{"paper_id":"3b4264c3-2dae-46b1-917c-f1d36bb0886c","body_text":"Lichen sclerosus (LS) and lichen planus (LP) are chronic inflammatory dermatoses predominantly affecting the anogenital area, which can lead to scarring, stenosis and, rarely, complete vaginal obliteration. 1 – 5  Chronic inflammation in LS creates a pro-oncogenic environment, increasing the risk of vulvar squamous cell carcinoma (VSCC), often associated with TP53 mutations. 6 – 9  Early recognition and treatment with ultrapotent topical corticosteroids or calcineurin inhibitors are critical to prevent irreversible anatomical distortion and reduce malignancy risk. 8\nWe present a unique case of a postmenopausal patient with complete vaginal obliteration due to LS/LP overlap, concealing a high-intermediate risk endometrial carcinoma. This case highlights diagnostic challenges, decision-making for urgent surgical intervention and individualised management strategies.\n\nA postmenopausal woman in her late 70s presented with acute lower abdominal pain that had persisted for several weeks. Additional symptoms included mild weight gain (3 kg over 6 months) and severe constipation. She had a history of a caesarean section, no hormone therapy and no postmenopausal bleeding. LS/LP overlap was previously diagnosed but remained untreated. She lived independently and had no family history of gynaecological malignancies. Examination revealed severe vulvar atrophy, lichenification and complete vaginal obliteration. Rectal examination identified a bulging mass compressing the rectum.\n\nTransvaginal ultrasound was not feasible due to vaginal obliteration; transabdominal ultrasound was limited by bowel gas and patient discomfort. Endorectal ultrasound demonstrated a 12-cm unilocular pelvic cystic mass displacing the uterus and compressing the rectum ( figure 1 ).\nAlthough MRI or CT was considered, urgent surgery was prioritised due to the patient’s acute pain, symptomatic pelvic mass, severe constipation and suspicion for obstructive defecation, with cross-sectional imaging unlikely to alter immediate management. Laboratory findings included mild anaemia (haemoglobin 11.9 g/dL) and elevated CA-125 (125 U/mL). Cytology from the occluded vagina was negative.\n\nIntraoperatively, the uterus was enlarged, tense and displaced cranially. The vagina was markedly distended due to haematocolpos, corresponding to the cystic pelvic mass identified on preoperative ultrasound. The ovaries and fallopian tubes appeared normal. The initial laparoscopic approach was converted to exploratory laparotomy due to the intraoperative findings and distal vaginal occlusion. The pronounced vaginal distension precluded further parametrial dissection. Therefore, the vagina was opened anteriorly via an abdominal approach to evacuate the haematocolpos. A large volume (approximately 900 mL) of thin, brownish fluid was drained and suctioned without contamination of the peritoneal cavity. Inspection of the vaginal cavity raised suspicion of vaginal malignant involvement, whereas the cervix appeared macroscopically unremarkable. Subsequently, a total hysterectomy, bilateral salpingo-oophorectomy and subtotal colpectomy were performed ( figure 2 ). No suspicious lymph nodes were identified intraoperatively; therefore, lymphadenectomy was omitted because of the patient’s frailty, the absence of nodal disease and the overall risk–benefit assessment.\nHistopathology confirmed grade 2 endometrioid endometrial carcinoma with cervical infiltration and lymphatic invasion. Vaginal tissue showed chronic inflammation, atrophy and fibrosis consistent with LS/LP, without malignancy. Final staging: pT2 pNx L1 V0 Pn0 G2 R0 (UICC 2017), FIGO IIB, high-intermediate risk mismatch repair (MMR)-deficient (MutL Homolog 1 (MLH1)/Postmeiotic Segregation Increased 2 (PMS2 loss)) endometrial carcinoma. Genetic testing excluded Lynch syndrome.\nPostoperative CT thorax/abdomen revealed no metastases. Adjuvant external beam pelvic radiotherapy (48.6 Gy in 27 fractions, volumetric modulated arc therapy (VMAT)) was administered. The vulvar disease was managed with long-term ultrapotent topical corticosteroids (clobetasol applied daily for 3 months, followed by two times per week maintenance) and daily emollients.