Vaginal Tumors Research Articles

Minihysteroscopy for examination and management of pathologic lesions of virginal reproductive tracts: can we preserve the hymen intact?

Dear Editors, Hysteroscopy has been widely used for uterine cavity examination and management. Although the possibility of hymen preservation is high, virgins are highly resistant to this procedure [1]. This may be due to a belief that the procedure causes disruption of virginity and worries associated with their future partners. Case 1 was a 31-year-old virgin complaining of abnormal vaginal bleeding for months despite of medical treatment. Hysteroscopic examination was indicated, but she initially hesitated. After extensive counseling about the beneWts and limitations of both conventional hysteroscopy and minihysteroscopy, she chose a minihysteroscopy with 4-mm continuous-Xow outer sheath, 5Fr operating channel and 2-mm 0°-telescope (Karl Storz, Tuttlingen, Germany) rather than a 8-mm hysteroscopy. The procedure was conducted under intravenous sedation without use of speculum, tenaculum and cervical dilators. An operative assistant was assigned to hold the hysteroscope in place to make sure the downward pressure was not excessive and for paying attention to safety of the hymen. Additionally, avoidance of wide movements during manipulation was necessary. Vagina and cervical canal were normal; one 8-mm endometrial hyperplastic polyp was found at the posterior wall of the uterine cavity and removed by a Xexible biopsy forceps piecemeal through the channel. Case 2 was a 43-year-old virgin complaining of a vulvar mass for a long time, but she was too embarrassed to visit a gynecologist. Physical examination revealed a 6-cm erosive tumor protruding from the vagina (Fig. 1a). On minihysteroscopy, the uterine cervix was normal and the tumor growing from the left lateral vaginal wall 4 cm behind the introitus (Fig. 1b) was extracted cautiously by smallest Pean forceps. The hymen integrity was preserved (Fig. 1c), and a benign polyp was diagnosed pathologically. Operation duration for both patients was less than 20 min, and both were uneventful. Their symptoms were relieved thereafter, and they were satisWed with the procedure and outcome. Informed consent was obtained from Case 2 for use of the pictures. Hymen integrity is an important representation of virginity in some countries even though it is not absolutely related to virginity. When a reproductive tract examination or transvaginal operation must be arranged for a virgin, the operator faces a challenge and may hesitate to utilize hysteroscopy, which can result in a delayed diagnosis or improper treatment. The most common indication for hysteroscopy was abnormal vaginal bleeding, experienced by 52.5% of 40 virginal patients [1, 2]. The acceptance rate for surgery, however, was only 78% [1]. Hymen integrity was preserved in all reported cases without major complications. Our Wndings concurred with their results. So far, only a few reports have discussed the protection of hymen integrity in hysteroscopy [1, 2], and the physical and psychological impacts of this surgery in virgins are not conclusive. Although hysteroscopy can improve diagnosis and thereby improve quality of life, virgins may decline this procedure. Patients with delayed diagnosis and management in some uncommon but serious situations, such as endometrial malignancy, are life-threatening. This is an important issue that gynecologists encounter, but which has seldom been discussed. In the two cases described above, minihysteroscopy was able to fulWll their physical and psychological needs after endometrial polypectomy or vaginal tumor removal. M.-L. Cheong (&) Department of Obstetrics and Gynecology, Cathay General Hospital, #280, Sect. 4, Jen-Ai Road, Taipei 106, Taiwan e-mail: joymlcheong@gmail.com

Primary Vaginal Extraosseous Ewing Sarcoma/Primitive Neuroectodermal Tumor with Cranial Metastasis

Extraosseous Ewing sarcoma is now regarded as a member of the Ewing sarcoma/primitive neuroectodermal tumor (PNET) family. It typically involves the soft tissues of the chest wall, pelvis, paravertebral region, abdominal wall, retroperitoneal region and extremities of children, adolescents and young adults, but it seldom occurs in the female genital tract. We report an extremely rare case of retrospective diagnosis of vaginal extraosseous Ewing sarcoma/PNET which metastasized to the right frontoparietal scalp, skull, and dura. Surgical resection, followed by adjuvant radiotherapy and chemotherapy resulted in a favourable clinical outcome. Both the vaginal and head tumors had similar light microscopic features supporting the diagnosis.

