Mesenchymal tumors and tumor-like lesions of the female genital tract: a selective review with emphasis on recently described entities

Aggressive angiomyxoma of pelvis: A case report and literature review

RATIONALE

Aggressive angiomyxoma (AAM) is a rare mesenchymal tumor primarily involving the lower genital tract of reproductive females. It often shares pathologic morphology with other mesenchymal lesions, which result in diagnostic difficulties for pathologists.

PATIENT CONCERNS AND DIAGNOSES

We described the case of a 32-year-old female presenting with a pelvic mass. Imaging examination showed a "swirling sign" within the mass. The mass was 10.2 × 10 × 7.7 cm, located in the right front of the uterus, with unclear demarcation from the surrounding organs and tissues. The gross appearance was grayish brown with a solid section and a myxedematous cut surface. Microscopically, it was a mesenchymal tumor with a presence of perivascular smooth muscle fibers radiating from the blood vessel and an infiltrative growth pattern. The pelvic AAM was diagnosed based on clinicopathologic and imaging features.

INTERVENTIONS AND OUTCOMES

A surgery with local excision of the mass was performed. The patient experienced 1 relapse during 2-year follow-up and underwent the radiation therapy.

LESSONS

When the pathological morphology of AAM overlaps with other mesenchymal lesions, the comprehensive understanding of tumor clinicopathological characteristics combined with imaging features is important for the accurate diagnosis of AAM.

A Rare Case of a Giant Vulval Fibroepithelial Stromal Polyp

BACKGROUND

A fibroepithelial stromal polyp is an uncommon benign pathology of the female genital tract. Rarely, these benign tumors present as a giant lesion and are clinically difficulty to distinguish from other pathologies.

CASE

A 19-year-old female presented with a vulval fibroepithelial stromal polyp measuring ∼8 × 8 × 3 cm that extended from the right labia majora. Present for 2 years, the lesion caused mild discomfort and aesthetic dissatisfaction due to its size but otherwise had no associated symptoms. It was diagnosed using a combination of imaging techniques including ultrasound and magnetic resonance imaging and histological analysis. It was removed surgically and has had no recurrence.

SUMMARY AND CONCLUSION

The consideration of both benign and malignant pathologies is paramount when differentiating vulval masses. Thorough clinical reasoning and appropriate use of imaging modalities and histological analysis are essential.

Vulvar Cutaneous Myxoma in a Patient With Carney Complex: Avoiding Pitfalls of Myxoid Lesions of the Vulva

We present the case of a 31-year-old woman who underwent surgical excision for a polypoid, vulvar lesion. Histopathological analysis showed a diffuse myxoid stroma admixed with scant collagen fibrils. Thin-walled and branching blood vessels were prominent, with a mild perivascular lymphocytic infiltrate. Cytologically bland spindle cells with inconspicuous nucleoli were immersed in a loose myxoid stroma. This combination of histopathological features along with multinodularity in the subcutaneous fat raised concern for deep angiomyxoma, a locally destructive neoplasm. Among our differential of myxoid lesions of the vulva, we ultimately favored the diagnosis of vulvar cutaneous myxoma. Upon further investigation, we learned that our patient was indeed known for the Carney complex. We highlight that vulvar cutaneous myxomas arising in the context of the Carney complex pose a significant diagnostic challenge for pathologists and should not be overdiagnosed as aggressive lesions such as deep angiomyxoma or other malignant stromal neoplasms.

Review of 189 Consecutive Female Genital Skin and Mucosal Biopsies Submitted to an Academic Dermatopathology Practice

OBJECTIVES

To describe consecutive vulvar biopsy cases and to create an educational template for pathology trainees and practicing pathologists.

METHODS

We reviewed 189 consecutive biopsies from the female genital area skin and mucosa. We classified them based on etiologies and examined limited clinical information.

RESULTS

We classified diagnoses as squamous intraepithelial neoplasia (21.5%), melanocytic neoplasia (17.9%), lichenoid dermatoses (15.9%), nonlichenoid dermatoses (11.3%), infectious (6.2%), reparative (4.6%), or miscellaneous (22.6%). The miscellaneous diagnoses included common entities (polyps and cysts) and rarer entities (calcinosis cutis, adnexal neoplasms, or basal cell carcinoma) and nonspecific descriptive diagnoses. Clinicians most often included the actual diagnosis in their differential for melanocytic lesions (83%) and least often for inflammatory lesions (32%). However, some cases included a clinical description without a differential diagnosis (14%) or no helpful clinical information (4%). The distribution of whether correct diagnoses were included in the clinical differential was similar between submitting physicians and midlevel providers.

