Abstract

Vaginal Schwannoma is very rare and till now few cases have been reported in the literature. A case of vaginal Schwannoma is reported here. The patient was a 59 years old woman with the complaints of per vaginal bleeding with an attempt of D&C failure. Ultimately hysterectomy was done and the diagnosis of Vaginal Schwannoma was made on histopathological examination of the excised tumor. Clinicians should be aware and bear in mind about the differential diagnosis of vaginal Schwannoma in case of any per vaginal bleeding.

Ibrahim Med. Coll. J. 2010; 4(2): 90-91

Key Words: Vaginal Schwannoma, Per vaginal (PV) bleeding.

Address for Correspondence:Dr. Shamsun Nahar, Consultant, Department of Gynae & Obstertrics, BIRDEM Hospital, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka 1000 Bangladesh

Introduction

Schwannomas are usually benign tumors that arise from the neural crest derived Schwann cells. They can arise as isolated tumors or as part of a neurofibromatosis type 2. Symptoms are referred to local compression of involved nerve or adjacent structures. Sporadic Schwannomas are due to mutation of NF2 gene located in chromosome number 22. It occurs commonly within cranial vault common site root of cerebellopontine angle attached to the vestibular branch of 8th nerve. The patient presents with tinnitus and hearing loss. Other common sites are within dura. Sensory nerves are preferentially affected like branches of trigeminal nerve and dorsal roots. In extramural locations, Schwannomas are associated with large nerve trunks where motor and sensory modalities are intermixed. Rarely Schwannomas can occur in the retroperitoneum, orbit, vagina and cervix. Grossly Schwannomas are well circumscribed, encapsulated mass attached to nerve root and can be separated from it. They are firm, gray masses but may have retrograde changes. Microscopically there are more cellular areas (AntoniA) and less cellular areas (AntoniB). The cells are elongated, have cytoplasmic process and arranged in fascicles. Nuclear pallisading in cellular areas are called Verocay bodies. A variety of degenerative changes may be found in Schwannomas like nuclear pleomorphism, xanthmatous change, vascular hyalinization. Malignant changes can occur but are extremely rare. Local recurrence can occur after incomplete resection. Schwan cells show positive reactivity for S100.1

Case Report

A 59 year old woman hailing from Khulna district, house wife by profession, widowed, post menopausal and mother of 3 children was admitted with the complaints of per vaginal bleeding for last few months. PV examination could not be done because of the growth and a failed attempt of D&C due to the huge tumor mass obscuring the cervical canal.

The patient was obese (72 kg), height 160 cm, BMI 35.5. Hematological tests revealed mild anaemia, raised ESR, but other hematological and biochemical tests for liver function, renal function, lipids were normal. Her glycaemic tests revealed IGT. USG showed a bulky mass arising from the vaginal wall and extending around the cervix. Abdominal hysterectomy was done and the growth was removed piece by piece which was grossly ulcerated and bled on touch. The vault and vaginal wall became free of the tumor. The tumor was sent for histopathological examination and the diagnosis of Schwannoma made.

Fig.1: Photomicrograph of the tumor: Schwannoma, showing cellular (thick arrow) and hypocellular areas (thin arrow)

The post operative period was uneventful and the patient recovered well during 2 weeks and later discharged with proper medication. Follow up was done after 3 months/6 months. On follow up patient was alright. Her vault cytology was negative after 6 months. She was advised for glycaemic control by diet, OHG agent and later physical exercise. After one year the patient could not be traced as she didn’t come up for further follow up.

Discussion

Schwannoma of the female genital tract is very rare. They are generally benign and simple excision is the adequate treatment.2 Schwannoma has been reported to occur in the tongue and retroperitoneum3,4 presacral, optic sheath.5 Malignant Schwannoma of uterine cervix has also been reported in three cases where the patient’s age was 25, 65, 73 years respectively and the presenting complaints were polyp and irregular vaginal bleeding.6 Light microscopical diagnosis of Schwannoma must be substantiated by immunohistochemistry. Cases of familial syndrome presenting with Schwannoma and multiple nevi are also reported; here the syndrome is manifested by dominant inheritance.7 Vaginal Schwannoma has been reported in a 37 years old women.7 Para vaginal tumor usually bears a differential diagnosis of schwannoma, neurofibroma, lipoma, desimoid tumors and require histopathological and immunohistochemistry for exact diagnosis.9

Conclusion

From the present case report, it may be concluded that any tumor/polyp in vagina in any age group should bear a differential diagnosis of Schwannoma, neurofibroma, lipoma, desimoid tumors and require histopathological and immunohistochemistry for exact diagnosis. PV examination, USG, biopsy or resection and IHC are essential for confirmation of diagnosis of Schwannoma. This will lead to define a better treatment plan and reduce the clinical complains like irregular PV bleeding, and tumors difficult to approach by PV route.

References

1.   Pathologic Basis of Disease. editor Kumar, Abbus, Fausto. 7th ed 2004, Publisher Saunders Elsevier, USA, 1411.

2.   Obeidat BR, Amarin ZO, Jallad MF. Vaginal Schwannoma: a case report. Reprod Med 2007; 52: 341-2.

3.   Inoue T, Kato H, Yoshikawa K, Adachi T, Eton K, Wake N. Retroperitoneal Schwannoma bearing at right vaginal wall. J Obstet Gynaecol Res 2004; 30: 454-7.

4.   Kell SB, Clement PB, Prat J, Young RH. Malignant Schwannoma of the uterine cervix: a study of three cases. Int J Gynecol Pathol 1998; 17: 223-30.

4.   Gorlin RJ, Koutlas IG. Multiple Schwannomas, multiple nevi, and multiple vaginal leiomyomas: a new dominant syndrome. Am J Med Genet 1998; 78: 76-81.

6.   Gonzalvo PV, Polo PA, Gomes CA, Presencia RG, Gaso MM, Botella AR. Retrovessical Schwannosarcoma. Actas Urol Esp 1997; 21: 416­9.

7.   Johann C, Amanda DB. Neurilemoma (Schwannoma) of the ischiorectal fossa: a case report and a brief review of the relevant pathology. Pelviperineology 2007; 26: 152-153.

8.   Ueda M, Okamoto Y, Ueki M. A pelvic retroperitoneal Schwannomaarising in the right paracolpium. Gynecol Oncol 1996; 60: 1480-83.

9.   Ellison DW, Mackenzie IZ, Mcgee JO. Cellular Schwannoma of the vagina. Gynecol Oncol 1992; 46: 119-21.