Clinical analysis of 20 patients with vaginal intraepithelial neoplasia

Objective To explore the clinical-pathologic characteristics, treatment modalities and prognosis of patients with vaginal intracpithelial neoplasia ( VAIN ). Methods The clinical, pathologic and follow-up data of 20 cases with vaginal intraepithelial neoplasia treated primarily in Cancer Hospital of Chinese Academy of Medical Sciences from Jan. 1999 to Dec. 2007, were reviewed and analyzed retrospectively. Results There were not any of symptoms on diagnosis in all patients, and most of them ( 17 cases, 85% ) were frequently detected VAIN for the abnormal pap smears or pelvic examination from cervical carcinoma patients and under the colposcopy as well as colposcopic biopsies. There were 3 cases (15%) with cervical cancer were diagnosed as VAIN during the postoperative follow up, while 17 cases (85%) of patients were accompanied with cervical cancer( 12 eases) or cervical intraepithelial neoplasia (CIN, 5 cases ) concomitantly or antecedently. Ninety percent of patients were diagnosed as VAIN Ⅲ,17 cases (85%) were mainly localized in the upper third of vagina, and 13 cases (65%) affected to the multiple vaginal walls. Thirteen cases were performed surgery, and 7 cases were treated by irradiation. The local control rate was achieved to 100% in all of patients. Three cases ( included 1 post-irradiated and 2 post-operative) were relapsed after treatment, but still be controlled completely by radiotherapy or surgery. Conclusions VAIN was difficult to be diagnosed independently, which was frequently accompanied by cervical cancer or CIN, significantly localized in the upper third of vagina involving the multiple walls of vagina, and treated synchronously with cervical carcinoma and CIN accompanying. Surgery and radiotherapy was equally effective to control VAIN, and then follow-up post-treatment should be closely to detect, diagnose and treat recurrent VAIN as soon as possible after treatment. Key words: Vaginal neoplasms; Precancerous conditions; Biopsy

Analysis of diagnosis and treatment of vaginal intraepithelial neoplasia and correlation to cervical intraepithelial neoplasia

To investigate the diagnosis and therapy of vaginal intraepithelial neoplasia (VAIN) and correlation to cervical intraepithelial neoplasia (CIN). The clinical and pathological data about age, liquid-based cytology, human papillomavirus (HPV) DNA test, colposcopy, histology types and treatment in 35 patients with VAIN were reviewed to investigate the diagnosis and therapy of VAIN and correlation to CIN. Mean age at presentation was 43.9 years. The percentage of VAINI, VAINII and VAINIII were 52% (18/35), 34% (12/35) and 14% (5/35), respectively. 8% (1/13) of patients were younger than 40 years developed VAINIII, while 18% (4/22) patients were elder than 40 years. There were 83% (29/35) cases were diagnosed from 2007 to June 2008. 69% (24/35) or 17% (6/35) cases had the history of CIN or cervical cancer, respectively. VAINII-III accounted for 3/9, 53% (8/15) and 4/6 of CINI, CINII-III and cervical cancer, respectively. There were 87% (13/15) positive high risk HPV infection in VAINI, while 100% in VAINII and VAINIII. There were 97% (33/34) cases with abnormality for liquid-based cytology and 86% (30/35) cases of lesions were located in the upper 1/3 vagina. Among 19 cases received therapy, 14 cases (74%) were treated by surgery, 2 cases (11%) by brachytherapy, 3 cases (16%) used drug on the surface of vagina and the lesions were shown recovery in 9 cases followed up. The clinical characteristics of VAIN are similar to CIN and the principles of diagnosis and treatment are also the same as that of CIN.