CONCLUSIONS

Understanding squamous and melanocytic pathology and the various lichenoid and other inflammatory diagnoses is critical for signing out female genital tract skin pathology. The cases examined in this report can serve as an educational template for trainees and practicing pathologists.

Primary low grade myxoid liposarcoma of the ovary: A case report and review of literature

A 20-year-old female patient presented with the complaint of pelvic pain. Radiological studies showed a cystic mass in the left ovary. Histological examination revealed a myxoid tumor with a chicken wire-like, thin vascularization. The diagnosis of the lesion, morphologically resembling myxoid liposarcoma was supported by demonstration of rearrangement of the DDIT3 gene by fluorescence in situ hybridization.

Plexiform Neurofibroma of the Uterus: A Case Report

The female genital tract system is rarely affected by neurofibromatosis type 1 (NF1). Plexiform neurofibromas are congenital lesions that occur in patients with NF1. The vulva is the most frequent genital location but vaginal, cervical, uterine, and ovarian neurofibromas have rarely been reported. We describe a case of plexiform neurofibromas involving the uterine cervix in a patient with known NF1 that presented with chronic pelvic pain and heavy menstrual bleeding.

Large-sized pedunculated and polypoidal angiomyofibroblastoma of the vulva: A case report and literature review

Angiomyofibroblastoma (AMF) represents a rare, benign mesenchymal tumor with a predilection for the vulvovaginal region, which may be misdiagnosed as aggressive angiomyxoma (AAM). Herein, we report a case of a 20-year-old nulliparous Chinese woman with a unique pedunculated and polypoidal mass, which had been developing within the previous 6 months in the left labium majus, exhibiting the AAM clinical impression but diagnosed as AMF. The mass measured 18 × 10 × 6 cm, and contained diffuse ulcerated areas and purulent discharge. A complete excision of the mass was performed. There was no subsequent evidence of recurrence, according to a 13-month follow-up. As a rare benign vulvovaginal tumor, AMF can present on patients of an early reproductive age with rapidly growing, polypoidal pattern. The whole exon sequencing analysis revealed the genomic alterations, which may contribute to the occurrence of AMF.

A Vaginal Angiomyofibroblastoma as a Rare Cause of a Prolapsing Vaginal Mass: A Case Report and Review of the Literature

Introduction

Angiomyofibroblastoma (AMFB) is a rare, benign, mesenchymal cell tumour which presents as a slow-growing mass. It is most commonly seen in the vulva and is often mistaken for Bartholin's abscess. It is histologically diagnosed by the presence of stromal cells intermingled with small blood vessels. It is morphologically similar to cellular angiofibroma and aggressive angiomyxoma, the latter of which is locally invasive and has a possibility of metastasis and a high risk of local recurrence. There is one reported case of an AMFB undergoing sarcomatous transformation.

Case Report

We report a case of a multiparous, 36-year-old woman with an anterior vaginal mass which was inappropriately treated as a vaginal prolapse prior to definitive surgical management. This is only the second reported case of an AMFB presenting as a prolapsing mass.

Vulvar Fibroepithelial Polyps in a Female Adolescent: A Case Report

BACKGROUND

Fibroepithelial polyps (FEPs) are benign tumors, of possibly hormone-dependent nature, found in the vulvovaginal region of women of reproductive age.

CASE

A 15-year-old adolescent girl, receiving hormonal contraceptive therapy, who presented with multiple vulvar masses with histopathology consistent with FEP.

SUMMARY AND CONCLUSION

The spectrum of the morphology of FEPs might make their diagnosis challenging. We describe a rare presentation of vulvar FEPs in an adolescent girl receiving hormonal contraceptive therapy.

Sonovaginography: A Useful Technique in the Assessment of the Lower Genital Tract

Conventional sonographic evaluation of the cervix and vagina is compromised by inattention, poor subject contrast, and obscuring artifacts. We describe a technique involving distention of the vaginal canal and fornices with ultrasound gel, providing an acoustic window for improved definition of the cervix and vagina. This exam is usually performed in concert with transvaginal sonography, but a transabdominal or transperineal approach may be more useful in selected scenarios. A wide variety of formerly sonographically inconspicuous conditions are demonstrable with this technique, many of which were undetected or inadequately characterized on the physical exam. Cervical polyps were the most commonly seen abnormality.

Proposed novel nomenclature of vulvar smooth muscle tumors; a case of Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP) of the vulva

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Clinical experience with smooth muscle tumors of the vulva is limited.

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Some tumors present ambiguous histological features concerning for malignancy.

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These include infiltration, mitotic activity, size, atypia and tumor cell necrosis.

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A case of smooth muscle tumor of the vulva with cellular atypia is presented.

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“Smooth Muscle Tumor of Uncertain Malignant Potential” of the vulva is advocated.

