Bartholin\'s gland carcinoma

Clinical History

A 49-year-old female presented with a 3 month history of painless perineal mass for which antibiotics had been administered based on the diagnosis of an infected Bartholin gland cyst. Because relief was not obtained with this treatment, a pelvic MRI study was then requested.

Imaging Findings

Pelvic MRI was performed on a 1.5T unit. Axial, sagittal, and coronal T2-weighted images and postgadolinium axial T1-weighted images with fat saturation were obtained. MRI revealed an ill-defined mass in the right perineum of intermediate signal intensity on T2-weighted images (Figures 1, 2) with pronounced enhancement following administration of gadolinium (Figure 3). The mass was contiguous with the right posterolateral aspect of the vaginal introitus, and extended involving the right levator ani muscle and the sphincter anal complex. Right groin lymph nodes were also identified.
Percutaneous biopsy was performed and pathological analysis revealed a squamous cell carcinoma of Bartholin's gland (Figure 4). The patient underwent chemotherapy and local radiation therapy.

Discussion

The Bartholin glands are a pair of mucus-secreting glands in the vulvar vestibule. They are located at the posterolateral vaginal introitus, at or below the level of the pubic symphysis, medial to the labia minora and inferior to the perineal membrane. The Bartholin gland duct communicates with the posterolateral wall of the vagina [1].

Bartholin gland carcinomas (BGCs) are extremely rare tumours, accounting for 2-7% of vulvar carcinomas and 0, 1% of all female genital malignancies. Adenocarcinoma and squamous cell carcinoma are the most common histological types [2, 3].

These tumours commonly occur in postmenopausal females (median age: 50 years) [1, 2]. Although the pathogenesis of BGCs remains unknown, the human papilloma virus has been shown to be associated with squamous and adenocarcinoma histological type of BGCs and may play a role in the genesis of this malignancy [2, 3].

Vulvar cancer is usually diagnosed clinically, but BGC is commonly misdiagnosed as Bartholin gland cyst or abscess due to the deep location of Bartholin glands and the lack of early clinical symptoms. The most common presentation of a Bartholin gland carcinoma is a painless vulvar mass [2, 4].

MRI plays an important role in staging of vulvar tumours, especially assessing the extent of disease and selecting operable versus inoperable candidates [4, 5]. Although the role of MRI in the evaluation of BGCs has not been definitively established, this technique is the best imaging modality for the evaluation of vulvar anatomy and Bartholin gland cysts [4], the detection of early-stage BGCs and the differentiation of BGCs from cysts and abscesses of the Bartholin gland [1].

Our patient showed similar MRI features to most common locally advanced vulvar carcinomas [4, 5]. The tumour appeared as an ill-defined soft-tissue mass involving the vaginal introitus, the right levator ani muscle and the sphincter anal complex. The mass showed intermediate-signal intensity on T2-weighted images and intense enhancement on dynamic sequences. Large vulvar tumours may appear hyperintense on T2-weighted sequences due to the presence of internal necrosis [1, 4, 5].

Current treatment of BGC include radical local excision with margins of at least 1 cm and inguinal-femoral lymphadenectomy for resectable lesions. For nonresectable lesions, neoadjuvant radiation or chemotherapy and local radiation therapy can be administered, followed by surgical resection if neoadjuvant therapy renders the lesion resectable [4-6].

Differential Diagnosis List

Final Diagnosis

Bartholin's gland carcinoma

URL:	https://www.eurorad.org/case/12314
DOI:	10.1594/EURORAD/CASE.12314
ISSN:	1563-4086