Clinical analysis of 42 cases of primary malignant tumor in vagina

To analyze the clinical characters, treatment and prognosis of primary malignant tumor in vagina. A retrospective analysis of 42 patients diagnosed with primary malignant tumor in vagina in Peking Union Medical College Hospital (PUMCH) between Jan 1984 and Aug 2006 was performed. Primary malignant tumor accounted for 0.98% (42/4286) in the total gynecological malignant tumors during that period in PUMCH. According to the International Federation of Gynecology and Obstetrics (FIGO) staging system, 19 cases were at stage I, 12 cases at stage II, 5 cases at stage III, and 6 cases at stage IV. Thirteen cases were squamous carcinoma, 13 cases were malignant melanoma, 8 cases were adenocarcinoma, 3 cases were yolk sac tumor and 5 cases were other types. The majority of patients were treated with surgery combined with radiotherapy and chemotherapy. Up to August 2007, 19 cases survived, 18 cases were dead and 5 cases were lost. The longest follow up was 10 years, with the median time of 2 years. The overall 2-year survival rate was 60.6%. For stage I, stage II and stage III - IV, the 2-year survival rates were 71.3%, 58.3% and 29.6% respectively. The 2-year survival rate of patients with squamous carcinoma was 46.8%, malignant melanoma 72.9%, adenocarcinoma 20.0% and patients with yolk sac tumor were all alive tumor-free after 6 - 10 years' follow up. The prognosis of primary malignant tumor in vagina is affected by clinical stage and histological type. As to malignant melanoma, radical surgery combined with chemotherapy and immunotherapy produce good effects. Patients with yolk sac tumor can be cured only with chemotherapy. As to other types, more treatment experiences are needed.

Carcinoma escamoso in situ de endometrio y vagina asociado a carcinoma microinvasivo de cérvix

Squamous cell carcinoma of the endometrium is an uncommon type of endometrial tumor, which is usually associated with invasive or intraepithelial lesions of the cervix, although this neoplasm has been described as a primary tumor. While intraepithelial vaginal tumors associated with intraepithelial neoplasms of the cervix are relatively frequent, their simultaneous association with endometrial carcinoma has rarely been reported.We describe a case of in situ squamous cell tumor of the endometrium and vagina associated with invasive carcinoma of the cervix that was treated with radical surgery and brachytherapy. The patient is currently disease-free.

Concurrent chemoradiation for locally advanced squamous cell carcinoma of the vagina: case series and literature review

We reviewed our experience with patients with primary squamous cell carcinoma of the vagina who received concurrent chemoradiation therapy (CCRT). We retrospectively analyzed six patients (median age, 60 years) with squamous cell carcinoma of the vagina who underwent CCRT between 2002 and 2005 at the University of the Ryukyus Hospital. Two patients were in International Federation of Obstetricians and Gynecologists (FIGO) stage II, one in stage III, and three in stage IVA. All patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 2 or less. Tumor size ranged from 3.2 to 7.7 cm. All patients were treated with true pelvic external-beam radiotherapy (EBRT) at 50 Gy. Then two of the six patients underwent intracavitary vaginal brachy-therapy. The remaining four patients received boost EBRT with shrinking fields. Total radiation dose to the vaginal tumor ranged from 60 to 66 Gy. All patients received two or three concomitant cycles of cisplatin during EBRT. All six patients completed their scheduled CCRT, and achieved a clinical complete response. One stage II patient died of disease 24 months after treatment, and the stage III patient had local failure at 12 months. The remaining four patients were free of their disease at 18, 23, 33, and 55 months, respectively. One patient with stage IVA developed a vesicovaginal fistula during CCRT. Nevertheless, CCRT was well tolerated by all six patients, and no grade 3 or 4 late toxicity was observed, as evaluated by the Radiation Therapy Oncology Group (RTOG) scoring system. CCRT is effective for primary squamous cell carcinoma of the vagina and should be considered for treatment in patients with high-risk disease having good performance status.