A rare case of angiofibroma of the mandible: A case report

Angiofibroma is a rare, highly vascular nonencapsulated tumor, which is locally invasive. A rare case of angiofibroma of the mandible in a 16-year-old female patient is reported here. The lesion was excised along with surgical removal of right mandibular third molar tooth. Patient was followed up for 1 year without any recurrence.

Nodular fasciitis of the vulva: a challenging histopathologic diagnosis supported by the detection of USP6 gene rearrangement

Nodular fasciitis involving the vulva on physical examination can mimic a Bartholin gland lesion, and histologically can have overlapping features with more ominous mesenchymal pathologies. We describe a case in which a 52-year-old perimenopausal woman presents with a vulvar mass. After an initial biopsy and later excision, the myofibroblastic lesion was noted to have areas of differing cellularity, with compact nodule formations at the periphery. Immunohistochemical staining showed lesional cells to be positive for desmin, estrogen receptor, progesterone receptor, and smooth muscle actin, and negative for CD34, ALK-1, myogenin, caldesmon, S100, and wide spectrum (Oscar) cytokeratin. Desmin is generally negative in this lesion type, but the positivity in this case was considered to be secondary to the origin of the myofibroblastic cells of the vulva. The morphologic pattern and immunophenotype favored a diagnosis of nodular fasciitis, however, the degree of hypercellularity and desmin positivity warranted further analysis. The diagnosis was supported with fluorescence in situ hybridization that demonstrated USP6 gene rearrangement. This highlights the necessity in certain challenging cases for ancillary molecular and/or cytogenetic analysis.

Angiofibroma of the vulva

BACKGROUND

Cellular angiofibroma is a benign and rare tumor. It usually arises in middle-aged women and involves the vulva. Complete local excision of the tumor is the best cure, and, usually, there is no recurrence after surgery.

CASE REPORT

We describe a 20-year-old woman with a painless, growing vulvar mass who presented about 3 years ago. Her past medical history was negative for oral contraceptives, tobacco, and alcohol, and there were no similar lesions in her family history. A physical examination revealed two masses on the right and the left labia majora and similar lesions on the left axilla and both breasts. An uncomplicated simple resection of the vulvar masses was done in the operating room. There was no evidence of recurrence 12 months after surgery. Histopathologic examination revealed that the findings were consistent with the diagnosis of the cellular angiofibroma. Based on our knowledge, this patient is the youngest case of vulvar angiofibroma. The lesions were large and symmetrical (on both labia majora), although they differed in size. Extravulvar (breast and axilla) lesions were also noteworthy in this patient.

A Rare Clinical Presentation of Giant Bilateral Labial Fibroepithelial Stromal Polyps in Patient with Psoriasis Disease

Fibroepithelial polyps (FEPs) are rarely seen lesions of the lower female genital tract with polypoid proliferations of stroma. These tumors usually present in the vulvovaginal region of the reproductive aged women. In this presentation, we report a case of a psoriatic woman who developed unusual multiple polypoid lesions approximately 15 cm in size arising from both left and right labia minora and unique connection of FEPs with psoriasis disease.

Aggressive Angiomyxoma of the Pelvis with a Cellular Nodule Composed of Tumor Cells showing Epithelioid Features

A 49-year-old female presented with an aggressive pelvic angiomyxoma (AAM). The completely resected specimen revealed the usual myxedematous tumor with a nodule inside it. Histopathologically, the myxedematous area consisted of bland spindle-shaped cells in the background of blood vessels of varying calibers, and the nodule was composed of tumor cells with epithelioid features. In the nodule, cellularity was increased and nuclear enlargement was observed, but nuclear atypia was not significant and mitotic figures were scarce. Immunohistochemically, both components were positive for desim, αSMA, estrogen receptors, and progesterone receptors. However, they were negative for AE1/3, EMA, S100, CD34, HMB45, and Melan A. The MIB-1 labeling index was 5.8% in the nodule and 1ess than 1% outside it. The nodule was therefore considered a benign component of AAM. To the best of our knowledge, the presence of such a nodule in AAM has not been reported previously.

