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Vaginal Cancer in Patient Presenting with Advanced Pelvic Organ Prolapse: Case Report and Literature Review

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Vaginal Cancer in Patient Presenting with Advanced Pelvic Organ Prolapse: Case Report and Literature Review Proceedings in Obstetrics and Gynecology, 2015;5(1):3 Vaginal cancer in patient presenting with advanced pelvic organ prolapse: case report and literature review Joseph Kowalski, MD,1 Johanna Savage, MD,2 Catherine S. Bradley, MD, MSCE1 Keywords: Vaginal cancer, pelvic organ prolapse, pessaries Abstract Introduction Background: Vaginal cancer presenting Primary vaginal carcinomas are concurrently with stage 4 uterovaginal prolapse extremely rare, accounting for only is a rare occurrence, representing less than 1% about 1% of all gynecologic of all gynecologic malignancies. malignancies.1 At the time of diagnosis, Case: We review the case of an 82-year-old patients are typically in their 6th or 7th woman who presented for care of prolapse. decade of life and most commonly Examination demonstrated complete present with vaginal bleeding from a uterovaginal prolapse and a vaginal ulcer, later lesion localized to the upper third of the confirmed to be vaginal cancer. vagina. There are currently no specific Conclusion: The management of these guidelines for treatment of vaginal complicated patients is limited by a lack of data cancer due to the paucity of available available to guide treatment. This case and the data. However, certain cases of early literature review highlight the need for a multi- stage disease may be treated with disciplinary approach to treatment and a high level of clinical suspicion for diagnosis of these primary surgery. Advanced disease is very challenging cases. generally treated with chemoradiation or radiation alone.1 1University of Iowa Hospitals and Clinics, Department of Obstetrics and Gynecology, Iowa The incidence of symptomatic prolapse City, Iowa 2University of Iowa Hospitals and Clinics, and prolapse surgery increases with Department of Pathology, Iowa City, Iowa age. Women older than 80 years are the fastest growing segment of the 2,3 population. However, primary vaginal Please cite this paper as: Kowalski J, Savage J, Bradley CS. Vaginal cancer in patient presenting with advanced pelvic organ prolapse: case report and literature review. Proceedings in Obstetrics and Gynecology, 2015;5(1):Article 3 [ 8 p.]. Available from: http://ir.uiowa.edu/pog/ Free full text article. Corresponding author: Joseph Kowalski, Fellow, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242-1080, USA. Telephone: 319-356-1616, Fax: 319-384- 8620. Email: [email protected] Financial Disclosure: The authors report no conflict of interest. Received: 21 January 2015; received in revised form: 26 March 2015; accepted 6 May 2015; POG in Press, 6 May 2015 Copyright: © 2015 Kowalski et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 1 Proceedings in Obstetrics and Gynecology, 2015;5(1):3 carcinomas are rare. A primary vaginal She had no known oncologic history and carcinoma presenting in conjunction had no history of abnormal Pap smears. with stage IV uterovaginal prolapse is an Her last normal Pap smear had been even rarer phenomenon. The reported approximately one year prior to initial incidence of prolapse from referral presentation. Her medical history was centers range from 13.6% to 16.3% of significant for atrial fibrillation, patients with primary vaginal cancer.4,5 hypertension and a remote history of A comprehensive review of the available right salpingo-oophorectomy for English language literature reveals only unknown reasons. She had never 7 case reports and 1 case series (6 smoked. Physical examination in the patients) of primary vaginal cancer office revealed complete, irreducible associated with pelvic organ prolapse uterovaginal prolapse that was (Table 1).4,6-12 Conversely, finding an moderately tender. There was a 4 by 5 erosion of the vaginal mucosa in a cm. indurated, ulcerated, foul-smelling postmenopausal woman in the setting of vaginal lesion remote in location from treatment for pelvic organ prolapse is the cervix. The lesion had a grey, not uncommon. This finding may be necrotic-appearing base, and it present with or without the use of a appeared to track about 2 cm. into the vaginal pessary and warrants very close left vaginal sidewall (Figure 1). Her monitoring. POP-Q exam included: Aa +3, Ba +12, C +12, D +12, Bp +12, and Ap +3. GH. We will describe the case of a patient PB and TVL were not able to be referred for management of pelvic organ assessed. prolapse who was found to have vaginal cancer. We will also review all other The patient was directly admitted to the English language reports of prolapse urogynecology