Abstract
Although uterine prolapse and carcinoma of the uterine cervix are not rare events, their association is very uncommon. The treatment of cervical cancer has been protocolled, but the management of uterovaginal prolapse associated with carcinoma of the cervix is not standardised and therapy strategies vary considerably among authors. Our case reports a 74-year-old patient, admitted to the emergency department with an ulcerated prolapsed uterus. Biopsy of the cervical lesion confirmed a squamous-cell carcinoma. The patient underwent vaginal hysterectomy plus open bilateral iliopelvic lymphadenectomy complemented with radiotherapy with quimiosensibilisation. With this aggressive treatment approach, there was progression of the disease. The authors believe that this case typiaddition to the few published reports.
Background
The association of carcinoma of the cervix and uterine prolapse is uncommon and the best treatment approach in such cases is not standardised and varies considerably among authors. Few cases have been published which does not allow the comparison of outcomes with different therapeutic approaches. We wish to add to the scientific community our experience and results.
Case presentation
A 74-year-old patient gravida 10, para 9 was admitted with an ulcerated lesion in a prolapsed uterus of 20 years duration. The patient reported of local pain, fever and anorexia. Physical examination revealed procidentia with a 4.5 cm ulcerated lesion on the posterior lip of the cervix and a low-grade cystocele-rectocele (figure 1). Rectovaginal examination gave no evidence of vaginal, rectal or parametrial involvement. Biopsy of the ulcerated cervical lesion confirmed a squamous-cell carcinoma (SCC) and a pelvic MRI suggested a disease limited to the cervix. Thumalignancy, according to International Federation of Gynecology and Obstetrics (FIGO) classification.
Figure 1.
Carcinoma of the cervix in association with complete uterine prolapse.
Investigations
Pelvic MRI, as part of the pretreatment clinical staging tests/procedures, showed a tumour of the cervix with 4.5 cm of diameter, without apparent extent to vaginal mucosa and with no evidence of bladder, rectal or parametrial invasion. Histological examination of the surgical specimen demonstrated a poor differentiated SCC with involvement of the posterior vaginal wall and lymphatic space (FIGO IIIB—pT2A2G3N1Mx). All resection margins were clear. CT scan after the coadjuvant treatment confirmed progression of the disease, showing multiple lumbar aortic adenopathy, the largest with 4 cm of diameter. CT scan during the palliative treatment revealed lumbar-aortic adenopathy with 16 cm, surrounding the aorta and extending to the left common and external iliac vessels.
Treatment
The patient underwent a vaginal hysterectomy plus open bilateral iliopelvic lymphadenectomy, and based on the pathological stage (IIIB—pT2A2G3N1Mx) proceeded with coadjuvant treatment with radiotherapy (pelvic external beam radiotherapy—50Gy/25F plus vaginal brachytherapy—3×7Gy) and chemotherapy with cisplatin (40 mg/m2/weekly). Overall, the treatment was well tolerated.
Outcome and follow-up
Despite the initial aggressive treatment approach, the patient showed disease progression and initiated palliative therapy with paclitaxel (175 mg/m2) plus carboplatin (AUC5) every 3 weeks. After completing four cycles of the protocol, this approach was also ineffective in halting the disease progression, as shown by progression of the regional disease. Palliative radiotherapy was considered but the patient underwent rapid deterioration of her general condition manifested by increasing asthenia, anorexia and cachexia, as well as severe oncological lumbar pain and refractory nausea and vomiting episodes, postponing several times the treatment. Twelve months after the diagnosis the patient was admitted in the hospital due to an insidious onset of altered mental status and end-life care measures, regarding her comfort, were performed.
Discussion
Carcinoma of the cervix and uterine prolapse are common diseases in developing countries, but their association is quite rare.1 When this occurs, most patients are in the 60 to 80-year age group and procidentia has been present for 10 years or more in 60% of cases.2 It has long been established clinically that the prolapsed uterus, although exposed to constant mechanical irritation, is remarkably free from the risk of cancer. This is explained by the assumption that its displacement removes it from the environment of the vagina, rendered harmful by exudates.3 However, procidentia with carcinoma of the cervix may be influenced by the age group, for carcinoma of the cervix is usually seen in relatively younger women, the older women thus have gone safely through the period when carcinoma develops, finally developing prolapse without carcinoma; those of the younger age may develop carcinoma of the cervix and are cured or succumb before procidentia develops; also, carcinoma of the cervix by causing fixation of the uterus may prevent the development of procidentia. Several studies have shown that concomitant chemoradiotherapy has become the standard of care for high-risk early-stage and locally advanced cervical cancer, and has been offered as an alternative to radical hysterectomy for patients with tumour confined to the cervix but larger than 4 cm (IB2).4 5 However, carcinoma of the cervix on a prolapsed uterus is usually accompanied to cystocele–rectocele, and thus the use of radiation might increase visceral injury and for this reason, it might not be considered an option of treatment. Despite that, Reimer et al5 reported a successful treatment with external beam therapy in an irreducible uterovaginal combined with a SCC of the cervix, without aberrant wound healing. Despite the conflicting opinions, most authors indicate a radical vaginal surgery with bilateral iliopelvic lymphadenectomy complemented with external pelvic irradiation and chemotherapy as the best therapeutic approach.1 4 5 However, further studies are needed to determine the best therapy in cases of association of carcinoma of the cervix with uterovaginal prolapse.
Learning points.
The management of uterovaginal prolapse associated with carcinoma of the cervix is not standardised and therapy strategies vary considerably among authors.
Radiotherapy is a therapeutic option for locally advanced cervical cancer, but its use might be limited in the association of uterine prolapse with cervical cancer because of the risk of radic cystitis.
Most authors indicate a radical vaginal hysterectomy with bilateral iliopelvic lymphadenectomy complemented with external pelvic irradiation and chemotherapy as the best therapeutic approach in such cases.
Further studies are needed to determine the best therapy in cases of association of carcinoma of the cervix with uterovaginal prolapse.
Footnotes
Contributors: Under the guidance of PS (head of ward staff), CP and CC were the attending physicians of the patient; both responsible for the diagnosis and treatment of the patient as well as revising the literature and writing the case report.
Competing interests: None declared.
Patient consent: Obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
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