Unusual benign polypoid and papular neoplasms and tumor-like lesions of the vulva

We aimed to investigate the prevalence and spectrum of unusual benign neoplasms and tumor-like lesions presenting as vulvar polyps and papules, to study their clinical, pathologic, hormonal, and developmental features and whether they have important associations with other pathologic lesions or clinical diseases. We conducted a retrospective review study of 115 vulvar specimens over 7 years. Common lesions, for example, fibroepithelial polyps, skin tags, papillomas, abscesses, viral warts and common cysts, were excluded. We found 21 cases (18%) with uncommon benign vulvar lesions. They included 7 epithelial cysts, 3 vascular lesions, 3 glandular neoplasms, 3 endometrioses, 1 caruncle, 1 pilonidal sinus, 1 prolapsed urethra, 1 seborrheic keratosis, and 1 granular cell tumor. The age range was between 1 and 64 years with a mean age of 33 years. Most (86%) were 2.5 cm or less. Many were asymptomatic incidental pathologic findings that can be missed clinically. Nine cases have important clinical associations or coexisting incidental pathologic lesions. Some lesions demonstrated hormone receptors. Some were clinically confused with fibroepithelial polyps, abscesses, warts, melanocytic lesions, and tumors. In conclusion, although the vulva is a small compartment, its developmental and histologic complexity can result in a variety of unusual and rare benign polypoid and papular lesions, some unique to the vulva, which might present diagnostic challenges to the clinicians and pathologists. In addition, many bear controversy regarding their histogenesis and origin of development in the vulva.

Angiomyofibroblastoma of the vulva

Angiomyofibroblastoma (AMFB) is an uncommon benign mesenchymal tumor. AMFB occurs almost in the vulvo-vaginal area of women. The gross features of AMFB are well-circumscribed so it clinically is often thought as Bartholin gland cyst or aggressive angiomyxoma. Usually, most tumors grow slowly, and patients do not feel pain. It also has low tendency for local recurrence. The histologic findings of the tumors are abundant thin-walled blood vessels with hypocellular and hypercellular areas. Almost all tumor cells have immunoreactivity for both desmin and vimentin. It also has estrogen and/or progesterone receptors, but staining for cytokeratin is negative. Here is a case of AMFB of the vulva occurring in a 40-year-old woman, involving the right labia majora. The patient described that her vulva mass grew in about few months. The maximum dimension of the tumor was measured as 2 cm, and we resected the tumor one month after as her second visit.

An unusual case of a large fibroepithelial stromal polyp presenting as a nipple mass

Background

Fibroepithelial stromal polyps (FESP) are benign lesions that typically occur in the genital area and are known to represent a diagnostic challenge for pathologists. Not only do they have a spectrum of morphological changes that ranges from bland morphology to rather atypical appearances, but they also share morphological features with a number of benign and malignant lesions.

This is a report of a rare presentation of a FESP of the breast.

Case presentation

We describe an unusual case of a large polypoid mass arising from the nipple and connected to it by a long pedicle in a female of 45. The lesion comprised spindle and stellate shaped cells with bizarre stromal giant cells. The morphological and immunohistochemical diagnostic features are provided together with a discussion of possible mimics.

Conclusion

FESPs may occur in the female breast. It is important to differentiate the lesion from other benign and malignant spindle cell lesions particularly metaplastic carcinoma.

Cellular pseudosarcomatous fibroepithelial stromal polyp of the vagina during pregnancy: a lesion that is overdiagnosed as a malignant tumor

Fibroepithelial stromal polyp (FSP) is a benign lesion that can occur at various sites, including the lower female genital tract. In rare cases, however, it may exhibit hypercellularity, bizarre cytomorphological features, and atypical mitoses resulting in an overdiagnosis as a malignant tumor despite its benign clinical course. Recently, we experienced one case of a 30-year-old pregnant woman with cellular pseudosarcomatous FSP that was initially diagnosed as a malignant fibrous histiocytoma at a primary clinic. In addition to describing the rare features of this case, we wish to increase awareness about this benign lesion which will be essential for avoiding unnecessary radical surgery or chemoradiation treatment.

The 2 stromal compartments of the normal cervix with distinct immunophenotypic and histomorphologic features

Cervical plasticity is partially attributed to subepithelial stromal cells. Knowing this population of cells in its variable physiologic states, with its immunophenotypic variations, will lead to better understanding of neoplastic processes related to these stromal cells. We reviewed slides of cervices from premenopausal, postmenopausal, and postpartum patients and used mesenchymal immunohistochemical stains. Results demonstrate 2 distinct subepithelial compartments, within the ectocervix and the endocervix/transformation zone. The endocervix/transformation zone has twice the number of stromal cells as the ectocervix, regardless of age. Ectocervical stromal cells are desmin+/smooth muscle actin (SMA)-, and endocervical stromal cells are desmin+/SMA-. In postpartum/premenopausal patients, the cervix has less desmin+ ectocervical and SMA- endocervical cells. In postmenopausal/prolapse patients, the cervix has no desmin+ ectocervical cells. Desmin+/SMA, calponin, caldesmon, myogenin, myoD1, CD34- cells could represent unusual myofibroblasts that should not be confused with a neoplastic process, especially if a mass is not present.

Clinicopathological determinants of vaginal and premalignant-malignant cervico-vaginal polyps of the lower female genital tract

OBJECTIVE

To establish pathology frequencies for polyps in the vagina and cervix and to identify determinants of vaginal polyps and premalignant-malignant cervico-vaginal polyps.

