A case of vaginal clear cell adenocarcinoma complicated with congenital anomalies of the genitourinary tract and metanephric remnant without prenatal diethylstilbestrol exposure

Vaginal clear cell adenocarcinoma in Herlyn-Werner-Wunderlich syndrome: A case report

BACKGROUND

Herlyn-Werner-Wunderlich (HWW) syndrome is a rare Müllerian duct anomaly, characterized by a combination of urogenital abnormalities. The occurrence of primary cervico-vaginal carcinomas in patients with HWW syndrome is exceptionally rare, posing significant challenges for screening, early diagnosis, and effective management.

CASE SUMMARY

We report a rare case of primary clear cell carcinoma of the vagina complicated in a 40-year-old woman with HWW syndrome. The patient presented with irregular vaginal bleeding for 4 years. On gynecological examination, an oblique vaginal septum was suspected. Surgical resection of the vaginal septum revealed a communicating fistula and a tumor on the left vagina and the left side of the septum, which was confirmed as clear cell carcinoma. One month later, she underwent a radical hysterectomy, vaginectomy, bilateral salpingo-oophorectomy, and pelvic lymph node dissection. Due to significant side effects, she completed only one course of chemotherapy. A year later, lung metastasis was detected and continued to grow. A thoracoscopic wedge resection of the right upper lobe was performed 4 years after the initial surgery. We also conducted a systemic review of the literature on primary cervical or vaginal carcinoma in HWW syndrome to explore this rare entity.

CONCLUSION

Cervico-vaginal adenocarcinomas in patients with HWW syndrome are occult, and require early surgical intervention and regular imaging surveillance.

Gastric-type glandular lesions of the female genital tract excluding the cervix: emerging pathological entities

In the last two decades or so, a spectrum of benign, premalignant and malignant cervical glandular lesions exhibiting gastric differentiation has been described, with gastric-type adenocarcinoma representing the most common human papillomavirus (HPV)-independent cervical adenocarcinoma. More recently, limited literature has reported a variety of gastric-type glandular lesions at other sites within the female genital tract and, as in the cervix (the most common site for these lesions), a spectrum of benign, premalignant and malignant lesions has been proposed. We provide an update and review of the emerging spectrum of gastric-type glandular lesions at female genital tract sites other than the cervix. In the endometrium, putative gastric-type glandular lesions include mucinous metaplasia of gastric-type, atypical mucinous proliferation of gastric-type and gastric-type adenocarcinoma. Similarly in the vagina, gastric-type adenosis, atypical adenosis and adenocarcinoma have been described. There have also been occasional reports of gastric-type lesions involving the ovary and fallopian tube. We provide guidance on how to recognise gastric-type lesions morphologically and immunophenotypically and stress that sometimes these lesions occur at more than one site within the female genital tract (synchronous/multifocal gastric-type lesions of the female genital tract), sometimes in association with Peutz-Jeghers syndrome.

Fertility sparing treatment of vaginal clear cell adenocarcinoma in a DES-Naïve young woman

Background

Primary vaginal cancer is rare and comprises 1-2% of female genital tract cancers. Among the types of vaginal cancer, adenocarcinoma accounts for only 10% with the peak incidence in women less than 20 years old. Clear cell type vaginal adenocarcinoma is most associated with exposure to diethylstilbestrol (DES) in-utero.

Case

We present a case of an 18-year-old nulliparous woman, DES-exposure naive, who was diagnosed with stage I clear cell vaginal adenocarcinoma during a routine pelvic exam for abnormal vaginal bleeding. She underwent a fertility-preserving radical vaginectomy and pelvic lymphadenectomy with neovagina creation and uterovaginal cervical reconstruction. She has been without disease for 28 months.

Conclusion

Although rare, vaginal cancer can be diagnosed on routine women's health exams. Early screening and diagnosis allow for innovative fertility-preserving surgical approaches without compromising oncologic outcomes. To our knowledge, this is the first case of a fertility-preserving radical vaginectomy, neovagina creation using a vertical rectus abdominis myocutaneous (VRAM) flap, and uterocervicovaginal reconstruction to successfully treat early stage clear cell vaginal adenocarcinoma with surgery alone, sparing the patient from adjuvant chemotherapy or radiation.

