Primary Malignant Melanoma of the Endocervix Uteri: Hysteroscopic View and Diagnosis of a Rare Yet Very Aggressive Entity

Abstract

Study Objective

To show the hysteroscopic view and diagnosis of primary malignant melanoma of the endocervix uteri.

Design

A 69-year-old nulliparous woman presented at the Emergency Department complaining of postmenopausal abnormal uterine bleeding. She recently underwent a Pap test, which showed Atypical Glandular Cells. Examination showed a normal vulva, vagina, and ectocervix, nodular parameters, and fixed uterus.

Setting

Academic Hospital " Azienda Ospedaliero-Universitaria SS. Antonio e Biagio e Cesare Arrigo" Alessandria, Italy.

Interventions

We performed outpatient hysteroscopy without anesthesia or analgesia using a 3.9 × 5.9 mm rigid hysteroscope and 5 Fr mechanical instruments. Cavity distension was obtained with saline solution and a peristaltic pump [1]. The procedure lasted 12 minutes without complication.

Surgical Steps: - Vaginoscopic approach showed normal vagina and atrophic ectocervix.

 - Cervical stenosis type I [2] with active bleeding was identified: mechanical adhesiolysis was performed with 5 Fr sharp scissors at 12 and 6 o'clock position.

 - Entering the canal, we identified a whitish “snowflake-like” swelling of 4 cm, with poor vascularization, occupying the right wall of the caudal part of the endocervix, and a friable bleeding necrotic tissue in the cranial part of the endocervix. Inside the cavity, an endometrial polyp of 1 cm was observed.

 - Considering the office setting and the clinical conditions of the patient, we performed the excision of the endometrial polyp and multiple biopsies of the lesions, using a 5 Fr grasping forceps.

The histological exam reported a malignant melanoma. The presence of primary melanoma in other sites was excluded. Staging computerized tomography and magnetic resonance imaging were performed. The patient was staged using the the International Federation of Gynecology and Obstetrics staging system for cervical cancer to stage IV B.

Conclusion

This appears to be the first hysteroscopic diagnostic vision of primary malignant melanoma of the endocervix uteri [3, 4, 5]. Hysteroscopy can be considered as a fundamental diagnostic tool for endocervical lesions.