MATERIALS AND METHODS

The pathology reports of all cervico-vaginal polyps examined for 6 years at a single institution were classified, and frequencies were calculated. In 2 separate case-control studies, clinical and pathological variables of vaginal cases were compared with cervical controls, and premalignant-malignant cases were compared with benign controls. Differences in variables that were abstracted from patients' chart and pathology reviews were tested for significance.

RESULTS

There were 4,402 polyps; 4,340 cervical (98.6%), 62 vaginal (1.4%), 4,268 benign (97.0%), 62 premalignant-malignant (1.4%) (CIN, endometrial hyperplasia, and carcinoma), and 72 unsatisfactory (1.6%). Age was a significant determinant of vaginal and premalignant-malignant polyps, and polyp size and number were significant determinants of vaginal polyps. Vaginal polyps were 3 times more frequent among women 40 years and younger and twice as frequent among those 60 years and older (p < .001). Premalignant-malignant polyps were twice as frequent among women 40 years and younger (p = .04), and malignant polyps were 6 times more frequent in those 60 years and older, which approached statistical significance (p = .09). Multiple polyps were 2 times more frequent (p = .04) and greater than 2 cm was 4 times (p = .01) more frequent among vaginal polyps.

CONCLUSIONS

Vaginal polyps and premalignant-malignant cervico-vaginal polyps are rare. Vaginal polyps are larger and multiple and cervico-vaginal polyps in younger and older women are at greater risk of premalignant-malignant changes.

Pedunculated angiomyofibroblastoma of the vulva: case report and review of the literature

Angiomyofibroblastoma (AMFB) is a rare benign mesenchymal tumour that occurs almost exclusively in the vulvovaginal region of women but can also occur occasionally in the inguinoscrotal region of men. It is a well-circumscribed lesion that clinically is often thought to represent a Bartholin's gland cyst and usually does not form a pedunculated mass. To our knowledge, only five cases of vulvar AMFB with pedunculated mass have been reported in the English literature and all cases involving the labia majora and middle-aged women. We report the first case of pedunculated AMFB of the vulva occurring in a young woman of 21 years old and involving the left labia minora. After excluding the most common diseases, pedunculated AMFB should be part of differential diagnosis in the workup of any pedunculated vulvar mass even in young women with a lesion involving the labia minora. We reviewed the literature and summarized all reported cases.

Myxoma of ovary: an uncommon entity

PURPOSE

In this brief report, we have described a rare case of myxoma of ovary.

METHODS

We have studied the detailed histopathological features of this case and discussed the relevant differential diagnosis.

RESULTS

A 20-year-old female patient presented with right sided adnexal mass. Tumor marker level and other biochemical parameters were within normal limits. Exploratory laparotomy and debulking of the mass showed a large solid cystic right ovarian tumor. Microscopically, the tumor showed abundant myxoid matrix with interspersed randomly traversed sparse stellate or spindle-shaped tumor cells. The diagnosis of myxoma was offered.

CONCLUSION

Ovarian myxoma is a rare but distinct entity and this should be differentiated from the other lesions of ovary with myxoid changes.

Magnetic resonance imaging findings of fibroepithelial polyp of the vulva: radiological-pathological correlation

We describe the magnetic resonance (MR) imaging findings in a 20-year-old woman with a fibroepithelial polyp of the vulva. Within the lesion, abundant fibrous tissue was visualized as stratiform hypointense areas on T2-weighted magnetic resonance imaging (MRI) scans. At the center of the attachment site, clustered fatty tissue was revealed as linear hyperintense areas on T1-weighted MRI. A mild degree of edematous stroma including less fibrosis and cellularity was demonstrated as hyperintense areas on T2-weighted MRI and hypointense areas on T1-weighted MRI. Although the MRI findings of fibroepithelial polyps of the vulva are often similar to those of aggressive angiomyxoma, angiomyofibroblastoma, and cellular angiofibroma, a fibroepithelial polyp should be considered when radiological images demonstrate the following features: stratiform hypointense areas surrounded by patchy hyperintense areas on T2-weighted MRI and hyperintense areas on T1-weighted MRI.