Precursor Lesions of Cervical Clear Cell Carcinoma: Evidence For Origin From Tubo-Endometrial Metaplasia

Cervical clear cell carcinoma (CCC) is an HPV-independent tumor historically associated with in-utero exposure to diethylstilboestrol. With the cessation of diethylstilboestro use, most contemporary cases are sporadic and of uncertain pathogenesis, with no established precursor lesion. Following the detection of 3 incidental "early" (FIGO stage IA1) cervical CCCs, all of which displayed adjacent tubo-endometrial metaplasia, we examined further cases, including resection specimens, of this tumor in an attempt to delineate potential precursors. We identified tubo-endometrial metaplasia in proximity to the tumor in 5 of 5 additional primary cervical CCCs, with some tubo-endometrial glands exhibiting subtle mild cytologic atypia. This observation adds to the sparse existing literature proposing tubo-endometrial metaplasia as a precursor to sporadic cervical CCC, with possible progression via an "atypical" transitional phase to malignancy. We also review the published literature regarding possible precursor lesions of primary cervical CCC.

Transperineal Ultrasonographic and Magnetic Resonance Imaging Findings of Vaginal Adenosis

BACKGROUND

Vaginal adenosis is a rare clinicopathological entity which refers to the presence of glandular endometrial tissue in the vaginal wall.

CASE REPORT

A gravida 46-year-old woman was presented to the gynecology department with symptoms of chronic pelvic pain. Maternal Diethylstilbestrol (DES) usage has been proven effective in the development of vaginal adenosis. It can also be idiopathic. Its sonographic or magnetic resonance imaging (MRI) findings have not been described in English literature previously.

CONCLUSION

Here, we report the clinical, transperineal ultrasonographic (US) and MRI findings of a pathologically proven case of vaginal adenosis.

Menstural function preservation treatment of a primary vaginal clear cell carcinoma with ovarian transposition and vaginal brachytherapy

Early stage vaginal carcinomas are typically treated with radical surgical procedures or radiation therapy. Both modalities impair the reproductive ability of the patients. We hereby report a case of menstrual function preservation in a 24-year-old patient with an early-stage primary vaginal clear cell carcinoma. We treated the patient with intravaginal brachytherapy after appropriate laparoscopic surgical staging and separate transposition of the ovaries and tubes. The patient is now 6 years without any evidence of disease. She reports minor. complaints during sexual intercourse, while her menstruation and hormonic profile are normal.

Anterior Pelvic Exenteration for Chemo-irradiated Non-diethylstilbestrol Exposed Clear Cell Vaginal Cancer

BACKGROUND/AIM

Clear cell vaginal adeno-carcinomas are rare tumors occurring in women which are usually treated by chemo radiotherapy with good outcomes. However, in certain cases, this treatment is not associated with complete response and a further surgery is needed.

CASE REPORT

We present the case of a 38-year-old patient diagnosed with stage IVA clear cell vaginal cancer who had been previously submitted to radio chemotherapy and in whom the lesion persisted after the oncological treatment; therefore, the patient was proposed for surgery with curative intent. The tumor was resected by performing an anterior pelvic exenteration with good outcomes, the patient being discharged in the seventh postoperative day. At one-year follow-up the patient remains free of recurrent disease.

CONCLUSION

Pelvic exenteration with curative intent might be the option of choice for persistent locally advanced clear cell vaginal cancer.

Malignant transformation of vaginal adenosis to clear cell carcinoma without prenatal diethylstilbestrol exposure: a case report and literature review

Background

We report an extremely rare case of vaginal clear cell carcinoma, which originated from the malignant transformation of vaginal adenosis without prenatal diethylstilbestrol (DES) exposure.

