METHODS
Transvaginal sonography was done in another center which revealed a well-defined mass lesion of homogeneous echogenicity measuring 6.0 x 4.0 cm in the anterior vaginal wall completely filling the vaginal lumen with increased intrinsic vascularity. Fine needle aspiration and cytology (FNAC) of periurethral mass done was suspicious of lymphoma. Biopsy of the mass revealed chronic nonspecific inflammation.
Magnetic resonance and imaging (MRI) of the pelvis revealed well defined solid encapsulated smooth outlined lesion measuring 7.0 x 5.1 x 4.8cm in size in the perineal region inferior to the pubic symphysis, extending cranially in between the urethra anteriorly and vagina posteriorly. The lesion is extended up to the bladder neck and anterior vaginal fornix level superiorly and extended up to the introitus inferiorly. Posteriorly, it is abutting the anal canal with a distinct fat plane in between and displacing the bulb of the vestibule and crura of the clitoris. The vaginal lumen is compressed posteriorly by the lesion.
The patient then presented to the gynecology unit of our center for further evaluation and management. On examination, a huge ulcerative growth periurethral mass was noted. Cystoscopy revealed a periurethral mass, with external compression at distal 1 cm of the urethra. Subsequently, a multiple-punch vulvar biopsy was taken. Histomorphological examination of sections revealed show ulcerated tissue revealing infiltrating discohesive sheets of atypical lymphoid cells in the subepithelial stroma. These atypical lymphoid cells exhibit pleomorphism and have a high nucleo-cytoplasmic ratio, large nucleus, irregular nuclear contours, conspicuous nucleoli, and scant cytoplasm. Mitosis noted. Fibrinoid necrosis of vessels seen. (Figure 1) IHC analysis was done.
Immunohistochemistry (IHC) analysis showed tumor cells positive for CD20, BCL6, MUM1, CMYC, and BCL2 and negative for CK, CD3, CD10, SOX11, and Ki67 70%. (Figure 2a-2c) The overall histomorphological features combined with the immunohistochemical profile were suggestive of Diffuse large B-cell lymphoma, active B-cell immunophenotype.