Discussion part:
The case above shows the dilemma in diagnosis still in the modern era.
Starting from the diagnosis of cancer to granuloma of various origins
was tried to fit in the diagnosis to solve the mystery.
A rare case report published by Narendra et al from KMC oncology team in
2010 of extrarenal malignant rhabdoid vulval tumor in a 50-year-old lady
who came with complaints of a vulval growth from past 3-months
associated with pain and was managed with surgery and radiotherapy.3
Wiebren et al, published a case report on an aggressive nature of rare
verrucous carcinoma of clitoris in a 79 years old lady with history
Lichen planus.4
Nilima et al published a case report in the year 2020 of clitoral
squamous cell cancer in a 68 years old female who presented to the
hospital with complaints of vulval swelling and itching and with lymph
node involvement. The lady was diagnosed in the advance stage which made
the management of the case a challenge to the oncology
team.5
Ji-Won Min et al, reported the first case of the GCT of the clitoris in
postmenopausal women in Korea. A 45-year woman presented with a mass
lesion over the left side of clitoris developing over 2 years. Surgical
complete resection was done for her and histo-pathology showed it to be
a granular cell. There was no recurrence in one year follow up
time.6
There have been rare reported cases of epithelioid hemangioendothelioma,
arteriovenous hemangioma, congenital hemangiopericytoma, angiokeratoma,
nevus lipomatosus cutaneous superficialis, squamous cell carcinoma,
plexiform schwannoma, and Paget’s disease of the clitoris.
A case report and review of pyogenic granuloma of vulva in a post
menopausal lady published in 2011. They discussed that although pyogenic
granuloma is common to occur due benign vascular proliferations of the
skin and mucous membranes, they are relatively rare on the vulva. They
presented a case report of postmenopausal multiparous women who
presented with a history of foul smell and bleeding multiple lesions at
vulva. Like our case she gave a history of itching but no pain. After
complete excision, histopathological features suggestive of pyogenic
granuloma. 7
Claudio Guerrieri et al in 2019 published a case report in the
international journal of gynecological pathology in regards to vulvar
Silicone Granuloma in a 51 year old multiparous lady following a labia
majora augmentation surgery using silicone-based liquid injection. It’s
a type a foreign body granuloma when silicone is used with the intention
of enhancing the labia majora as a part of esthetic
procedure.8
Ahmad et al discussed a rare idiopathic condition of vulvitis
granulomatosa. It is a part of anogenital granulomatosis and is a form
of noncaseating granulomas and associated lymphedema. They discussed a
57 year multiparous lady post hysterectomy with no evidence of crohn’s
disease presented with labial induration associated with swelling of the
skin of the groin. She was treated with oral hydroxychloroquine with
significant improvement.9 Vulvitis granulomatosa has
also been reported with Melkersson-Rosenthal
syndrome.10
Abdulcadir et al discussed a case series of 7 women with clitoral
neuroma post trauma due to female genital mutilating surgeries, of which
6 were diagnosed with neuroma during clitoral reconstruction surgeries
and one case diagnosed before the surgery. 6 of the operated cases
presented with pain while the last case discussed also had a complaint
of swelling at the genital region. Post surgery all the patients were
relieved of pain. 2
Yukiko et al discussed a case of secondary adenocarcinoma of clitoris
presented with pain and swelling at the clitoris, from the uterine
cervical cancer involving the vagina, parametrium and obturator lymph
nodes. She was treated initially with radiotherapy and later underwent
surgical excision of clitoral mass. 16