Isolated and synchronous vulvar granular cell tumors: a clinicopathologic study of 17 cases in 13 patients

Granular cell tumors (GCTs) are benign Schwann cell-derived neoplasms occurring throughout the body. Vulvar GCTs are usually isolated, but occasionally multifocal. On account of their anatomic location, surgical interventions aiming for negative resection margins can result in significant morbidity. We describe the clinicopathologic features of 17 vulvar GCTs in 13 patients followed for an average of 7 years. The average age at presentation was 46 years, and 84% of the patients were black. The tumors were multifocal in 3 (23%) patients, and all, either at presentation or subsequently also developed extravulvar foci. Patients with multifocal vulvar GCTs were nearly 10 years younger at presentation than patients in whom the disease was isolated. The most common complaint was a slow-enlarging mass occasionally associated with pruritus or overlying hyperpigmentation. Clinically, the tumors were subcutaneous, mobile, and nodular (2.1 cm on average), without overlying ulceration, and most often were found in the labia majora (6/17). The neoplasms were histologically heterogeneous, but exhibited either a predominantly nodular (3/17) or infiltrative (13/17) pattern of invasion. Cytologically, the tumors displayed round to polygonal cells with a granular cytoplasm, small hyperchromatic nuclei with minimal pleomorphism, and less than 2 mitoses per 10 high power fields. One tumor (1/17) consisted of cells with predominantly vesicular nuclei and prominent nucleoli and was classified as an atypical vulvar GCT. All tumors so examined were reactive for S-100 protein. Eight of 17 tumor excision specimens had positive margins. Of these, 5 tumors remained stable whereas the other 2 with follow-up progressed to require reexcisions after periods of 14 and 8.0 years, respectively. All patients with excisions with negative margins remained stable. Patients with multifocal tumors did not have a higher risk of recurrence per tumor, compared with patients with isolated disease, regardless of the margin status. No patient died from her disease. As granular cell neoplasms have such a low risk or recurrence and behave generally in an indolent manner, aggressive therapy is usually unwarranted.

Immature teratoma of the vulva with an inguinal lymph node metastasis: report of a case and review of literature

Neoplasms of the vulva are rare and most commonly reported amongst them are epithelial tumors. Teratomas have been reported in many extragonadal sites. We report the only case of an immature teratoma of the vulva with inguinal lymph node metastasis.

Radiologic Evaluation of Mesenchymal Tumors of the Female Genital Tract

Mesenchymal neoplasms of the female genital tract are a diverse group of tumors, of which the most common are smooth muscle tumors. There is a significant overlap in the imaging characteristics of benign and malignant tumors and final diagnosis often requires pathologic correlation. However, familiarity with typical radiologic features, common imaging pitfalls, and the utility of different imaging modalities can be valuable in the evaluation of mesenchymal tumors. This article highlights the imaging features of the most commonly encountered mesenchymal tumors in the female genital tract.

Miscellaneous Pseudotumors and Mesenchymal Tumors of the Female Genital Tract

Benign and malignant soft tissue tumors and pseudotumors can rarely arise anywhere in the female genital tract. Their pathologic features as well as behavior typically overlap with those described in tumors involving typical locations. However, due to their rarity, not infrequently these tumors represent a diagnostic challenge. Their diagnosis should be based on careful gross examination, thorough sampling, and morphologic evaluation, applying a selected immunohistochemical panel and molecular studies. Accurate classification of these tumors is important because their clinical behavior, prognosis, and therapy differ markedly. This article outlines several mesenchymal lesions reported in the female genital tract, encompassing recent histologic, immunohistochemical, and molecular findings, with special emphasis on problems in the differential diagnosis.

Mesenchymal Lesions of the Lower Genital Tract

A variety of site-specific mesenchymal lesions of the lower genital tract may occur, which are often diagnostically challenging because of their morphologic overlap. Some of this morphologic homogeneity presumably stems from a potentially shared origin from the specialized superficial stroma of the distal female genital tract. Despite shared appearances, morphologic distinction remains the gold standard for diagnosis of most of these lesions, as immunoperoxidase staining is often not helpful in their distinction.

Cellular angiofibroma of oral mucosa: report of two cases

Cellular angiofibroma is a benign vascular neoplasm that typically arises in the vulva, perineal, and paratesticular region. Microscopically the lesions exhibit multiple small, non-dilated capillary channels, many of which contain erythrocytes. The endothelial lining cells are prominent, with monomorphic oval nuclei. Interposed among the vessels are both delicate and mature collagen fibers with fibroblastic hypercellularity that is variable in older lesions where sclerosis is prominent. The lesions usually do not recur following simple excision. Recent evidence indicates that cellular angiofibromas may be cytogenetically related to spindle cell lipoma. This represents the first reported instances of cellular angiofibroma in the oral cavity.

Association of psoriasis and vulval fibroepithelial polyp: first reported case

Fibroepithelial stromal polyps of the vulvovaginal region display a wide range of morphologic appearances. This morphologic spectrum allows the correct diagnosis to be made in some cases but when histology reveals unusual features, the lesion may be misinterpreted as malignant. We present a case of a 35-year-old woman with psoriasis who developed a 15-cm polypoid lesion localized in the left labium. The labial lesion was resected and no recurrence was detected 12 months after the initial treatment. Histologically, the lesion exhibited the characteristics of a fibroepithelial stromal polyp with focal myxoid areas and underlying vulval psoriasis disease. The clinical, microscopic, and immunohistochemical findings of this case suggest a fibroepithelial polyp of the vulva. This vulval lesion represents a unique example of giant fibroepithelial stromal polyp developed in association with psoriasis.

