|Year : 2015 | Volume
| Issue : 3 | Page : 188-190
Vaginal leiomyoma mimicking Schwannoma
Mohmed Imran Wagay1, Imtiyaz Ahmad Khan1, Aasif Abdullah2, Naseer Ahmad Choh1
1 Department of Radiodiagnosis and Imaging, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
2 Department of Obstetrics and Gynaecology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||16-Jul-2015|
Mohmed Imran Wagay
Senior Resident Hostel Set 12, Block C, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Leiomyomas are quite common in women of childbearing age however usually seen in uterus or cervix. Vaginal location is very rare for leiomyomas with only about 300 cases reported until date. Leiomyomas at vaginal location usually present with swelling at introitus with or without urinary symptoms. These lesions show varied imaging features and are reported to possess high malignant potential. We report a patient having both uterine and vaginal leiomyomas. The uterine leiomyoma showed magnetic resonance imaging features of a typical leiomyoma, but vaginal leiomyoma showed magnetic resonance imaging characteristics indistinguishable from Schwannoma.
Keywords: Leiomyoma, magnetic resonance imaging, Schwannoma
|How to cite this article:|
Wagay MI, Khan IA, Abdullah A, Choh NA. Vaginal leiomyoma mimicking Schwannoma. Int J Health Allied Sci 2015;4:188-90
| Introduction|| |
Leiomyomas have been reported from multiple sites but majority of leiomyomas arise from body of the uterus and sometimes from cervix. The common extrauterine sites are round ligament, uterosacral ligament, ovary and inguinal canal. Primary vaginal fibroids are very rarely encountered  with only about 300 cases reported till date. These tumors arise most commonly from the anterior vaginal wall causing varied clinical presentations. Transvaginal excision of the tumour is the modality of choice and diagnosis is usually done on histopathology.
| CASE History|| |
A 40 year old woman para 3 came to OPD with a chief complaint of swelling at introitus for last 6 months .There was associated history of increased urinary frequency. Menstrual cycles were regular with normal flow (4-5/30). There was no history of any abnormal vaginal discharge. On per speculum examination, a well defined sessile round swelling was noted in anterior wall of vagina [Figure 1]. Cervix was healthy. On per vaginum examination, uterus was normal in size, anteverted. Bilateral fornices were free. The mass was noted to be arising from vagina, firm in consistency on palpation approx 4x4cm in size. On Ultrasound, a round hypoechoic lesion was seen in relation to vagina/cervix. Patient was sent to our department for MRI for proper characterization and localization of lesion.
|Figure 1: Preoperative image of patient with well-defined round mass lesion at introitus|
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The MR images revealed a uterine and vaginal lesion. Uterine lesion was well defined in the submucosal location 2x2 cms in size with homogeneous low intensity signal on both T1- and T2- weighted images. Postcontrast images showed heterogeneous mild contrast enhancement suggestive of leiomyoma. The vaginal lesion in the anterior wall showed different MRI features. The vaginal tumor had smooth margins, 4 x 3.5 cms in size and showed homogenous low signal intensity on the T1-weighted images and a high signal intensity on T2- weighted images. Postcontrast images showed early homogenous marked contrast enhancement. [Figure 2],[Figure 3] and [Figure 4]. On the basis of MRI, vaginal lesion behaved different from the uterine lesion and differential diagnosis included Schwanomma and vaginal leiomyoma with atypical imaging features.
|Figure 2: T1-weighted magnetic resonance image revealing a uterine lesion in the submucosal location and vaginal lesion in the anterior wall with homogeneous low signal intensity|
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|Figure 3: T2-weighted magnetic resonance image showing marked homogeneous low signal intensity in the uterine lesion and a high signal intensity of the vaginal lesion|
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|Figure 4: Postcontrast T1-weighted image showing heterogeneous mild contrast enhancement of uterine lesion and early homogenous marked contrast enhancement of vaginal lesion|
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Patient was operated by transvaginal approach and lesion was found to be well defined and was enucleated uneventfully with no injury to urethra and bladder neck. Vaginal hysterectomy was then undertaken at the same time. No postoperative complications were noted.
On histopathology, both uterine and vaginal lesions proved to be leiomyomas. The two histological differences between the lesions included (1) hyaline degeneration was noted in uterine leiomyoma (2) cellularity in the vaginal lesion was relatively higher [Figure 5] and [Figure 6].
|Figure 5: HPE of uterine tumor showing lot of fusiform cells consistent with leiomyoma with areas of hyaline degenerative changes (H and E, ×40)|
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|Figure 6: HPE of vaginal tumor showed similar cells with relatively high cellularity, consistent with leiomyoma (H and E, ×40)|
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| Discussion|| |
Vaginal tumors are rare and include papilloma, hemangioma, mucus polyp, andt rarely leiomyoma. Vaginal leiomyomas are usually located on anterior wall however lateral and posterior wall fibroids have also been reported. Owing to its anterior location, they commonly are related to the urinary tract and include voiding difficulties, dysuria and urinary frequency. 
Being very rare, diagnosis is usually made on histopathology of the operated specimen however modalities like USG and MRI has made it possible to diagnose it preoperatively in most of the patients. Transvaginal excision of the tumor is the modality of choice. Some observers have reported recurrence, but are not so common. No recurrence was recorded in a follow-up period of 8 months to 20 years in eight patients of leiomyoma of the vagina by Nel and Tiltman. 
Sonological features in the vaginal leiomyoma are not different from uterine leiomyoma but regarding magnetic resonance features few studies have been done and varying results have been found.
Ruggieri et al.  found in a case of vaginal leiomyoma on MRI showed a homogeneous lesion with a signal similar to that of the myometrium.
Hubert et al.  in a series of five patients noticed these lesions to be hypointense or isointense to muscle on T1- and hyperintense or isointense to muscle on T2-weighted images, and uniform enhancement.
Shadbolt et al.  described a vaginal leiomyoma showing relatively low signal intensity on T1-weighted and T2-weighted images and uniform contrast enhancement. Same findings were reproduced by Sherer et al. 
Vaginal leiomyoma showed low signal intensity in T1- and heterogeneous high signal on T2-weighted images, with homogenous contrast enhancement in a case reported by Bae et al. 
Hwang et al.  in four patients with extremity leiomyomas noted on T2-weighted MRI showed mixed areas that were hyperintense and isointense to skeletal muscle in all patients. The smooth muscle and numerous vessels within each type of vascular leiomyoma corresponded to the hyperintense areas in the T2-weighted MRI. They also concluded differentiating vascular leiomyomas from schwannomas may be difficult on MRI.
Based on the review of literature and the findings of our case, it is likely that vaginal leiomyomas are relatively more cellular than uterine leiomyomas and less prone to degeneration and there is a large subgroup of vaginal leiomyomas, which behaves like extremity leiomyomas. Moreover, such leiomyomas will be indistinguishable from vaginal Schwannomas on MRI.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]