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Lipoleiomyosarcoma of the vagina

In January 2005 a 56-year-old woman (G1P1) presented to her GP with vaginal discomfort, associated with frequency of micturition. She smoked 10 – 15 cigarettes per day. A mid-stream specimen of urine (MSSU) was negative and no further action was taken. No pelvic assessment was undertaken. In May 2005, she attended for a routine cervical smear. There was some ‘difficulty’ in passing a Cusco’s speculum and she was referred to her local gynaecologist. At this time, a 4 cm mass was found arising from the anterior vaginal wall. An examination under anaesthesia (EUA) and cystoscopy was scheduled. While the bladder base appeared to be distended by the mass within the vagina, the mucosa was intact. Biopsy of the mass suggested a lipoleiomyosarcoma (see Figure 1), and the patient was referred to a surgeon in gynaecological oncology. An MRI confirmed the presence of a 5 cm solid mass, with heterogeneous signal, situated between the posterior aspect of the bladder and the anterior aspect of the upper vagina (see Figure 2). Although the bladder was compressed and displaced by this mass, there was no suggestion of frank invasion. An enlarged left common iliac lymph node (2.0 cm61.5 cm) was also noted. A CT of the chest and abdomen showed no para-aortic lymphadenopathy. In order to ensure complete removal, the patient was scheduled for anterior pelvic clearance, partial vaginectomy and urinary diversion (right-sided ileoconduit). The psychosexual dysfunction that can be associated with such surgery was discussed. A divorcee, she lived alone and did not seem concerned. The procedure went without complications and she made a good recovery. At laparotomy no enlarged lymph nodes (including common iliac) were found. Histology confirmed complete excision of lipoleiomyosarcoma, Trojani grade II (a three-grade system based on the evaluation of three parameters: tumour differentiation, mitotic rate and extent of tumour necrosis), with clear resection margins. No positive nodes were identified. The options for adjuvant therapy were discussed at review 6 – 8 weeks later. Chemotherapy may reduce the risk of relapse, but no survival benefit has been demonstrated. Radiotherapy would reduce the risk of local recurrence, but have no influence on distant metastases. A chest X-ray was clear, and a full body CT showed no residual disease or metasases. On balance, adjuvant therapy was withheld. The patient remains well 1 year later.