Application of immunohistochemistry to gynecologic pathology

CONTEXT

A large variety of tumors and lesions arise in the female genital tract. Although the majority of these can be correctly recognized on routine hematoxylin-eosin-stained slides, occasional cases present a diagnostic challenge. Immunohistochemical stains are extremely useful in resolving many of these problematic cases. As the knowledge in this area is constantly expanding, it is useful to have this updated information in a review form for easy access.

OBJECTIVE

To present our current knowledge of immunohistochemistry of the lesions of the female genital tract in a readily accessible form.

DATA SOURCES

The review is based on previously published articles on this topic.

CONCLUSIONS

Immunohistochemical stains help in reaching a conclusive diagnosis in a variety of problematic lesions seen in gynecologic pathology. As in any other system, immunohistochemical findings need to be interpreted in light of the clinical history and morphologic findings.

Ovarian spindle cell lesions: a review with emphasis on recent developments and differential diagnosis

Ovarian lesions composed of spindle cells comprise a heterogeneous group; most are neoplastic but several non-neoplastic conditions are also composed of spindle cells. This review discusses the main differential diagnoses of an ovarian spindle cell lesion, especially concentrating on the recent literature. The majority of ovarian spindle cell lesions fall into the broad category of fibromatous neoplasms whereas others in the sex cord-stromal group may also be composed of spindle cells, including thecomas, granulosa, and Sertoli-Leydig cell tumors and rarer neoplasms, such as sclerosing stromal tumor and signet-ring stromal tumor. In the recent past there have been several major contributions on various aspects of ovarian spindle cell lesions, including cellular and mitotically active cellular fibromatous lesions, smooth muscle neoplasms, and metastatic gastrointestinal stromal tumors. Other mesenchymal or epithelial tumors and mixed epithelial and mesenchymal neoplasms may also enter into the differential diagnosis of an ovarian spindle cell lesion. Several non-neoplastic lesions may be composed of spindle cells, including massive edema, ovarian fibromatosis, stromal hyperplasia, and stromal hyperthecosis. Morphology remains the mainstay in diagnosis but immunohistochemistry may be invaluable in certain circumstances, one example being the identification of a metastatic gastrointestinal stromal tumor within the ovary.

Vaginal polyps and hormones—is there a link?

Fibroepithelial stromal polyps (FSP) of the vault after hysterectomy are an uncommon, though well recognised finding. Both tibolone and tamoxifen have been reported to cause polyps in the endometrium but their connection with the same pathology in the vagina has never been described. Here, we report a case of a patient presenting with a symptomatic FSP 30 years after her hysterectomy while on treatment with both tamoxifen and tibolone. This prompted us to see if there was an association between these hormone-modulating agents with vaginal polyp formation. We reviewed all the cases notes of patients having FSP surgically removed in Hull over a 4 years period. Thirty-four women were identified. Some kind of hormonal influence, natural or otherwise, was found in 22 out of the 34 women. Endogenous or exogenous gonadal hormones or hormones modulators thus appear to influence the formation of vaginal polyps, but in this cohort a precise contribution of specific drugs could not be established.

Vulvar cellular angiofibroma: a case report

Cellular angiofibroma is a benign growth initially described in 1997, with few reports to date. A 31-year-old woman presented with a 3-year history of a small left labial mass, which had recently increased in size to 5 cm, and was clinically thought to be a lipoma. A simple excision was performed. Histologically, the mass was consistent with a cellular angiofibroma. Ten months later, the growth has not recurred. Cellular angiofibroma is a rare, benign mesenchymal lesion typically occurring on the vulva, and should be considered in the differential diagnosis of a painless, soft, vulvar mass.

