Primary vaginal adenocarcinoma arising from the metanephric duct remnant

Malignant transformation of vaginal adenosis to clear cell carcinoma without prenatal diethylstilbestrol exposure: a case report and literature review

Background

We report an extremely rare case of vaginal clear cell carcinoma, which originated from the malignant transformation of vaginal adenosis without prenatal diethylstilbestrol (DES) exposure.

Case presentation

In this case, the patient was a Chinese woman with a history of two decades of intermittent vaginal pain, sexual intercourse pain and vaginal contact bleeding. On September 1, 2011, when the patient was 39 years old, a vaginal biopsy revealed vaginal adenosis. After intermittent drug and laser treatment, her symptoms did not improve. Four years later, on March 4, 2015, another vaginal biopsy for abnormal vaginal cytology revealed atypical vaginal adenosis. After treatment with sirolimus, her symptoms and abnormal vaginal cytology results persisted, and she underwent laparoscopic hysterectomy with bilateral salpingo-oophorectomy and excision of the vaginal lesions. One year after the hysterectomy, on August 15, 2017, the vaginal cytology results suggested atypical glandular cells, and a biopsy revealed vaginal clear cell carcinoma originating from the atypical vaginal adenosis. A wide local resection of the vaginal lesions was performed, followed by concurrent chemoradiotherapy. Regular follow-up over 16 months showed no evidence of the recurrence of vaginal adenosis or cancer.

Conclusions

Based on the evolution of a series of pathological evidence, we report the fourth case in the world of vaginal clear cell carcinoma originating from vaginal adenosis without prenatal DES exposure. Wide local excision with radiotherapy provided at least 16 months of disease-free survival.

Primary Vaginal Gastric-type Adenocarcinoma and Vaginal Adenosis Exhibiting Gastric Differentiation: Report of a Series With Detailed Immunohistochemical Analysis

So-called gastric-type adenocarcinoma and related premalignant lesions have been characterized in the cervix, but similar lesions are not widely recognized in the vagina. We report a series of 11 vaginal glandular lesions exhibiting gastric differentiation, comprising 5 cases of adenocarcinoma and 6 of adenosis. All cases occurred in adults (aged 33 to 69) with no known history of diethylstilboestrol exposure. The vaginal adenocarcinomas exhibited morphologic features identical to gastric-type adenocarcinoma of the cervix, but 1 case additionally demonstrated basaloid and sarcomatoid components, which have not been previously reported in cervical gastric-type adenocarcinoma. Immunohistochemically, the adenocarcinomas were positive for MUC6 (4/5), PAX8 (3/5), CK7 (5/5), CK20 (1/5), CDX2 (5/5), CA19.9 (5/5), CEA (4/5), CA125 (5/5), and hepatocyte nuclear factor 1β (5/5). p16, estrogen receptor, and Napsin A were negative in all cases tested, whereas p53 exhibited mutation-type staining in 3/5 cases. In all 5 adenocarcinomas, a component of adenosis with benign or atypical nuclear features was identified; the adenosis displayed gastric morphology in 4 cases and tuboendometrial morphology in 1. The 6 cases of pure vaginal adenosis (without associated adenocarcinoma) all contained gastric-type mucinous glands together with tuboendometrial glands in 2 cases. There was focal intestinal differentiation with goblet cells in all 6 cases and neuroendocrine cells with eosinophilic granules in 3. Cytologic atypia was observed in 4/6 cases of pure vaginal adenosis. Immunohistochemically, the gastric-type adenosis (10 cases) was positive for MUC6 (10/10), estrogen receptor (5/10), PAX8 (8/10), CK7 (9/9), CK20 (2/9), CDX2 (5/9), CA19.9 (8/9), CEA (6/9), CA125 (6/9), hepatocyte nuclear factor 1β (10/10), and Napsin A (1/10). p53 exhibited wild-type immunoreactivity in all 10 cases, whereas p16 was negative in all cases tested. Scattered individual chromogranin-positive cells were present in all 5 cases of pure adenosis tested. Follow-up was available in 4 of the adenocarcinoma cases, with 3 patients dead of disease within 1 to 3 years and 1 patient alive with disease at 1 year. The morphologic and immunohistochemical findings in our study suggest a close relationship between vaginal gastric-type adenocarcinoma and adenosis exhibiting gastric differentiation. This probably represents a distinct pathway of vaginal gastric-type carcinogenesis analogous to that occurring in the cervix. We propose that gastric-type adenocarcinoma be recognized as a distinct histologic subtype of vaginal adenocarcinoma while vaginal adenosis of gastric-type represents a novel subtype of adenosis that requires further study to clarify its biological potential.