\n\nFollow-up at 3, 6, 12 and 24 months showed no recurrence of endometrial cancer ( table 1 ). Vulvar topical therapy resulted in subjective symptomatic improvement and enhanced skin elasticity and trophism. The patient was educated in mirror-guided self-examination. The patient experienced dementia progression and discontinued follow-up.\nEBRT, external beam radiation therapy; LP, lichen planus; LS, lichen sclerosus; LS/LP, lichen sclerosus/Lichen planus; MMR, mismatch repair.\n\nThis case highlights the diagnostic challenges in postmenopausal women with severe vulvovaginal obliteration due to LS and LP overlap. 1 \n 10 – 12  LS was first described over a century ago as a chronic, sclerotic dermatosis of the vulva, 1  and early studies recognised its potential to cause scarring and stenosis, occasionally leading to complete vaginal obliteration. 2 \n 3  Absence of classic symptoms such as bleeding or discharge can delay recognition of underlying malignancy, while anatomical distortion limits transvaginal ultrasound. 4 \n 5  The differential diagnosis in this setting includes obstructive gynaecologic masses (eg, haematocolpos, endometrial or ovarian tumours), pelvic infections or abscesses and gastrointestinal causes such as bowel obstruction. Cross-sectional imaging with MRI or CT may help identify occult pathology and guide surgical planning 13 ; however, in this patient, acute pain, constipation and difficulty with defecation prompted immediate surgical intervention without additional imaging.\nEarly recognition and treatment of LS and LP are critical to prevent scarring, functional impairment and malignant transformation. 1 \n 3 \n 7  Chronic inflammation predisposes to vulvar intraepithelial neoplasia and VSCC, often associated with TP53 mutations rather than human papillomavirus-driven pathways. 7 – 9  Emerging biomarkers, including p53 immunohistochemistry and DNA methylation, may identify patients at higher risk of malignancy. 8 \n 9\nThe association between LS/LP overlap and endometrial carcinoma remains uncertain, 13 – 15  with any coexistence likely coincidental or due to increased surveillance. Shared molecular alterations, including TP53 dysregulation, suggest overlapping oncogenic mechanisms. 11 \n 12\nEndometrial cancer frequently exhibits mismatch-repair deficiency 16 \n 17 ; Lynch syndrome was excluded in this patient. Stage II disease guidelines recommend nodal assessment, 16 \n 18  but this was omitted due to frailty and intraoperative findings, with adjuvant radiotherapy mitigating potential occult nodal disease.\nThis case underscores vigilance in patients with advanced vulvovaginal scarring and illustrates how individualised, multidisciplinary care balances oncologic efficacy with anatomical and functional constraints.\nClinical assessment\nSymptoms: pain, distension, constipation, urinary retention, weight change, fever.\nAbsence of bleeding does not exclude malignancy.\nFirst-line imaging\nTransabdominal ultrasound (may be limited).\nEndorectal ultrasound if pelvic structures inaccessible.\nSecond-line imaging\nMRI pelvis (preferred for soft tissue and uterine assessment).\nCT thorax/abdomen/pelvis (for staging or acute abdomen).\nLaboratory tests\nInfection markers: Complete blood count, C-reactive protein, urinalysis and other relevant tests to rule out infectious causes of abdominal pain.\nTumour markers: CA-125 (and others if clinically indicated) are adjunctive tools and cannot confirm malignancy alone.\nIndications for surgical exploration\nLarge or symptomatic pelvic mass.\nInconclusive imaging.\nAcute clinical deterioration.\nSuspicion of obstructive pathology.\nThe patient was relieved her condition was accurately diagnosed and treated. She emphasized the importance of prompt evaluation for persistent genital symptoms and valued guidance on self-examination.\nEarly recognition and guideline-based management of lichen sclerosus/lichen planus overlap prevent irreversible scarring and reduce malignancy risk.\nIn cases of vaginal obliteration, consider alternative imaging or endoscopic approaches when standard diagnostics are not feasible.\nSurgical planning should be individualised based on patient factors, anatomy and intraoperative findings.\nMultidisciplinary, patient-centred care optimises oncologic outcomes while preserving anatomical and functional integrity.","source_license":"CC0","license_restricted":false}