Clinical History
91-year-old nulliparous female with history of open hysterectomy plus bilateral salpingo-oophorectomy and pelvic lymphadenectomy for stage Ic endometrial carcinoma ten years earlier, negative oncologic follow-up during the first five years after surgery.
Currently complained of bloody vaginal discharge for a few weeks. Routine laboratory assays within normal limits for age.
Imaging Findings
Hampered by the patient's lack of cooperation, initial physical examination revealed asymmetric vagina with a "polypoid" mass oozing blood.
MRI (Fig.1) confirmed absent uterus and adnexa from previous surgery, and the presence of an elongated mass which occupied most of the vagina: the lesion showed mildly increased T1 signal intensity compared to muscles and moderately hyperintense T2 signal, did not invade the T2-hypointense peripheral vaginal layer, and did not enhance after intravenous gadolinium contrast. Peritoneal effusion, adenopathies and other abnormal findings were absent.
Colposcopic biopsy was performed, and pathology diagnosed recurrent papillary endometrial carcinoma.
Since the tumour recurrence was limited to the vagina, the patient underwent external beam radiotherapy. Four months later, clinical examination and follow-up unenhanced MRI (Fig. 2) showed complete disappearance of the neoplastic vaginal mass. Two years later, the patient is still alive and free of neoplastic disease.
Discussion
Worldwide, endometrial uterine carcinoma (EUC) is the commonest malignancy of the female genital tract, and generally occurs in postmenopausal women (median age of 63 years). According to the current International Federation of Gynaecology and Obstetrics (FIGO) system, the standard approach to EUC is surgical staging including total hysterectomy, bilateral salpingo-oophorectomy, systematic pelvic and para-aortic lymphadenectomy. Adjuvant brachytherapy, external radiotherapy and chemotherapy are commonly used in advanced tumours [1, 2].
The majority (almost 80%) of recurrences develop within 3 years after initial surgery. A long relapse-free interval, low-grade histology, and isolated vaginal recurrence represent favourable prognostic factors. Recurrent and metastatic EUCs are generally treated with repeated surgery, or with a different therapeutic regimen (cytotoxic, hormonal, or molecular targeted). The vagina represents a common site of local EUC relapse. In women who were not previously irradiated, vaginal recurrences after primary surgery are effectively treatable with radiotherapy [1, 2].
With its multiplanar capability and superb contrast spatial resolution, currently MRI is the preferred modality to image the genital and perineal structures, particularly for locoregional staging and post-treatment evaluation of gynaecological tumours. High-resolution T2-weighted images well depict the normal anatomy and disorders of the vagina [3-7].
Vaginal mass-forming lesions may be categorized as congenital abnormalities, cysts, abscesses, benign and malignant tumours. Secondary tumours are by far (80-90%) more frequent compared to the rare primary vaginal squamous carcinoma. Metastases to the vagina may result from local spread of adjacent tumours in the uterine cervix, endometrium, urinary bladder or anorectum, sometimes through lymphatic or haematogenous dissemination. Contiguous spread from gynaecological tumours generally involves the anterior aspect and upper portion of the vagina; conversely anorectal tumours tend to invade the lower vaginal third and posterior wall. As exemplified by this case, the vaginal vault is often involved by recurrent EUC [6].
The MRI features of vaginal metastases are commonly nonspecific. Possible appearances include well-demarcated or lobulated masses, infiltrative or annular circumferential lesions. The MRI signal intensity is generally low-to-intermediate on T1-weighted, intermediate-to-high on T2-weighted sequences. The degree of contrast enhancement is variable and may reflect that of the primary tumour. Therefore, MRI allows limited differentiation between squamocellular carcinoma, the rare non-squamous primary malignancies, and vaginal metastases, so that biopsy is almost invariably required. Finally, as shown in this case, reproducible MRI acquisitions allow for reliable follow-up after surgery, radio- or chemotherapy [3-7].
Differential Diagnosis List
Vaginal recurrence of endometrial carcinoma.
Primary vaginal squamous carcinoma
Vaginal adenocarcinoma
Vaginal lymphoma
Vaginal (leiomyo)sarcoma
Vaginal melanoma
Benign tumour e.g. leiomyoma
Bartholin cyst / abscess
Local spreading anorectal tumour
Final Diagnosis
Vaginal recurrence of endometrial carcinoma.
