Wolf in lamb's skin: Vulval carcinoma mimicking bartholin gland abscess.

Vulvar cancer is a rare malignancy, representing approximately 4% of the female genital tract malignancies. This case emphasizes the importance of considering the unusual diagnosis of vulval cancer in a young woman when confronted with a large or recurrent Bartholin gland lesion, and underlines the need for careful pathological examination of such specimens.

INTRODUCTION

Squamous cell carcinoma (SCC) of the vulva is an unusual neoplasm with an overall incidence of approximately 1.8 per 100,000.[1] It most frequently occurs in women between 65–75 years of age,[2] whereas it is rare in patients younger than 30 years. This case is uncommon because it has presented at a young age and mimicked bartholin's abscess.

CASE REPORT

A 30-year-old patient presented to us with swelling on the right part of vulva and fever with pain for five days prior to admission. There was no past history of pruritus vulvae or vulval dystrophy. On local examination, there was a swelling over the right labia majora measuring 6 × 4 cm, variable in consistency with tenderness over the swelling [Figure 1]. General physical examination revealed no abnormality except enlarged right inguinal lymphnode. Provisional diagnosis of bartholin's abscess/cyst was made. As fluctuation could be elicited, incision and drainage was proposed. When incision was made on the medial aspect of the swelling, blood instead of pus drained from the swelling. This made us suspect carcinoma of vulva; and biopsies taken from the vulvar lesion revealed moderately differentiated squamous cell carcinoma. Ultrasound of the abdomen and pelvis was normal.

Figure 1

Swelling on the right aspect of vulva

DISCUSSION

The vast majority (90%) of vulval carcinoma are squamous cell carcinomas, and other histologic lesions including melanomas, adenocarcinomas, basal cell carcinomas, and sarcomas account for the remaining 10%.[3] On physical examination, the vulvar lesion is usually raised and may be fleshy, ulcerated, leukoplakic, or warty in appearance.[4] Indications for biopsy include any grossly suspicious lesion such as a confluent, wart-like mass; persistent ulceration or itchy area; or change in the color, elevation of surface of a lesion.[56] Biopsy can be performed in the office under local anesthesia using excisional or punch biopsy.[4] Lymphatic spread, usually to the inguinal lymph nodes, can occur early in the disease process. From the inguinal nodes, the cancer spreads to the femoral nodes, followed by the pelvic nodes, and specifically to the external iliac chain.[4] The overall five-year survival is 70% and correlates with the stage of disease and lymph node status.[7] Our patient had a history of vulval swelling with fever and pain and examination revealed a fluctuant tender swelling, suggestive of bartholin's abscess. Bleeding from the incision site made us suspect vulval carcinoma, which was confirmed by the biopsy.