Adenocarcinoma of the Gartner’s duct. A case from practice

Key words: Background . A malignant tumour of the Gartner’s duct is one of the rarely encountered tumours in gynaecological oncology. Only in rare cases does the epithelium of the Gartner’s duct become a source of vaginal and cervical adenocarcinoma, as the Gartner’s duct is present in 25% of women, and mesonephric cysts occur in 1% of cases. Purpose . To familiarise the medical community with the peculiarities of the clinical course of malignant tumours of the Gartner’s duct and methods of their treatment. Materials and methods. Patient L., born in 1974, who underwent special treatment at the State Organization «Grigoriev Institute for Medical Radiology and Oncology of the National Academy of Medical Sciences of Ukraine» with a diagnosis of grade II adenocarcinoma of the Gartner’s duct (T2NxM0), clinical group 3. Results and discussion . After examination, the patient underwent two cycles of neoadjuvant polychemotherapy and a preoperative course of external beam radiation therapy (EBRT) on the vulvar area with a total radiation dose of 30 Gy. Two weeks later, surgery was performed to remove the tumour of the Gartner’s duct from the surrounding tissues. Three weeks after the surgery, the patient’s course of EBRT was extended to the total dose of 50 Gy, and 3 cycles of adjuvant polychemotherapy were performed. The follow-up period was 3 years, with no evidence of disease recurrence. Conclusions . The dissemination of information about this rare but serious disease will allow doctors to be informed, as well as to predict and diagnose it in a timely manner. As a result, they can plan adequate special treatment and determine the prognosis of this disease. adenocarcinoma of the Gartner’s duct, surgical treatment, chemoradiotherapy.

A malignant tumour of the Gartner's duct is one of the rarely encountered tumours in gynaecological oncology.Only in rare cases does the epithelium of the Gartner's duct become a source of vaginal and cervical adenocarcinoma, as the Gartner's duct is present in 25% of women, and mesonephric cysts occur in 1% of cases [1].Adenocarcinoma of the Gartner's duct can affect not only adult women but also pre-pubescent girls (3-12 years old).Only few publications have been devoted to this pathology.
To understand low incidence of this pathology, it is necessary to consider the anatomical features of the Gartner's duct, biological aspects, and pathogenesis o f the Gartner's duct tumour.
The embryonic remnants of the Gartner's ducts are formed in the antenatal period during the formation of the fetal genitourinary system from the Wolffian duct.This duct is the excretory channel of the primary kidney -the primary ureter.As the embryo develops, the mesonephric duct loses its original function, passing into the epididymis, vas deferens and ejaculatory ducts in the male embryo.In the female embryo, the duct is reduced, and only its rudimentary remnants remain in the form of ovarian appendages -epoophoron and paroophoron.In a quarter of newborn girls, the distal part of the mesonephric duct -Gartner's ducts -is also preserved.They are the duct's segments that pass through the parametrium along the uterine ribs and penetrate the uterine tissue at the level of the internal orifice, extending longitudinally through the cervix and anterolateral vaginal wall to its vestibule.
In some patients, cysts are congenital and form before birth, while in others, fluid in the Gartner's ducts accumulates at any stage (more often in reproductive age) of the postnatal period.The growth of Gartner's cysts occurs mainly towards the vaginal lumen, without disturbing the topography of neighbouring anatomical structures, but the presence of large tumors can lead to urethral displacement [2,3].
Gartner's cyst is a benign embryonic neoplasm named after the Danish anatomist Gartner, who described it in the early nineteenth century.It is a cavity formed by the rudimentary remnants of the mesonephric (Wolffian) duct and filled with serous and mucous fluid (Fig. 1).
Зазвичай перебіг захворювання безсимптомний.У таких випадках невелике, м'яке або тугоеластичної Single-chamber (less often multi-chamber) cysts are located under the vaginal wall epithelium.They do not exceed 3-5 cm in diameter, but sometimes reach large sizes and can go deep into the parametric tissue with their upper pole.Their growth is not proliferative and is caused only by fluid accumulation.Malignancy is extremely rare.
In 10% of women, the disease runs in families.One of the main reasons for the occurrence of a mass lesion is trauma to the vaginal walls as a result of vaginal delivery or vaginal surgery.Since the development of mesonephros is closely related to the process of nephrogenesis, Gartner's cyst is often combined with congenital defects of the urinary system -ureteral ectopia and renal hypoplasia.
The disease is usually asymptomatic.In such cases, a small, soft or tightly elastic oval mass located in a vertical
МРТ таза дозволяє візуалізувати локалізацію утворення в стінці піхви, розташування до навколишніх тканин [7].При МРТ дослідженні утворення локалізуються нижче діафрагми таза (рис.2).line on the lateral wall of the vagina is detected by the woman herself or is accidentally found by the doctor during a gynaecological examination [4].Subjective signs begin to appear when the cyst is sufficiently large or inflamed.Space-occupying cysts of the Gartner's duct are accompanied with difficulty and pain during sexual intercourse, discomfort during physical activity, walking, and sitting.Cysts located in the lower parts of the vagina can bulge outward through the vulvar slit [5,6].
