Background
Methods
Results
Case 1 | Case 2 | Case 3 | |
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Age (yr) | 64 | 8 | 52 |
Gestation & parity | G2P2 | G0P0 | G4P3 |
History of disease | Severe laceration | No | Severe laceration |
Clinical presentation | An incomplete incontinence of feces | Vaginal bleeding | An incomplete incontinence of feces |
Vaginal Location | Lower posterior wall | Posterior wall | Lower posterior wall |
Surgery | Vaginal polypectomy; LEEP | Vaginal polypectomy | Removal of the endometrial polyp and leiomyoma; repair of the perineal laceration and the posterior vaginal wall |
Gross findings (size) | Polypoid mass (3.5*2.5*1.0 cm) | Polypoid mass (1.5*1.2*0.5 cm) | Unremarkable vaginal wall (3*2*0.4 cm) |
Histopathological findings | Rectal mucosal prolapse-like polyp | Rectal mucosal prolapse-like polyp | Intestinal-type adenosis |
Other findings | CINII | Rectovaginal fistula | Endometrial polyp; submucosa leiomyoma |
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Clinical Findings
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Case 1
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A 64-year-old Chinese woman, gravida 2 para 2, transferred to our hospital in February 2012 because she was diagnosed as cervical intraepithelial neoplasia grade II (CINII) by biopsy recently. During her admission, a reddish, soft, sessile polypoid mass was found in the lower posterior wall of the vagina (near the vaginal orifice). The polyp dropped from the vagina to the anus along the perineal skin. It was completely free from the vulvar skin and the anus. The smooth surface of the mass looked like the colorectal mucosa grossly. It measured 4.0 × 3.0 × 3.0 cm. The vulvar skin had an obsolete severe (Grade III) perineal laceration. The uterus and the uterine cervix looked unremarkable. Anal examination showed the decreased contraction capacity. The patient had undergone severe perineal laceration 45 years ago in the vaginal delivery of her first child, which resulted in an incomplete incontinence of feces. The patient was treated with a loop electrosurgical excision procedure (LEEP) of the uterine cervix and a vaginal polypectomy. She remained uneventful after her surgery.
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Case 2
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An 8-year Chinese girl presented with vaginal bleeding for 2 days. Her mother denied the use of diethylstilbestrol (DES) during pregnancy. Clinical examination found a pedunculated polyp in the posterior vaginal wall of the navicular fossa beneath the hymen. It measured 1.5 × 1.5 × 0.8 cm. Anal examination showed that the polyp was close to the right-anterior side of the rectum. The rectal mucosa was felt to be rough and cicatrical at the site of 1 cm from the anus. A rectal fistula to navicular fossa (rectovaginal fistula) was clinically suspected, but colonoscopy and colposcopy were not performed. The pelvic sonography was unremarkable. She underwent a polypectomy of the vagina. The suspicious rectovaginal fistula remained untreated because of her young age and potential diagnostic pitfalls by physical examination alone. She recovered well from the surger. She has been free of symptoms for 2 years at present.
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Case 3
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A 52-year Chinese woman, gravida 4 para 3, complained of an incomplete incontinence of feces after the severe perineal laceration more than 30 years ago in the vaginal delivery of her first child. She had no history of topical 5-fluorouracil use in the vagina. Gynecological examination showed an old severe (Grade III) perineal laceration at 12 o’clock which was involved the rectum. The sonography indicated the presence of a uterine endometrial polyp and a submucosa leiomyoma. She underwent hysteroscopic surgery to remove the endometrial polyp and leiomyoma, and repair of the perineal laceration and the posterior vaginal wall.
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Pathological Findings
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Case 1 & 2
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The vaginal polyp measured 3.5 × 2.5 × 1.0 cm and 1.5 × 1.2 × 0.5 cm in case 1 and case 2, respectively. Both polyps had a smooth surface. The cut surface was red, soft and edematous. The LEEP specimen in case 1 measured 1.0 × 3.0 × 1.0 cm and looked unremarkable grossly.
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Both case 1 & 2 showed consistent histopathological features. Their histology resembled to that of a colorectal mucosal prolapse characterized by the surface “colonic-like mucosa” and the underlying “mucularis” [Fig. 1a]. The “colonic mucosa” manifested as elongated, distorted intestinal-type crypts and glands. Superficial erosions and inflammatory exudative were also focally present. A prominent lymphoplasmacytic infiltration with occasional lymphoid nodules was present in the mucosa. In addition to the glandular component, squamous epithelium was also seen [Fig. 1b]. The transitional pattern between glandular and squamous epithelium was morphologically identical to that of so called “anal transformational zone” in the rectal-anal canal junction [Fig. 1c]. There was no evidence of dysplasia in the polyps.×
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The “muscularis mucosa” in the polyps was thickened and somewhat different from that in the rectum by showing a disordered arrangement of smooth muscles. Some smooth muscle fibers may protrude into the mucosa proper and separate the intestinal glands. The “submucosa layer” contained loose fibrous tissue, fibro-adipose tissue and focal clusters of dilated lymphatic vessels.
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The LEEP specimen in case 1 had focal CIN II with glandular involvement and clear margins.
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Case 3
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The removed lower posterior wall of the vagina measured 3.0 × 2.0 × 0.4 cm. It was grossly unremarkable. A small cluster of “intestinal-type” glands in the lamina proper were incidentally found in routine slides. They were composed of predominant columnar cells with brush borders and scattered goblet cells with a single large mucin-containing vacuole [Fig. 1d]. The glands showed no evidence of dysplasia. The surface squamous epithelium showed a transition into the clonic type glands. Paneth cells, squamous metaplasia, and endocervical glands of common adenosis were not identified on routine stained slides. Mild inflammatory cell infiltration was found in the lamina proper. The endometrial polyp and leiomyoma were also histologically confirmed.
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Immunohistochemical findings
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Immunohistochemical staining showed that the intestinal glands in all cases were positive for CK20 and CDX2 [Fig. 2a, c], and negative for CK7, GATA3 and PAX8. Neuroendocrinal cells in the intestinal glands were demonstrated by positive chromogranin A staining [Fig. 2b, d]. They were predominantly distributed in the lower compartment of the crypt. The squamous epithelium was negative for all these markers.×
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