A CASE REPORT OF PERINEAL AND VAGINAL LEIOMYOMA : AN EXCEPTIONAL ENTITY

Sounni A., Belachkar L., Jayi S., Fdili Alaoui FZ, Chaara H. and Melhouf My A Department of Gynaecology and Obstetrics II, CHU HASSAN II Fez. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 10 March 2020 Final Accepted: 12 April 2020 Published: May 2020


…………………………………………………………………………………………………….... Introduction:-
The uterine leiomyoma is a very frequent and well-known pathological entity, the extra uterine location remains rare andpresents several diagnostic, therapeutic, as well as prognosticproblems. We report a rare case of a large tumour,developed at the perineal and vaginal level, extended over the entire left lateral side of the vagina and protruding in the left labia majora, in addition, we try to discuss themanagementproblems of this type of tumour.

Observation:-
A 40-year-oldfemale patient, grand multiparawith an unremarkable medical history, she hadantecedents of laborious deliveriessuch as theuse of vacuum extractor and episiotomy, still getsher menstruations and consulted for a perineal tumefaction.
The physical examination showedat the inspection, a round formation at the perineal level, as well as theexistenceof a well limited and solid formation-measuring 12 cm in its long axis-regarding the tubarischiadicum at the palpation. The pelvic ultrasound was normal, but the soft tissue ultrasonography couldn't characterize the mass; hence the decision to complete by a pelvic MRI.
The Pelvic MRI results revealedan ovarian vulvar tumor process having a left posterolateral development, measuring 6-10cm, and invading the posterior wall of the vagina, the anal margin and the left ischioanal fossa (equivalent to the T4 stage of the FIGO classification).It was accordinglydecided to performa resection and enucleation of the two vaginal tumors, in cooperation with general surgeons, whose perioperative exploration objectified a well-encapsulated cystic formation, measuring 10cm andlocated at the perineal level next to thetubarischiadicum. The histopathologicalexamination of the two surgical excisions revealed a gynecological leiomyoma.

Discussion:-
Leiomyomas are solid tumors made of fusocellular smooth muscle fibers and collagen stroma [1], and aredeveloped at the expense of the myometrium.

ISSN: 2320-5407
Int. J. Adv. Res. 8(05), 395-396 396 Vulvovaginal localization is very rare.In the literature, the number of describedleiomyomasdoesn't exceed 120 cases for vulvar location and 300 cases for vaginal location [3,4].While no vulvovaginallocationis reported, vulvovaginal leiomyoma is usually developed after puberty and appears as a single, well-circumscribedand slow-growing tumor, rarely exceeding 5cm.The clinical presentations are variable, depending on the size and location of the tumor.The principal revealing symptoms are gravity, dyspareunia, vaginal bleeding and signs of urinary and digestive compression (dysuriaand constipation). The coincidentaldiagnosis of the tumor during an examination of another system is also possible [3,5,6], and the preoperative diagnosis remains difficult.
The pelvic CT allows usto characterize a well circumscribed hypodenselesionhaving a heterogeneous and hyperdense rolling upwithout any specific signs. The MRI can lead to the diagnosis of leiomyoma by revealing a lesion characterized by a T1 intermediate signal or ahypointense signal and a T2-hypointense signal, which can be reversed by the injection of gadolinium [2,5,6].The diagnosis is established byahistopathologicalexaminationand an immunohistochemical study revealing a tumor made of fusiform cells, identified as smooth muscle fibers by highlightingantidesmin and antiactin antibodies as in our case [2,4].

Monobloc
surgical excision remains the only treatment for vulvovaginal leiomyoma. The tumor is usually treated -as in our case-by a perinealapproachwith an incision next to the tumor and a progressiveenucleation [3,6].
Owing to the rarity of cases described in the literature, there are difficulties in reliably predicting the risk of recurrence and differentiating between benign and malignant tumors; hence the need for along-term follow-up [5].

Conclusion:-
The vaginal leiomyoma is a benign tumor, very rare compared to the uterine location, frequently asymptomatic, and accidentally diagnosed during a physical examination (it appears as a firm and painless nodule).Imaging allows us to affirm the vaginal origin of the lesion. A surgical excision is indicateddue to thepossiblesarcomatous degenerations. Finally, the diagnosis is established by the histopathological study of the excision.