Clinical analysis of six cases of vaginal intraepithelial neoplasia

To investigate the clinical characteristics, diagnosis and treatment of vaginal intraepithelial neoplasia (VAIN). A retrospective study was made of 6 patients with VAIN, who were hospitalized at Peking Union Medical College Hospital from 1980 to 2006. Five cases had a history of hysterectomy, two of whom were because of cervical intraepithelial neoplasia (CIN) or invasive cervical cancer. Four cases had the infection of high-risk oncogenic human papillomaviruses detected with hybrid capture II (HC-II), the other two had no record. In all patients the VAIN lesions were within the upper one third of the vagina. They were all diagnosed by colposcopic examination and directed biopsy after the abnormal cytology by thinprep cytology test (TCT). Six cases of VAIN II-III were treated by excisional surgery. One case had residual lesion and had another surgery 3 months after the first one. Two patients obtained remission at one-year follow-up, three had abnormal cytology by TCT 6 months after surgery, and one had abnormal cytology by TCT at six-month follow-up but normal at one-year follow-up. A history of CIN is the main risk factor for VAIN, so routine vaginal cytology is needed for the patients after hysterectomy due to CIN. Cytology, colposcopic examination and directed biopsy are the mainstays of VAIN diagnosis. Excisional surgery is recommended for the patients with VAIN II-III. Long term follow-up is necessary after treatment.

Vaginal haemangioendothelioma: an unusual tumour

Vaginal tumours are uncommon and this is a particularly rare case of a vaginal haemangioendothelioma in a 38-year-old woman. Initial presentation consisted of symptoms similar to uterovaginal prolapse with "something coming down". Examination under anaesthesia demonstrated a necrotic anterior vaginal wall tumour. Histology of the lesion revealed a haemangioendothelioma which had some features of haemangiopericytoma. While the natural history of vaginal haemangioendothelioma is uncertain, as a group, they have a propensity for local recurrence. To our knowledge this is the third reported case of a vaginal haemangioendothelioma. Management of this tumour is challenging given the paucity of literature on this tumour. There is a need to add rare tumours to our "knowledge bank" to guide management of these unusual tumours.

Mixoid leiomyoma of the vagina: Case report with emphasis to diagnostic challenges

Leiomyoma is the most common benign mesenchymal tumour of the vagina in adult women,1 but no case of myxoid variant has been reported at this site. A 27-year-old nulliparous woman was admitted to hospital for dyspareunia, pressure symptoms on the urinary tract, vaginal pain and prolonged vaginal discharge. By vaginal exploration, a soft mass was palpated in the anterior wall vaginal measuring 7 × 6 cm. The magnetic resonance images revealed a vaginal tumour arising from the anterior vaginal wall (Fig. 1a,b). Enucleation of the vaginal tumour using a transvaginal approach was performed. (a) Sagittal T2-weighted magnetic resonance images show an inhomogeneous voluminous mass that displaced anteriorly the bladder (arrow). (b) Sagittal T2-weighted magnetic resonance images show an inhomogeneous voluminous mass that displaced cranially the uterus (head arrow). The vagina is dilated and show high signal intensity (*). (c–d) Histological pattern of mixoid leiomyoma: abundant amorphous mixoid material was present between the smooth muscle cells. (c) Haematoxylin and eosin (H&E) σταινινγ, ×200; (d) H&E staining, ×100. The mass was a well-encapsulated solid tumour measuring 8.5 × 7.5 × 6.5 cm with a smooth, pink surface. The cut surface was yellow and soft with a whorled or slightly nodular pattern and focal grey gelatinous areas. On microscopic examination, the majority of the tumour was hypocellular with delicate spindle cells dispersed in an amorphous, pale blue matrix (Fig. 1c). The matrix was positive for Alcian blue and colloidal iron stainings and was faintly positive for mucicarmine staining. Focal areas resembling typical leiomyoma were present. Nuclear atypia was absent, and the highest mitotic count was 1MF/10 HPF. The tumour cells showed strong positivity for muscle specific actin and focally for desmin. Fourteen months after the surgical removal, she was asymptomatic. Vaginal leiomyomas vary in size up to 5 cm, and sometimes may simulate malignancies (large size, unusual subtype, degenerative changes). Microscopically vaginal leiomyomas resemble those of the genital tract organs and may display bizarre,2 epithelioid and clear cell patterns.3 Since the first report by Denys de Leyden in 1773, approximately 300 cases have been reported.4 The criteria used for smooth-muscle tumours of the uterine corpus appear to be organ-specific and cannot be applied to counterpart arising elsewhere in the female genital tract. In evaluating vaginal smooth muscle tumours, we apply the criteria of malignancy used by Tavassoli and Norris3: presence of moderate to marked atypia and five or more mitotic figures per 10 high-power fields. Myxoid change may be seen in both benign and malignant smooth muscle tumours. This change has achieved notoriety in the uterus because some myxoid leiomyosarcomas have little nuclear atypia and a low mitotic rate making evaluation of borders crucial for placement in either a benign or a malignant category. In our case the tumour was well circumscribed, with no cytological atypia and a low mitotic rate. The diagnosis of benignancy is confirmed by follow up. After 14 months of surgical removal, the patient is free of disease. In the diagnosis of myxoid leiomyoma another diagnostic challenge is found when the myxoid degeneration is extensive. In this instance it may be difficult to identify the smooth nature of the tumour. A desmin or actins staining may be helpful in this situation. In our case the positivity of actin was diffusely found, although extensive mixoid areas were present. After a review of the literature, we shall consider that this is the probably first case report of myxoid leiomyoma of the vagina.