Case presentation

In this case, the patient was a Chinese woman with a history of two decades of intermittent vaginal pain, sexual intercourse pain and vaginal contact bleeding. On September 1, 2011, when the patient was 39 years old, a vaginal biopsy revealed vaginal adenosis. After intermittent drug and laser treatment, her symptoms did not improve. Four years later, on March 4, 2015, another vaginal biopsy for abnormal vaginal cytology revealed atypical vaginal adenosis. After treatment with sirolimus, her symptoms and abnormal vaginal cytology results persisted, and she underwent laparoscopic hysterectomy with bilateral salpingo-oophorectomy and excision of the vaginal lesions. One year after the hysterectomy, on August 15, 2017, the vaginal cytology results suggested atypical glandular cells, and a biopsy revealed vaginal clear cell carcinoma originating from the atypical vaginal adenosis. A wide local resection of the vaginal lesions was performed, followed by concurrent chemoradiotherapy. Regular follow-up over 16 months showed no evidence of the recurrence of vaginal adenosis or cancer.

Conclusions

Based on the evolution of a series of pathological evidence, we report the fourth case in the world of vaginal clear cell carcinoma originating from vaginal adenosis without prenatal DES exposure. Wide local excision with radiotherapy provided at least 16 months of disease-free survival.

Primary Vaginal Gastric-type Adenocarcinoma and Vaginal Adenosis Exhibiting Gastric Differentiation: Report of a Series With Detailed Immunohistochemical Analysis

So-called gastric-type adenocarcinoma and related premalignant lesions have been characterized in the cervix, but similar lesions are not widely recognized in the vagina. We report a series of 11 vaginal glandular lesions exhibiting gastric differentiation, comprising 5 cases of adenocarcinoma and 6 of adenosis. All cases occurred in adults (aged 33 to 69) with no known history of diethylstilboestrol exposure. The vaginal adenocarcinomas exhibited morphologic features identical to gastric-type adenocarcinoma of the cervix, but 1 case additionally demonstrated basaloid and sarcomatoid components, which have not been previously reported in cervical gastric-type adenocarcinoma. Immunohistochemically, the adenocarcinomas were positive for MUC6 (4/5), PAX8 (3/5), CK7 (5/5), CK20 (1/5), CDX2 (5/5), CA19.9 (5/5), CEA (4/5), CA125 (5/5), and hepatocyte nuclear factor 1β (5/5). p16, estrogen receptor, and Napsin A were negative in all cases tested, whereas p53 exhibited mutation-type staining in 3/5 cases. In all 5 adenocarcinomas, a component of adenosis with benign or atypical nuclear features was identified; the adenosis displayed gastric morphology in 4 cases and tuboendometrial morphology in 1. The 6 cases of pure vaginal adenosis (without associated adenocarcinoma) all contained gastric-type mucinous glands together with tuboendometrial glands in 2 cases. There was focal intestinal differentiation with goblet cells in all 6 cases and neuroendocrine cells with eosinophilic granules in 3. Cytologic atypia was observed in 4/6 cases of pure vaginal adenosis. Immunohistochemically, the gastric-type adenosis (10 cases) was positive for MUC6 (10/10), estrogen receptor (5/10), PAX8 (8/10), CK7 (9/9), CK20 (2/9), CDX2 (5/9), CA19.9 (8/9), CEA (6/9), CA125 (6/9), hepatocyte nuclear factor 1β (10/10), and Napsin A (1/10). p53 exhibited wild-type immunoreactivity in all 10 cases, whereas p16 was negative in all cases tested. Scattered individual chromogranin-positive cells were present in all 5 cases of pure adenosis tested. Follow-up was available in 4 of the adenocarcinoma cases, with 3 patients dead of disease within 1 to 3 years and 1 patient alive with disease at 1 year. The morphologic and immunohistochemical findings in our study suggest a close relationship between vaginal gastric-type adenocarcinoma and adenosis exhibiting gastric differentiation. This probably represents a distinct pathway of vaginal gastric-type carcinogenesis analogous to that occurring in the cervix. We propose that gastric-type adenocarcinoma be recognized as a distinct histologic subtype of vaginal adenocarcinoma while vaginal adenosis of gastric-type represents a novel subtype of adenosis that requires further study to clarify its biological potential.

