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Year : 2017  |  Volume : 6  |  Issue : 2  |  Page : 123-125

An unusual diagnosis of postcoital vaginal bleeding in a menopausal woman

Department of Obstetrics and Gynecology, Military Training Hospital Mohammed V, Rabat, Morocco

Date of Web Publication15-Sep-2017

Correspondence Address:
Moukit Mounir
Department of Obstetrics and Gynecology, Military Training Hospital Mohammed V, Hay Riyad, 10100, Rabat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_54_17

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Cellular angiofibroma (CA) is a rare benign tumor originating from the superficial soft tissues of the genital area. It occurs in both the genders with equal predilection. The sites involved by this tumor are vulva in females and inguinoscrotal region in males. Vaginal involvements have rarely been reported. We present a case of 57-year-old woman, presented with moderate postcoital bleeding. Vaginal examination revealed a tender mass in the left vaginal wall, measuring 1.5 cm. A clinical diagnosis of benign tumors (leiomyoma, angiomyofibroblastoma, and CA) or aggressive vaginal tumors was made. A complete local excision was done and sent for histopathological examination, confirming the diagnosis of a CA.

Keywords: Cellular angiofibroma, postcoital bleeding, vagina

How to cite this article:
Mounir M, Jaouad K, Fatimazahra AE, Mohammed T, El Mehdi EM, Driss MR, Mohammed D. An unusual diagnosis of postcoital vaginal bleeding in a menopausal woman. Saudi J Health Sci 2017;6:123-5

How to cite this URL:
Mounir M, Jaouad K, Fatimazahra AE, Mohammed T, El Mehdi EM, Driss MR, Mohammed D. An unusual diagnosis of postcoital vaginal bleeding in a menopausal woman. Saudi J Health Sci [serial online] 2017 [cited 2022 Jan 22];6:123-5. Available from: https://www.saudijhealthsci.org/text.asp?2017/6/2/123/214850

  Introduction Top

Cellular angiofibroma (CA) is a rare benign tumor of mesenchymal origin, with a low recurrence rate and no metastatic potential, occurring in the vulvar region of middle-aged females as well as in the inguinoscrotal area of males.[1] However, it has been rarely reported to occur in the vagina. We report a case of vaginal CA in a 57-year-old woman, admitted for postcoital vaginal bleeding.

  Case Report Top

A 57-year-old menopausal woman, without medical or surgical history, presented with chief complaint of postcoital vaginal bleeding appeared 1 week before admission. There was no history of vaginal discharge, lower abdominal pain, or urinary complaints. The bleeding was moderate in amount. Her vital parameters were normal. Abdominal examination did not reveal any tenderness or rigidity. On speculum examination, a tender mass of 1.5 cm was seen in the left vaginal wall, bleeding on touch and not reducible [Figure 1]. The cervix was macroscopically normal. A differential diagnosis of benign vaginal tumors (leiomyoma, angiomyofibroblastoma, and CA) or aggressive vaginal tumors was made. Under spinal anesthesia, a circular incision was made around the lesion with clear margins (about 1 cm of the normal tissue) forcing enucleation of the mass; visible vessels was coagulated, and the wound was repaired with Monocryl number 0. The total operating time was 40 min, and the estimated blood loss was 50 ml. Grossly, the mass was nodular in shape and measured 1 cm × 0.6 cm × 0.5 cm in size. Cut section was solid, gray, with areas of hemorrhage without necrosis. Microscopic examination revealed bland spindle cells and prominent hyalinized blood vessels along with wispy collagen. The pathologic report was angiofibroma of vagina [Figure 2].
Figure 1: Speculum examination showing a small nodular mass in the left vaginal wall (white arrow)

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Figure 2: Higher power view (×400) revealing spindle- and stellate-shaped tumor cells with many prominent blood vessels in a fibrous stroma. No necrosis or significant mitotic activity is present (H and E)