Tumor carcinoide de vagina

A vaginal nodule in a 32-year-old woman is reported. Histologically, the nodule corresponded to a well delimited tumor with chromogranin, estrogen and AE1/AE3 expression. After a 5-year follow-up, benign behavior has been observed, with no recurrence or metastasis. We found only two cases of vaginal carcinoid tumor in the literature reviewed; both occurred in association with adenocarcinoma and showed aggressive behavior, with both patients dying within 1 year. In our opinion, the case reported herein was a primary benign vaginal carcinoid tumor. To the best of our knowledge, this type of tumor in this location has not previously been described and constitutes a benign counterpart to the above-mentioned neuroendocrine tumors.

Clinical analysis for 12 cases of severe vulvar intraepithelial neoplasm

Objective To study the clinical characteristics, diagnosis, treatment and its effectiveness of vulvar intraepithelial neoplasm Ⅲ(VIN Ⅲ).Methods Clinical data, including age of the patients, mode of surgical operation, pathological features, results of post-operation follow-up, of 12 cases of VIN Ⅲ admitted to the Peking Union Medical College Hospital(PUMCH)during January 1984 to December2006 were retrospectively analyzed.Results Mean age of the 12 cases was 40.3(ranging from 23 to 56)years.All the patients had symptoms of vulvar itching, three with VUlVar ulcer and one with vulvar pain.There was single neoplasm focus in two cases and multiple focuses in 10 cases, five cases with neoplasm in other sites and five with human papilloma virus(HPV)infection.All the 12 patients received surgical operation, three with simple vulvectomy(one with some residue at perianal incisal edge)and other nine with lumpectomy(four with some residue at incisal edge).Eight cases were followed-up for 9.0 months in average(ranging 1～22 months)after surgical operation, including three with some residue at incisal edge.Relapse was found in two cases three and 11 months after operation, respectively, who received re-operation, including one with residue at incisal edge and one without residue.Conclusions It is necessary to attach more importance to biopsy for the cases of suspected VIN Ⅲ, as well as colposcopic diagnosis for those with vaginal or vulvar neoplasm and testing for HPV infection.Surgical operation, including simple vulvectomy and lumpectomy with or without adjunctive measures, are main treatment for patients of VIN Ⅲ and follow-up is also important for all those with VIN Ⅲ. Key words: Vulvar Neoplasms; Gynecologic surgical procedures; Neoplasm,vulvar,intraepithelial; Human papilloma virus

Leiomyosarcoma of the vagina: a case report and review from the literature

Leiomyosarcomas comprise fewer than 2% of all malignant vaginal neoplasms. Due to their rarity, treatment for vaginal leiomyosarcomas have not been determined. We describe a 66 year old woman with vaginal leiomyosarcoma, which presented as a large palpable mass with vaginal spotting. Complete surgical excision was accomplished and after surgery, she underwent radiation therapy. Tumor recurrence was not detected for the last 5 years and now her general condition is very good. This is a rare case of leiomyosarcoma arising in vagina and we report the results of successful treatment.