Carcinoma of the lower female genital tract in patients with genitourinary malformations: a clinicopathologic analysis of 36 cases

Background: Lower genital tract carcinomas that coexist with genitourinary malformations are rare. The aim of this study was to investigate the clinicopathologic characteristics and outcomes of patients with this rare joint condition. The aim of this study was to investigate the clinicopathologic characteristics and outcomes of these patients to analyze the associations among clinicopathologic features in this rare entity.

Methods: The medical records of patients with carcinoma of lower genital tract combined with genital tract malformations who were treated at Peking Union Medical College Hospital (Beijing, China) between January 1995 and December 2017 were retrospectively reviewed and a comprehensive literature review was performed. The correlations between variables were determined using Fisher's exact test.

Results: Thirty-six patients were identified, among whom 22 had cervical carcinoma, 10 had vaginal carcinoma, and two had carcinomas of both the cervix and vagina. The most common genital tract anomaly was uterus didelphys (n=17), and 63.9% of patients had with urinary tract malformations. Twenty-five (69.4%) had pathologically confirmed adenocarcinoma, 10 (27.8%) had squamous cell carcinoma (SCC), and 1 had adenosquamous carcinoma. Patients with urinary tract malformations developed adenocarcinoma more frequently than those without malformations (95.7% vs. 30.8% P<0.001). Compared with patients with SCC, patients with adenocarcinoma presented at a younger age (36.1 vs. 47.0 years, P=0.011), had more advanced stages disease (57.7% vs. 10.0% were in stage II-IV, P=0.022), and tended to have poorer five-year overall survival rates (75.6% vs. 100.0%, P=0.279).

Conclusions: Patients with simultaneous malformations of the genital and urinary tracts had a high probability of developing adenocarcinoma. It is recommended that rigorous gynecologic exams with Pap smears and imaging analyses be performed periodically in women with genital malformations, as they may be at a risk of genital malignancies.

Clinicopathologic features and outcomes of primary vaginal adenosis as a dermatologic and gynecologic burden: A retrospective study

In the recent 20 years, primary vaginal adenosis is extremely rare and the data of clinical presentations, management, and outcome have not been studied systematically.In this retrospective study, women with vaginal adenosis between January 1997 and June 2017 were identified from the hospital's medical records. Data on patient age, history, symptoms, mass location, size, diagnosis, complications, treatment, and recurrence were analyzed by SPSS 20.0.Twenty women were histopathologically diagnosed as having vaginal adenosis (mean age, 37.9 ± 10.6 years). All patients denied utero exposure. The most common symptom was vaginal pain or abnormal bleeding. For all patients, the local vaginal lesions were surgically excised. Seven patients had complications with endometriosis. 15 patients lived without recurrence, and 1 patient underwent postoperative local recurrence after 81 months. Primary vaginal squamous cell carcinoma in another patient was confirmed to arise from adenosis; she survived with disease. The remaining 3 patients developed carcinoma of different types in varied periods of a disease-free state (5 months, 30 months, and 23 years, respectively); 1 patient died of progressive disease, and 2 patients survived with disease.Primary vaginal adenosis is a spontaneous lesion with a propensity for late canceration. Local lesion resection is the primary treatment.

Vaginal clear cell carcinoma in a Japanese Black cow

During artificial insemination of an 18-year-old female Japanese Black cow, a mass that was of a hen’s egg size was found in the vagina. On necropsy, the firm mass, measuring approximately 3.5 × 3.5 × 3.0 cm, was located at the superior region of the vagina. The cut surface of the mass was gray-white in color with occasional necrotic or hemorrhagic areas. Histologically, the mass was composed of tumor cells arranged in solid nests of various sizes with an occasional tubular structure separated by a delicate fibrovascular stroma. The tumor cells had a hypochromatic nucleus and abundant, faintly eosinophilic cytoplasm. The tumor cells contained diastase-sensitive periodic acid-Schiff positive granules. Immunohistochemically, tumor cells were positive for cytokeratin AE1/AE3, CAM5.2 and carcinoembryonic antigen, but not for vimentin, p63, estrogen receptor-α, progesterone receptor, α-smooth muscle actin, neuron-specific enolase, S-100 protein and chromogranin A. On the basis of these findings, the tumor was diagnosed as a clear cell carcinoma of the vagina.