Primary vaginal mucinous adenocarcinoma of gastric type arising in adenosis: a report of 2 cases, 1 associated with uterus didelphys

We report 2 cases of primary vaginal mucinous adenocarcinoma arising in adenosis in nondiethylstilbestrol-exposed women, 1 with uterus didelphys. Both tumors exhibited morphologic and immunohistochemical features (MUC6 and/or HIK 1083 positivity) identical to the recently described cervical gastric-type adenocarcinoma, a subtype of mucinous adenocarcinoma that is non-human papillomavirus related and possibly related to adenoma malignum. Both neoplasms were intensely p53 positive, suggesting that TP53 mutation may be implicated in their development. We believe that the vaginal tumors arose from adenosis through atypical adenosis, as benign and atypical glands were present at the periphery of the neoplasms. In reporting these cases, we discuss atypical adenosis and other types of non-diethylstilbestrol-associated vaginal adenocarcinomas. At least 9 other examples of primary vaginal, or more uncommonly cervical, adenocarcinomas arising in non-diethylstilbestrol-exposed women with congenital genitourinary malformations have been reported, suggesting a probable causal association between congenital malformation, vaginal adenosis, and vaginal adenocarcinoma.

A case of vaginal clear cell adenocarcinoma complicated with congenital anomalies of the genitourinary tract and metanephric remnant without prenatal diethylstilbestrol exposure

Vaginal clear cell adenocarcinoma (CCA) is well known to be associated with prenatal diethylstilbestrol exposure. We present a vaginal CCA with congenital anomalies of the genitourinary tract without prenatal diethylstilbestrol exposure. A 54-year-old woman complained of a 3-month history of genital bleeding. The examination revealed CCA at the anterior vagina and congenital anomalies. An anterior pelvic exenteration was performed. Macroscopically, bicornuate uterus, vaginal septum and left ureteral agenesis were found. Microscopically, vaginal CCA coexisted with adenosis and both metanephric and mesonephric remnants. The vaginal CCA was supposed to derive from coexisting adenosis. The adenosis was also supposed to occur as a congenital basis, together with genitourinary tract anomalies. Relations between congenital anomalies of the genitourinary tract and vaginal adenocarcinoma were suspected, resultantly.

Primary vaginal adenocarcinoma of intestinal type arising from a tubulovillous adenoma

Enteric or intestinal-type neoplasms of the vagina are extremely rare. The present report describes a 55-year-old woman who presented with a 6-week history of postmenopausal bleeding. On clinical examination, a lesion on the posterior vaginal wall was noticed. Rectovaginal examination suggested a tumor in the rectovaginal septum. Biopsy revealed an adenocarcinoma of the intestinal type, with a small remnant of a villous adenoma. The histologic interpretation pointed in the direction of a metastatic gastrointestinal tumor; yet, clinical examination, rectoscopy, colonoscopy, magnetic resonance imaging (MRI) of the abdomen, and positron emission tomography (PET) scanning excluded this possibility. This led to the conclusion that the lesion was a primary intestinal-type adenocarcinoma of the vagina that had arisen from a vaginal villous adenoma. It is important to be aware of this tumor type and to distinguish them from metastatic colorectal adenocarcinoma in order to plan appropriate treatment.

Single vaginal ectopic ureter of fetal metanephric duct origin, ipsilateral kidney agenesis, and ipsilateral rudimentary uterine horn of the bicornuate uterus

BACKGROUND

Congenital anomalies arising from the urogenital tracts are common. We experienced two cases of specific urogenital anomalies.

CASE

Two Japanese women had a single ectopic ureter opening in the central wall of the vagina, ipsilateral kidney agenesis, and ipsilateral rudimentary uterine horn of the bicornuate uterus. One had squamous cell carcinoma of the uterine cervix, and the other had adenocarcinoma of the vagina arising from the ectopic ureter meatus, which was histologically confirmed as fetal metanephric duct remnant. One had vesico-vaginal fistula postoperatively, resulting from separating the ureter-like duct from the bladder.

CONCLUSION

Concomitant occurrence of anomalies suggests the common genetic backgrounds, which are not well known. Clinically, the ectopic vaginal ureter is important as a possible background of vaginal adenocarcinoma, and information on the ureter-like duct course is required during surgery.