Vaginal Leiomyoma: A rare cause of Menometrorrhagia

Primary vaginal tumors are rare. They are usually secondary to either cervical or vulval lesions. The benign solid tumors arising from the vaginal tissue include papilloma, hemangioma, mucous polyp and rarely Leiomyoma. In the vagina, leiomyoma usually presents as a solid single nodule mostly from anterior vaginal wall in women between the ages of 35-50 years. We present a case report of a 26 year old multipara female patient who presented with menometrorrhagia of 2 months duration. On ultrasound examination she was found to have a large hypoechoic mass within the vagina which was diagnosed as a pedunculated cervical fibroid. Thereafter MRI was performed which revealed a diffusely enhancing well defined mass lesion of signal intensity similar to myometrium within the vagina. Per-operatively the mass was confined to the vagina and a diagnosis of vaginal leimyoma was made confirmed by histopathology. Previously presented at 61 st National Conference of the Indian Radiological & Imaging association

Primary Endometrioid Adenocarcinoma of the Vagina

Vaginal adenocarcinoma is the second most common primary cancer of the vagina, yet there has been very little study of most subtypes other than clear cell carcinoma. We reviewed 18 cases of primary vaginal endometrioid adenocarcinoma, in our experience the second most common subtype. The patients ranged from 45 to 81 years of age (mean 60). Most presented with vaginal bleeding, and had had a prior hysterectomy. Five had a history of unopposed estrogen therapy but none had a history of intrauterine diethylstilbestrol exposure. The tumors were at the vaginal apex in 10 cases, in the posterior wall in 3, the lateral wall in 3, and the anterior wall in 1. On microscopic examination, each of the tumors had a pure or predominant component of typical endometrioid adenocarcinoma. There was squamous metaplasia in 4 cases, mucinous metaplasia in 4, and prominent nonvillous papillae in 2. The tumors were grade 1 of 3 in 4 cases, grade 2 in 13, and grade 3 in 1. Eleven cases were FIGO stage I, 5 stage II, and 2 stage IV. Vaginal endometriosis was identified in 14 cases, and is important in indicating a primary vaginal tumor, rather than secondary spread from the endometrium. Other subtypes of adenocarcinoma (such as serous when the tumor has a papillary pattern) and atypical forms of endometriosis, including polypoid endometriosis, are the most common other differential diagnostic considerations. The prognosis seems to be good in low-stage patients, with 11 patients alive and well and 2 alive with recurrent disease.

Carbon ion radiotherapy for vaginal malignant melanoma: a case report

Malignant melanoma of the vagina is a very rare neoplasm and resistant to conventional radiotherapy. We report a case of vaginal malignant melanoma that was locally well controlled by carbon ion radiotherapy. A 55-year-old postmenopausal woman presented with abnormal vaginal bleeding. On pelvic and imaging examinations, an irregular mass of the posterior vaginal wall sized 7.5 x 5 x 5 cm, an enlarged right inguinal lymph node, and two lung metastases were observed. Histologic diagnosis based on positive immunostaining for HMB-45 was malignant melanoma. She received dacarbazine-based chemotherapy and carbon ion radiotherapy for vaginal and inguinal tumor sites with 57.6 Gy equivalent dose per 16 fractions using five ports. Six months later, she was also given carbon ion radiotherapy for regrowing lung metastasis with 52.8 Gy equivalent dose per four fractions using four ports. She died 19 months after initial treatment due to brain metastases. The primary irradiated tumor disappeared completely 12 months after initial treatment. The vaginal tumor, right inguinal lymph node, and lung tumor treated with carbon ion radiotherapy did not show any evidence of recurrence until her death. Carbon ion radiotherapy may be of value for vaginal malignant melanoma as a conservative approach.

Tumeur de Brenner vaginale

Vaginal tumours are rare, and Brenner tumour is one of the most infrequent vaginal lesions. Brenner tumour is a transitional tumour that typically arises in the ovaries. Some cases have been reported in the broad ligament, uterus and paratesticular structures. Only five cases have been reported in the vagina. We report a sixth case and discuss the histogenesis of this tumour, as well as the differential diagnosis with the mixed tumour of the vagina.