service from clinic and complicated by vaginal cancer with an started on intravenous antibiotic emphasis on the unique challenges of therapy. She was taken to the operating diagnosis and management that this room with the assistance of the situation presents. gynecologic oncology service for vaginal biopsies and cystoscopy as well as Case Report wound irrigation and debridement. The prolapse was able to be successfully An 82-year-old G6P6 female was reduced in the operating room. referred to our institution for further Intraoperative observations were management of uterovaginal prolapse. significant for left paravaginal nodularity A year prior, she had been evaluated at and tethering of the ulcerated area to an outside institution and declined the paravaginal tissue. Cystoscopy was surgical management or the use of a unremarkable. A rectal exam was pessary for treatment of her prolapse. unremarkable with the exception of mild Her primary presenting complaints were prolapse of the rectal mucosa. progressively worsening vaginal Histopathology of the vaginal biopsies pressure, incomplete bladder emptying, demonstrated moderately differentiated occasional urinary incontinence and a squamous cell carcinoma with newly recognized “crack” in the perineural invasion (Figure 2) prolapsed tissue of 2 weeks duration. Vaginal cancer with advanced pelvic organ prolapse 2 Proceedings in Obstetrics and Gynecology, 2015;5(1):3 Figure 1. Complete uterovaginal prolapse with a well-defined ulcer on the left vaginal side-wall (A-C). Figure 2. Histopathology of the vaginal biopsies demonstrating moderately differentiated squamous cell carcinoma (A-C) with focal perineural invasion (C). Vaginal cancer with advanced pelvic organ prolapse 3 Proceedings in Obstetrics and Gynecology, 2015;5(1):3 Table 1. Publications reporting vaginal carcinoma complicated by concurrent pelvic organ prolapse. Prolapse Author Year Title Stage* FIGO Stage Treatment Comments Berthelsen6 1957 Vaginal carcinoma associated 4** Not reported Vaginal hysterectomy and No follow up reported. with total prolapse vaginectomy. Howat7 1984 Carcinoma of the vagina 4** Not reported Total abdominal hysterectomy No follow up reported. presenting as a ruptured and bilateral salpingo- procidentia with an entero-vaginal oophorectomy and vaginal fistula and prolapse of the small biopsies taken. 15 cm small bowel bowel resection with end-to-end anastomosis followed by radiotherapy. Rao4 1986 Primary carcinoma of vagina with 3 (all cases) Not reported 5 patients underwent external Case series included 6 patients. 2 patients uterine prolapse beam radiation only. 1 patient with irreducible prolapse. 2 patients refused treatment. developed vesicovaginal fistula after radiation. 1 recurrence and 1 fatality reported. Iavazzo8 2007 Vagina carcinoma in a completely 3 1 Radical vaginal hysterectomy No recurrence during 3.5 years follow up. prolapsed uterus. A case report with excision of the upper two- thirds of the vagina followed by 5400 cGy external beam radiation. Gupta9 2007 A rare case of primary invasive 3 3 Chemoradiation with 5- Irreducible. Reported clinical improvement carcinoma of vagina associated fluorouracil and carboplatin and reduction in size of invasive growth. with irreducible third degree Length of follow up not specified. uterovaginal prolapse Ghosh10 2008 Primary invasive carcinoma of 3 1 Radical vaginal hysterectomy No recurrence during 12 months follow up. vagina with third degree with bilateral extraperitoneal uterovaginal prolapse: a case pelvic lymphadenectomy report and review of literature Vaginal cancer with advanced pelvic organ prolapse 4 Proceedings in Obstetrics and Gynecology, 2015;5(1):3 Batista11 2009 Uterine prolapse complicated by Not reported 1 Partial transvaginal colpectomy No recurrence during 24 months follow up. vaginal cancer: A case report and followed by 5040 cGy external literature review beam radiation. Wang12 2014 A rare case of invasive vaginal “Third 1 Vaginal hysterectomy, “apex No recurrence during 4 years follow up. carcinoma associated with vaginal degree” fixation”, anterior/posterior prolapse colporrhaphy and partial vaginectomy followed by 5040 cGy external beam radiation. * The method used to stage prolapse in these reports was not specified. ** Prolapse was described as, “total prolapse,” in the Berthelsen report and as, “complete procidentia,” in the Howat report. Given the diagnosis of vaginal squamous cell carcinoma, about 4 months after initial presentation to our institution. imaging studies were performed for clinical staging. A The precise cause of death is unknown to us. positron emission tomography/computed tomography (PET/CT) scan demonstrated hypermetabolic foci in the Comment vaginal wall, sigmoid colon, rectum and pelvic
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