walls (9,10,16). The majority of these tumors are localized and mobile masses. Also, they are usually solitary and small in size, approximately 3-4 cm in diameter (17), but occasionally may be multiple or enormous in size (10,16,18). In 1965, Kettle and Loeffler reported a case where the largest vaginal leiomyoma with a weight of 1,450 g (18). These are not tender tumors. In our case the leiomyoma had arisen from the anterior vaginal wall, was solitary and single, was 3-4 cm in diameter and there was no relationship between the uterus and the vaginal leiomyoma.
Leiomyomas may be seen anywhere in the smooth muscle cells. (19) The extrauterine sites of this tumour are the round ligament, uterosacral ligament, ovary, inguinal canal, kidney and very rarely vagina and vulva. Symptoms vary according to the size and location of the leiomyoma. At the onset, the tumor is asymptomatic. The tumor growing over time(â°¥ 6 cm) may cause complaints such as pain, protrusion of the mass from vagina, dyspareunia, constipation, leucorrhea, bleeding and urinary tract symptoms (8). After menopause, the tumor may regress spontaneously because it is hormon-dependent. They are often diagnosed incidentally when they grow outside of the uterus (20). In diagnosis ultrasound and CT scan can be used. But, correct diagnosis is made only after histological examination. But, early diagnosis in these tumours is beneficial for several reasons. The most important benefit is to prevent sarcomatous change of vaginal leiomyoma. Our patient was admitted to clinic for outpatients with a complaint of dyspareunia. Whereupon, vaginal leiomyoma with a hypoechoic mass within the vagina was diagnosed by the gynecology speculum and ultrasound examination.
The pathogenesis of vaginal leiomyoma is completely unknown, but they are hormon-dependent tumours. Vaginal leiomyomas resemble typical uterine leiomyomas at both gross and microscopic levels. But, the majority of published reports so far suggest that vaginal leiomyomas do not originate from uterine muscle cells (17). Vaginal leiomyomas are thought to arise from the smooth muscle of the vagina, rectum, bladder or urethra, or vascular smooth muscle, or embryonal cell rests within the vagina (4,10,18,21,22). There does not appear to be any correlation between the occurrence of leiomyoma in the vagina and any other sites (16). Biochemical studies and genetic analysis suggest that vaginal leiomyoma arises independently from a single smooth muscle cell (23) and there are karyotypic discordance even between multiple leiomyomas (24). However, Meniru et al. reported a case of vaginal leiomyoma co-existing with multiple leiomyomas in the uterus and the broad ligament (25). In addition, few writers have given an impulse to idea that vaginal leiomyomas develop from a breakaway group from the uterus (21). If this were true, the incidence of vaginal leiomyoma should be parallel to that of uterine leiomyomas. In spite of these, we can not exclude these theories in our patient completely. For the moment this issue is still an unknown response exactly.
In the differential diagnosis, the localization of the mass should be taken into consideration. In addition, the variable consistency of the mass can lead to preoperative misdiagnosis. When the mass is found in the anterior vaginal wall; cystocele, urethrocele, urethral diverticulum, inclusion cysts, cervical myoma and prolapse of the uterus should be considered. If the mass is found in the posterior vaginal wall; rectocele, enterocele, inclusion cysts and tumours of the rectum and the rectovaginal septum should be considered. In addition to the differential diagnosis, gartner duct cysts, inclusion cysts, paraurethral and Bartholinâ€™s cysts, endometriosis and malignant tumors of the vagina should be considered (8). Low-grade leiomyosarcoma should also be considered in the differential diagnosis.
These tumors have to be removed immediately to prevent further growth and sarcomatous change in the future (26). The treatment of the vaginal leiomyoma is surgical enucleation and the vaginal approach has become the preferred method in the majority of cases. During surgical enucleation, it may be sometimes useful to put an urethral catheter into the urethra and a gloved finger into the rectum to prevent injury to these structures (8). Vaginal leiomyomas usually can be separated easily from surrounding tissues. In our case, we preoperatively put an urethral catheter to prevent the risk of urethral injury. Then, with a transvaginal approach, the mass was removed completely and easily by sharp and blunt dissection following a midline vertical incision. If the tumor is large or in an inaccessible localization in the vagina, the abdominal approach should be preferred (3). Recurrence of the tumor is much lower than the uterine leiomyomas (10,26). The mass is completely removed to prevent recurrence. Despite everything, if recurrence occurs oopherectomy should also be done because it is an oestrogen-dependent tumor (10,26,27).
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Pathologically, vaginal leiomyomas are usually solid single nodules and are small in size. They are well circumscribed homogenous masses and resemble uterine leimyomas (28). Macroscopically, on a cut section they are firm, grey-yellow coloured. Microscopically, these tumors consist of uniform smooth muscle cells with indistinct cell borders and eosinophilic cytoplasm. Cystic degeneration can be seen in large tumors (17). Unlike uterine leiomyomas, vaginal leiomyomas have a rich matrix of collagen tissue. In addition, progesterone and estrogen receptors are positive in these tumors such as uterine tumors. In our case similar findings were seen.
The rate of sarcomatous change in this tumor is very low, but may occur (28).Â In a series of 11 cases, the incidence of sarcoma has been reported as 9.1% and the sarcomatous masses of the same series have been seen usually in the posterior vaginal wall (8,29). Just because of this, careful histological evaluation is required to rule out a malignant change. For the differential diagnosis of leiomyoma and leiomyosarcoma multiple biopsies should be taken. In the pathological evaluation, as evidence of leiomyosarcoma necrosis, mitosis, pleomorphism, and invasion of surrounding tissue must be sought. In our case, histologic examination revealed a leiomyoma with benign smooth muscle cell tumor. Hypercellularity, mitotic activity, or nuclear atypia in the tumor cells were not present.
As a result, vaginal leiomyoma is a benign tumor. The treatment is surgical enucleation. According to state, the surgical approach is through vaginal or abdominal route. It must be removed completely to prevent recurrence and a careful histological examination should be done to exclude malignancy following surgery.