Vaginal tumors with histologic and immunocytochemical feature of gastrointestinal stromal tumor: two cases and review of the literature

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract (GI). Although positive immunohistochemistry for c-kit protein (CD117) and CD34 is critical in establishing diagnosis, the clinicopathologic features of CD117-positive mesenchymal tumors without obvious connection to the GI tract are not well documented. We describe the clinicopathologic features of two cases of extra-GIST. Case 1 was a 42-year-old woman who presented with a submucosal tumor located in the posterior vaginal wall. Case 2 was a 66-year-old woman who presented with a mass that bulged from the right side of the middle vaginal wall. Both tumors were excised locally. The results of microscopic examination and immunohistochemistry for both cases indicated the diagnosis of GIST. Case 2, in addition, showed oncogenic mutation inKITexon 11. Case 1 is healthy without evidence of recurrence 4 years after surgery. Case 2 started imatinib therapy after resection of a recurrent mass. Gynecologists as well as diagnostic pathologists should be aware of GIST manifesting as a vaginal mass. Recognition of microscopic patterns and characteristic immunohistochemical phenotype, plus genetic study, is mandatory for establishing the correct diagnosis of GIST.

Tubulo-squamous Polyp

We report 10 cases of a morphologically distinct vaginal polyp which has hitherto not been characterized. The polyps occurred in women aged 39 to 78 years (most were postmenopausal) and were from 1.0 to 3.0 cm. Most of whose location is known to us were in the upper vagina. Histologically, all the polyps were remarkably similar and composed of well-circumscribed expansile nests of epithelial cells embedded in a hypocellular fibrous stroma. The epithelial elements, which were morphologically bland, were predominantly glycogenated or nonglycogenated squamous in type but small tubules were present at the periphery of some of the nests in all cases. Some of the squamous nests exhibited central necrosis with or without calcification and, in 3 cases, some contained keratin pearls. In 3 cases, a few tubules unassociated with squamous elements were present. In 3 of 4 cases tested, the cells lining the tubules were positive with prostatic acid phosphatase and in 2 of 4 with prostate-specific antigen. The epithelial elements reacted with broad-spectrum cytokeratins and cytokeratin 7 but the mesenchymal component was negative. The squamous elements were estrogen receptor positive and the mesenchymal component estrogen and progesterone receptor positive. The histologic features of this polyp, which we term "tubulo-squamous polyp of the vagina," are constant and distinctive and differ from other polyps and from mixed tumor of the vagina. Several cases reported in the literature as vaginal mixed tumor or Brenner tumor are likely examples of this entity. Possible theories of histogenesis include a Mullerian origin, derivation from mesonephric remnants or derivation from urogenital sinus-derived epithelium. Positive staining in some cases with prostatic acid phosphatase and prostate-specific antigen raises the possibility of ectopic prostatic tissue, although the overall appearance is different from that entity, or derivation from paraurethral Skene glands, the female equivalent of prostatic glands in the male.

Magnetic resonance imaging of primary vaginal carcinoma

To describe the magnetic resonance imaging (MRI) features of vaginal carcinoma and to suggest a role for MRI in its management. Twenty-five patients with primary vaginal carcinoma treated at our institution between 1996 and 2005 were included in the study. The MRI examinations were reviewed and tumour dimensions, signal characteristics and involvement of pelvic structures were documented, as were sites of enlarged lymph nodes and metastases. Details of patient treatment and outcome were obtained from the clinical notes. The median patient age was 54 years (range 31-86 years). Tumour maximum diameter ranged from 1.6-11.3 cm (mean 3.7 cm). Most tumours were of iso-intense signal to muscle on T1-weighted images and hyper-intense to muscle on T2-weighted images. Eighty-eight percent of patients had tumour extending beyond the vagina and 56% of patients had Figo stage III or above tumours. Sixteen patients were treated with radiotherapy (two with chemoradiotherapy), five with surgery and four with supportive care. Ten patients (40%) died of their disease during the study period. The MRI stage of the tumour correlated with survival. MRI identified over 95% of primary vaginal tumours in the present study, enabled radiological staging, which correlated with outcome, and provided information of use in treatment planning.