A case of vulvar superficial angiomyxoma with necrotizing angiitis-like lesions and expression of granulocyte-colony stimulating factor

A vulvar tumor of 3-year-old girl was resected. The tumor had a pedunculated polypoid appearance with a multinodular surface and was covered by normal colored skin. Histologically, the tumor was lobulated and consisted of sparse stellate- or spindle-shaped tumor cells with a large amount of edematous stroma admixed with myxomatous areas. The tumor was rich in blood vessels of various sizes. Several blood vessels showed fibrinoid necrosis. There was a diffuse neutrophilic infiltration in the stroma. The tumor was diagnosed as a superficial angiomyxoma. Immunohistochemically, the tumor cells diffusely expressed vimentin, focally alpha-smooth muscle actin and desmin. Both estrogen and progesterone receptors were negative. Occasionally, they expressed CD34. Most of the tumor cells expressed granulocyte-colony stimulating factor (G-CSF). Endothelial cells of tumor blood vessels occasionally expressed intercellular adhesion molecule-1 or E-selectin. Some endothelial cells in the tumor were immunolabeled by anti-vascular endothelial growth factor (VEGF) antibody along their luminal surfaces. In the present case, G-CSF and adhesion molecules to neutrophils may have played some roles in neutrophilic infiltration into the tumor and in fibrinoid necrosis of the blood vessels. In addition to these molecules, VEGF may have contributed to vascular growth, leading to edematous stroma.

A persistently recurring peri-urethral soft tissue lesion of the vulva

Various mesenchymal lesions, some of which have only recently been characterized, may affect the vulva. Because of their apparently shared origin from vulvovaginal mesenchyme, these lesions can resemble one another superficially and can be challenging diagnostically. Clinically, benign lesions and tumor-like conditions may mimic a malignant process because of hypercellularity, mitotic activity, and rapid growth. We report on a 84-year-old diabetic and hypertensive woman who had previously undergone skinning vulvectomy for lichen planus and an embolectomy of the left femoral artery. The patient presented with a rapidly growing vulvar mass. The biopsy showed spindle cell proliferation in a loose myxoid stroma with granulation tissue and a mixed inflammatory infiltrate. Based on histology and immunohistochemistry, the initial diagnosis was that of a benign lesion. In view of the persistent recurrence of the lesion and the absence of metastatic spread, we conclude that the lesion has a low-grade malignant potential and suggest the diagnosis of florid cellular reactive pseudosarcomatous myofibroblastic proliferation.

Lipomatous Variant of Angiomyofibroblastoma: Report of Two Cases and Review of the Literature

Angiomyofibroblastoma (AMF) is a rare, benign, mesenchymal tumor occurring mainly in the female genital tract. Some cases contain scattered mature adipocytes, but the lipomatous variant in which mature adipose tissue is prominent or striking is rare. Only five cases have been reported in the English literature. We report two more such cases that were composed of 70 to 80% and 30 to 40% adipose tissue, respectively. Immunohistochemical analysis showed that the tumor cells were positive for estrogen receptor, progesterone receptor, vimentin, and Bcl-2, and negative for cytokeratin AE1/1, EMA, and CD117. Tumor cells in the first case were positive for CD34 but not desmin and muscle-specific actin. The opposite expression profile of these three markers was observed in tumor cells in the second case: positive for desmin and muscle-specific actin and negative for CD34. Rare cells were positive for S-100 in adipose-rich areas in the first case. Our findings indicate that the tumor cells in the lipomatous variant have similar immunoprofile to those of usual AMF and support the concept that the lipomatous variant probably represents an extreme end of a wide spectrum of differentiation in AMF.

Superficial cervico-vaginal myofibroblastoma: a report of five cases

AIMS

To describe the pathological and immunohistochemical features of five cases of superficial cervico-vaginal myofibroblastoma (SCVM), a recently described mesenchymal tumour affecting middle-aged and elderly females.

METHODS

The histological features of five cases of SCVM arising in four patients were reviewed including one case which recurred locally 9 years after initial excision biopsy. All cases were immunostained using the streptavidin-biotin technique using antisera to vimentin, smooth muscle actin, desmin, S100 protein, cytokeratin, h-caldesmon, calponin, CD99, CD117 (c-kit), bcl-2, oestrogen receptor and progesterone receptor.

RESULTS

The patients were aged from 40 to 71 years (mean 55.2 years). The tumours were situated within the vagina (four cases) and cervix (one case) and ranged from 16 to 45 mm in greatest dimension. One patient had two separate vaginal SCVM. The tumours were characterised by uniform spindle and stellate-shaped cells separated by a collagenous or myxoid stroma. No mitotic activity was identified. Characteristically the tumours were well circumscribed and separated from the surface epithelium by a rim of normal stroma. The initial and recurrent tumours in one patient were similar except for increased stromal collagen in the recurrence. All tumours were immunoreactive for vimentin, desmin, CD34, CD99, bcl-2, calponin and hormone receptors while two tumours showed focal smooth muscle actin expression. There was no expression of S100 protein, h-caldesmon, CD117 or cytokeratin.

CONCLUSIONS

SCVM appears to be a relatively distinct lesion although there is some histological and immunophenotypical overlap with other mesenchymal tumours, particularly fibroepithelial polyp, leiomyoma and solitary fibrous tumour. As local recurrence developed 9 years after intial treatment in one patient, long-term clinical follow-up would seem appropriate.