A 46-year-old woman presented with coitorrhagias over the last year and pruritus.
The physical examination revealed a lesion in the vulva (left labia majora and labia minora) and the vagina, with an ipsilateral palpable inguinofemoral node. Biopsy showed an invasive squamous cell carcinoma. Positivity for HPV16 was recognized.
The magnetic resonance (MR) study documented a vulvar lesion, in the left labia majora and involving the anterior wall of the lower third of the vagina. The lesion showed intermediate signal intensity on T2-weighted sequences, restricted diffusion, and early contrast enhancement. It did not invade the urethra or the anus. There were no inguinal or pelvic lymph nodes with suspicious features, according to morphological and dimensional criteria on magnetic resonance imaging (MRI).
Vulvar and vaginal carcinoma are rare entities. Most cases are symptomatic and affect postmenopausal women [1,2].
Cervical, vulvar, endometrial and adnexal malignancies must be excluded when defining if a lesion is a primary vaginal carcinoma. In fact, tumours involving the vulva are considered vulvar malignancies, irrespective of whether the epicentre of the tumour is in the vagina .
Squamous cell carcinoma is the most common histological type and human papillomavirus infection (HPV) infection is a well-recognized risk factor. HPV-related carcinomas account for most cases of vulvar carcinomas in younger woman [1,3]. Indeed, in our case, passivity for high-risk HPV (HPV16) was documented.
Lymph node status is the most significant prognostic factor. The lymphatic drainage from the vulva is primarily via the superficial inguinal nodes. Lateral vulvar carcinomas drain to the ipsilateral inguinal nodes but midline lesions (or within 1cm of the midline) can drain bilaterally. In early stages, distant metastases are uncommon and the first-line treatment is surgical .
The radiological evaluation of vulvar lesions is best achieved with MRI.
The standard pelvic MRI protocol includes axial T1 and T2-weighted images (T1WI and T2WI) of the pelvis and axial high-resolution T2WI. Contrast-enhanced images (dynamic fat-saturated contrast-enhanced T1WI) are valuable in determining the possible extension to adjacent structures. Diffusion-weighted imaging is also advisable. T2WI with fat suppression may eventually improve tumour depiction. The upper abdomen should be assed, namely for possible abnormal lymph nodes [1,4].
Vulvar carcinoma appears as a solid mass with low signal intensity on T1WI and intermediate to high signal intensity on T2WI. On the contrast-enhanced study there is early contrast enhancement .
When evaluating lymph nodes, the short-axis diameter of ≥1cm is the standard dimensional criterion to categorize lymph nodes as suspicious. Other features of suspicion should be appreciated, such as the irregular contour, round shape, loss of fatty hilum and presence of necrosis. The latter has been considered the individual feature with the highest specificity .
According to the FIGO staging for carcinoma of the vulva (revised in 2009), our case was categorized as stage II as it invaded the lower third of the vagina .
Written informed patient consent for publication has been obtained.
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