Vaginal Carcinoma with Third-Degree Uterine Prolapse.

Carcinoma of vagina in a case of uterovaginal (UV) prolapse is very rare. We hereby present a case of 72-year-old woman with uterine prolapse with ulcerative growth of 4 cm × 2 cm on vagina commonly considered as decubitus ulcer. However, for confirmation, punch biopsy was performed, which confirmed it as vaginal carcinoma. The patient underwent vaginal hysterectomy with colpoperineorrhaphy with wide excision of tumor margin and received radiotherapy postoperatively. This case illustrates the importance of biopsy of an ulcer in cases of UV prolapse to rule out malignancy to avoid incomplete treatment. Copyright:

Introduction

Primary carcinoma of the vagina is rare and association with third-degree uterovaginal (UV) prolapse is even rarer, constituting 1%–2%[1] of all gynecologic malignancies. Incidence peaks in 6th and 7th decade of life.[2] It is commonly located in the posterior upper third of the vagina. The most frequent clinical symptom is vaginal bleeding, but dysuria and pelvic pain are also common. Unfortunately, the treatment guidelines are difficult to standardize due to its rarity. Hence, we report a case of a patient presented to our hospital with uterine prolapse combined with vaginal cancer.

Case Report

A 72-year-old, postmenopausal woman came to OPD with complaints of something coming out of vagina with foul-smelling discharge and per vaginal spotting for 1 month. On clinical examination, she had third-degree UV prolapse with cystocele and rectocele along with an ulcer of 4 cm × 2 cm on the anterolateral aspect of vagina, 1 o'clock–3 o'clock position, 5 cm away from cervix with margins everted, base indurated erythematous, which bleed on touch [Figure 1]. A punch biopsy was taken from the margin. Histology report of the biopsy revealed moderately differentiated squamous cell carcinoma. She was posted for vaginal hysterectomy with cystocele and rectocele repair with wide excision of the vaginal wall around the tumor. Gross examination of the specimen was suggestive of irregular tumor measuring 5 cm × 4 cm × 0.2 cm. The nearest tumor margin and deepest surgical margin were grossly involved with farthest margin 5 cm away. Microscopic examination revealed moderately differentiated squamous cell carcinoma of the vagina [Figure 2], acute on chronic nonspecific inflammation with surface ulceration of the cervix, atrophic endometrium. After postoperative recovery, she was sent for radiotherapy and was followed up.

Figure 1

Third-degree uterine prolapse with growth over anterior aspect of vaginal wall

Figure 2

Squamous cell carcinoma of the vagina

Discussion

In general, uterine prolapse combined with vaginal cancer is a very uncommon condition. It is common to have ulcerating lesion as decubitus ulcer over vagina as vagina may be exposed to inflammatory response and chronic irritation. Histopathology report of these ulcerative lesions showed chronic cervicitis in 97.9%, cervical decubitus ulcer in 13.6%, and carcinoma in situ in 1%.[3] It suggests the importance of preoperative evaluation in UV prolapse to exclude the possibility of carcinoma.

In cases of vaginal cancer presenting with significant prolapse, there are additional considerations during treatment planning. Most importantly, the bladder and any contents of an enterocele sac will have more exposure to the radiation resulting in vesicovaginal fistulas following primary radiation treatment. Furthermore, brachytherapy may not be technically feasible without prior surgery to reduce the prolapse. This treatment approach may limit the risk of urologic complications due to reducing exposure of the bladder to the radiation field.

The 5-year survival rate for squamous cell carcinoma of the vagina is 54%.[4]

The purpose of this report is to remind the clinical practitioner that vaginal carcinoma with UV prolapse can occur. The authors acknowledge its rarity but suggest that a differential diagnosis which includes a suspicion of its role in an etiology of vaginal carcinoma may help in optimization of appropriate patient care.

The importance of preoperative biopsies is highly required, as with concerns of the possibility of vaginal cancer if any changes in the epithelium or ulcer are suspected. It is essential to pay careful attention to patients with uterine prolapse by performing various tests to discover malignant lesions before surgical treatment.

The authors conclude that unfavorable conditions, including vaginal bleeding, foul-smelling discharge, and ulcerating lesions, biopsies must be performed before planning the final treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.