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  Discussion Top

CA belongs to soft tissue tumors that predominantly occur in the distal genital tract of both genders. In females, the most common anatomic sites are the vulva overall and labium majus area.[1] Vaginal localizations have rarely been reported.[1] Extragenital organs have also been reported to be involved by this tumor.[2] Like in our patient, women are affected usually in the fifth to eighth decade.[3] In fact, the occurrence of CA during menopausal transition and postmenopausal period and the description of a two cases associated with long-term estrogen replacement therapy suggest the role of a hormonal disturbance in the pathogenetic mechanisms of this tumor.[4],[5] In addition, the expression of estrogen receptor (ER) and/or progesterone receptors (PRs) by neoplastic cells can support this hypothesis.[6] Nevertheless, the direct role of these steroids in the CA pathogenesis still remains unclear since a subset of mesenchymal cells of the distal female genital tract normally expresses these receptors, and at the same time, the neoplastic cells in other soft tissue disorders, arising from the vulva, may also show immunoreactivity for ER and/or PR.[7] Clinically, it presents as a small asymptomatic polypoidal or nodular mass, gradually increasing in size, inducing women to check with their doctor long time after the tumor onset. Mandato et al. described an early symptomatic form of small CA, in woman complained coxalgia due to tumor's position, in retroperitoneal site, near to obturator nerve.[4] As well as in our case, with a small nodular mass in the vaginal wall, the postcoital bleeding was the reason of the early consultation. There are many mesenchymal tumors of vagina which enter into the differential diagnosis with CA. In this case, it was clinically confused with benign vaginal tumors (leiomyoma and angiomyofibroblastoma) and aggressive vaginal tumors (aggressive angiomyxoma and solitary fibrous tumor). This differentiation is done by means of the histological characteristics. Although there is some morphologic overlapping of CA with the above-mentioned differentials diagnosis, bland spindle cells and prominent hyalinized blood vessels along with wispy collagen are distinctive for CA.[8],[9] In doubt, the immunohistochemical features may be helpful. CA are consistently positive for vimentin with variable expression of CD34, desmin, and smooth muscle actin but negative for S-100 protein.[1] Moreover, immunohistochemistry plays an important role in differential diagnosis between usual CA and CA with atypia or sarcomatous transformation; p16 expression is commonly negative in usual CA while it is multifocal or diffuse in CA with atypia or sarcomatous transformation.[10] In the present case, bland spindle cells, prominent hyalinized with varying sized blood vessels and wispy collagens, according to the literature, are distinctive for CA without immunohistochemical study. Surgical approach consists of a complete local excision with clear margins.[8],[9] The tumor has an extremely low risk of recurrence if completely excised. To date, any cases of metastases with atypia/sarcomatous features were noted, suggesting that morphological atypical or sarcomatous aspects do not necessarily confer an aggressive biologic behavior to CA.

  Conclusion Top

CA is a soft tissue tumor characterized by its small size, which rarely occurs in vagina, but it should be considered in differential diagnosis of postcoital vaginal bleeding, especially in menopausal woman. This tumor needs to be distinguished from other benign tumors and aggressive tumors occurring in the same site. Histopathological examination after complete local excisions with clear margins is the “gold standard” for a definitive diagnosis and cure.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Mandato VD, Santagni S, Cavazza A, Aguzzoli L, Abrate M, La Sala GB, et al. Cellular angiofibroma in women: A review of the literature. Diagn Pathol 2015;10:114.  Back to cited text no. 1
Val-Bernal JF, Rubio S, Garijo MF, González-Vela MC. Extragenital subcutaneous cellular angiofibroma. Case report. APMIS 2007;115:254-8.  Back to cited text no. 2
McCluggage WG, White RG. Angiomyofibroblastoma of the vagina. J Clin Pathol 2000;53:803.  Back to cited text no. 3
Mandato VD, Aguzzoli L, Cavazza A, Abrate M, Silvotti M, La Sala GB, et al. Coxalgia? Call the gynecologist. J Minim Invasive Gynecol 2015;22:663-7.  Back to cited text no. 4
Lane JE, Walker AN, Mullis EN Jr., Etheridge JG. Cellular angiofibroma of the vulva. Gynecol Oncol 2001;81:326-9.  Back to cited text no. 5
McCluggage WG, Ganesan R, Hirschowitz L, Rollason TP. Cellular angiofibroma and related fibromatous lesions of the vulva: Report of a series of cases with a morphological spectrum wider than previously described. Histopathology 2004;45:360-8.  Back to cited text no. 6
Dargent JL, de Saint Aubain N, Galdón MG, Valaeys V, Cornut P, Noël JC, et al. Cellular angiofibroma of the vulva: A clinicopathological study of two cases with documentation of some unusual features and review of the literature. J Cutan Pathol 2003;30:405-11.  Back to cited text no. 7
Flucke U, van Krieken JH, Mentzel T. Cellular angiofibroma: Analysis of 25 cases emphasizing its relationship to spindle cell lipoma and mammary-type myofibroblastoma. Mod Pathol 2011;24:82-9.  Back to cited text no. 8
Nucci MR, Granter SR, Fletcher CD. Cellular angiofibroma: A benign neoplasm distinct from angiomyofibroblastoma and spindle cell lipoma. Am J Surg Pathol 1997;21:636-44.  Back to cited text no. 9
Chen E, Fletcher CD. Cellular angiofibroma with atypia or sarcomatous transformation: Clinicopathologic analysis of 13 cases. Am J Surg Pathol 2010;34:707-14.  Back to cited text no. 10


  [Figure 1], [Figure 2]


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