Transvaginal ultrasound is the most accurate, reliable, and affordable method for diagnosing tumors [7].
-МРТ малого таза: у проекції зовнішніх статевих органів визначається патологічне тканинне утворення розмірами 61х45х58 мм, яке створює проміжний сигнал в Т1 та Т2, підвищений в DWI, з обмеженням дифузії, наявністю помірної кількості геморагічного 3 years ago the patient noticed a mass on her left labia majora for the first time, therefore she considers herself sick for 3 years.She did not seek medical care, and was not regularly followed up by a gynaecologist.Over the past 6 months, she noticed an increase in the size of the tumour and its compaction.
Gynaecological examination showed a solid tuberous tumour formation with a diameter of 7,0 cm in the lower third of the left vaginal vestibule, which was intimately soldered to the adjacent tissues and limited in mobility.An examination was prescribed to the patient according to the protocol: -CT scan of lungs and abdominal organs: no pathology.
-MRI of the pelvis: in the projection of the external genitalia, a pathological tissue mass measuring 61x45x58 mm was detected, which created an intermediate signal in T1 and T2, increased in DWI, with The mass was intimately adjacent to the posterior lateral wall of the urethra and the anterior lateral wall of the internal sphincter, without any evidence of invasion.
To verify the diagnosis, a tumour puncture was performed.The result of cytological examination No. 401-45 was adenocarcinoma G-1.
Based on the examination of the patient, a clinical diagnosis was established: Malignant tumour of the left Bartholin's gland, stage II (T2NxM0), clinical group 2. A comprehensive treatment was planned, and it began with a preoperative course of chemoradiotherapy followed by surgery.
The patient underwent two cycles of neoadjuvant polychemotherapy according to the regimen -paclitaxel 450 mg, cisplatin 210 mg, and a preoperative course of EBRT on the vulvar area with a single radiation dose of 1,8 Gy to a total radiation dose of 30,6 Gy on the Clinac 600C linear accelerator modified with cisplatin 75 mg No. 3 (total dose -225 mg) in the setting of prevention of radiation reactions.
Two weeks after the cessation of radiation therapy, the patient underwent surgery to remove the tumour of the Gartner's duct from the surrounding tissues.
Surgical technique: the area above the tumour of the left labia majora was dissected in layers.The tumour was solid, grey in colour, tuberous, 7,0 cm in diameter, inactive, intimately soldered to the surrounding tissues, and deeply embedded in the pelvic tissues and fat.Intraoperatively, it was found that the tumour was coming out of the Gartner's duct.With great difficulty, the tumour was removed from the surrounding tissues with an electric knife by sharp dissection, and numerous vessels were ligated with silk.Vicryl sutures were applied to the enlarged Gartner's duct.Glove drainage was installed.Separate interrupted silk sutures were placed on the skin.
Description of the gross specimen: A solid neoplasm, grey in colour, tuberous, 7,0 cm in diameter in the section of solid structure of yellow colour, without signs of destruction.
After the operation, the patient received antibacterial, infusion, and anticoagulant therapy.On the 5th day of the postoperative period, a postoperative wound haematoma was detected, which was drained.The patient was discharged from the department two weeks after the operation in a satisfactory condition.
Three weeks after the operation, the patient's course of EBRT was extended to 50 Gy and 3 cycles of adjuvant polychemotherapy were performed according to the following regimen: paclitaxel 450 mg, cisplatin 210 mg.There were no complications during the special treatment.
На підставі проведеного обстеження хворої було встановлено клінічний діагноз: злоякісна пухлина лівої бартолінової залози II ст.(T2NxM0 causes discomfort to a woman only when it is large, thus indicating the need for examination and treatment of the Gartner's duct cysts in order to prevent their transformation into a malignant tumour.
The dissemination of information about this rare but serious disease will allow doctors to be informed, as well as to predict and diagnose it in a timely manner.As a result, they can plan adequate special treatment and determine the prognosis of this disease.
Taking into consideration the positive effect of the performed treatment, this rare clinical case has the potential to make special treatment more effective and improve survival of the patients with adenocarcinoma of the Gartner's duct.
The study was financed by the State Budget of Ukraine.
Description of the clinical case Patient L., born in 1974, has been under the care at the State Organization «Grigoriev Institute for Medical Radiology and Oncology of the National Academy of Medical Sciences of Ukraine» since 14.01.2021 with a diagnosis of grade II adenocarcinoma of the Gartner's duct (T2NxM0).Condition after complex treatment: clinical group 3.