The vagaries of proper imaging in diagnosing single-system ectopic ureter in children with continuous incontinence and outcomes of simple nephrectomy

PURPOSE

To investigate the proper diagnostic modalities and failure cases of treatment in patients with single-system ectopic ureter (SSEU) who underwent nephrectomy for incontinence.

METHODS

SSEU combined with dysplastic kidney is a rare cause of female incontinence. We retrospectively analyzed 45 pediatric SSEU patients that underwent simple nephrectomy at our institution during 1996-2013 for incontinence. We reviewed imaging studies to detect dysplastic kidney and ectopic ureter insertion, postoperative results, and urodynamic findings for remaining incontinence after nephrectomy.

RESULTS

Median operative age was 59.3months. Both ultrasonography and magnetic resonance imaging (MRI) showed 50.0% dysplastic kidney detection rates respectively. Dimercaptosuccinic acid (DMSA) scanning and computerized tomography (CT) showed equal detection rates of 95.5%. Ectopic ureter insertion sites were determined by ultrasonography, CT, and MRI in 17.5%, 13.6%, and 33.3% of patients, respectively. Renal vascular structures were identified in 3/22 patients (13.6%) with CT. Post-nephrectomy, incontinence disappeared in 41 patients (91.1%), but remained in 4 patients (8.9%); urodynamics suggested bladder neck incompetence in these patients.

CONCLUSIONS

DMSA is a highly sensitive diagnostic modality for detecting dysplastic kidney in SSEU patients with more than 95% detection rates. Once detected by DMSA, additional CT or MRI studies do not provide further information about ectopic ureter insertion or renal vascular structure. Although nephrectomy is successful in nearly 90% of SSEU patients with dysplastic kidneys, postoperative incontinence occasionally remains and requires additional treatment.

Non-diethylstilbestrol exposed vaginal clear cell adenocarcinoma has a common molecular profile with ovarian clear cell adenocarcinoma: A case report

•Primary vaginal clear cell adenocarcinoma (PVCCA) coexists with urinary tract anomalies without exposure to diethylstilbestrol in some cases.•PVCCA in our case showed genetic alterations of well-known cancer related genes, including a mutation of PIK3CA.•The genetic profile suggests that the carcinogenesis of PVCCA might have elements common with that of OCCA.

Primary vaginal mucinous adenocarcinoma of gastric type arising in adenosis: a report of 2 cases, 1 associated with uterus didelphys

We report 2 cases of primary vaginal mucinous adenocarcinoma arising in adenosis in nondiethylstilbestrol-exposed women, 1 with uterus didelphys. Both tumors exhibited morphologic and immunohistochemical features (MUC6 and/or HIK 1083 positivity) identical to the recently described cervical gastric-type adenocarcinoma, a subtype of mucinous adenocarcinoma that is non-human papillomavirus related and possibly related to adenoma malignum. Both neoplasms were intensely p53 positive, suggesting that TP53 mutation may be implicated in their development. We believe that the vaginal tumors arose from adenosis through atypical adenosis, as benign and atypical glands were present at the periphery of the neoplasms. In reporting these cases, we discuss atypical adenosis and other types of non-diethylstilbestrol-associated vaginal adenocarcinomas. At least 9 other examples of primary vaginal, or more uncommonly cervical, adenocarcinomas arising in non-diethylstilbestrol-exposed women with congenital genitourinary malformations have been reported, suggesting a probable causal association between congenital malformation, vaginal adenosis, and vaginal adenocarcinoma.