Report
True vaginal metastasis of rectal cancer G. Yagci, S. Cetiner, M. Dede1, O. Gunhan2 Departments of Surgery, 1Gynecology Obstetrics and 2Pathology, Gulhane Military Medical Academy, Etlik, Ankara, Turkey For correspondence: G Yagci, Department of Surgery, Gulhane Military Medical Academy, Etlik – 06018, Ankara, Turkey. E-mail:
[email protected]
Case
ABSTRACT Vaginal metastasis from colonic cancer is an extreme case and often indicates a poor prognosis. More frequently tumor cells from the colonic lesions spread out to vagina by direct contiguous way. We present a case of rectal carcinoma with true metastasis to the vagina that was discovered after an interval of 15 mounts when vaginal bleeding and discharge became evident. To our knowledge, there are only a few other papers in the English language previously documenting this phenomenon. Key words: Adenocarcinoma, rectal neoplasms, vaginal neoplasms How to cite this article: Yagci G, Cetiner S, Dede M, Gunhan O. True vaginal metastasis of rectal cancer. Indian J Surg 2005;67:270-2.
The first document in the literature regarding to vaginal metastasis of colorectal cancer was reported by Whitelaw[1] in 1956 when a vagi nal lesion was found to be adenocarcinoma. Further investigation of the patient showed that primary tumor was originated from a mid sigmoid tumor. In 1966, a series of four cases of remote vaginal metastases from colonic car cinoma was presented by Raider.[2] These le sions were found between 4 and 41 months after the initial colonic resection. In three of the four cases other sites of metastasis were also present with overall survival in these cases being less than 40 months. Since that time, however, there is only one other documented report of this interesting phenomenon was presented by Chagpar and Kanthan.[3] We re port a rectal carcinoma case with true metas tasis to the anterior wall of vagina.
CASE HISTORY Fifty-four-year-old woman presented to our clinic with left lower abdominal pain, rectal bleeding, weight loose, night sweets and diz ziness. She had no previous history of medi cal illness. Physical examination revealed a soft abdomen with a slightly tenderness in left lower quadrant. Flexible recto-sigmoidoscop ic examination showed a fragile tumor mass Paper Received: March, 2005. Paper Accepted: April, 2005. Source of Support: Nil.
270 Free full text available from http://www.indianjsurg.com
at 15 cm. And biopsy result of this lesion reported as adenocarcinoma with high mitotic activity and signif icant pleomorphism. Subsequent CT scan of the ab domen and ultrasound demonstrated a surface-seated liver nodule with diameters of 4.2–4.5 cm in segment 8 and a second small nodule in left lobe of liver with diameters of 2.8–2.4 cm both showing target sign. In the pelvic sections, there was thickening in the bowel wall beginning from rectosigmoid junction. Blood samples for tumor markers showed ten times fold in CA-19-9 and three times fold in CEA levels. Laparotomy with low anterior resection and tumorec tomy of metastatic lesions in liver was performed. Post operative period was uneventful and she was dis charged without any complication. Pathology con firmed a poorly differentiated adenocarcinoma of the rectum invading the whole thickness of the bowel wall with surrounding fatty tissue. Tumor was 2.5 cm in diameter in the largest section invading a 6-cm long bowel segment. The specimen was tumor free in both resection borders. Tumor showed both lymphatic and vascular invasion and two out of ten lymph nodes were attacked by tumor cells. The patient was accepted as stage-IV rectum carcinoma and given six cycles of post operative adjuvant chemotherapy by Oncology depart ment with 5-FU plus calcium leucovorin periodically. During the follow-up period, she was admitted with 3 months intervals for the first year. Approximately 13 months after her first surgery, she came with bloody vaginal discharge and pelvic examination confirmed a 3 x 5 cm friable mass in the anterior wall of vagina [Figure 1]. Bimanual pelvic examination revealed that Indian J Surg | October 2005 | Volume 67 | Issue 5
Remote vaginal metastases from rectal cancer
vulva, cervix, uterus and bilateral adnexal structures are normal. Speculum examination showed a polypoid mass 2 x 3 cm in diameter on the anterior wall of vagina at fifth centimeter. Transabdominal pelvic ul trasound reported that the uterus was 34 x 37 x 41 cm in diameter, with homogeneous myometrium, indistinct endometrial echo pattern and bilateral adnexal areas were normal.
only for approximately one percent of all malignant neoplasms of the female genital tract. Squamous cell carcinoma represents about 80% of malignant neo plasms primary to the vagina. Although primary neo plasms of the vagina are quite rare, secondary spread of malignant neoplasms to the vagina by direct exten sion or lymphatic or hematogenous metastasis is quite common.[4]
Incisional biopsy was performed and reported as met astatic infiltration of poorly differentiated adenocarci noma. The histological appearance of the tumor was similar to rectal carcinoma, which was diagnosed pre viously in the patient [Figure 2]. The patient was then treated with intracavitary radiation and chemothera py for the control of bleeding.
Development of adenocarcinoma of the vagina in young women has been reported associated with maternal ingestion of diethylstilbestrol in utero with a rising incidence. These women should be examined regular ly after menarche for prompt evaluation and treatment of precancerous lesions such as adenosis, cervical ero sion or transverse ridges. Since most of these patients are young, a conservative treatment is recommended. Primary vaginal adenocarcinoma unrelated to intrau terine hormone exposure is very uncommon.[5,6]
DISCUSSION Primary malignant vaginal tumors are rare and account
Secondary vaginal adenocarcinoma represents 2.6% of all gynecological adenocarcinomas while 92.5% of apical lesions were metastasized from the upper geni tal tract, and 90.0% of the posterior lesions were from the gastrointestinal tract. About two-thirds of recur rences or metastases were reported after removal of primary lesions, and 80.8% occurred within first 3 years.[7]
Figure 1: Speculum examination in genu-pectoral position showed a friable mass in the anterior wall of the vagina
Fu and Reagan found that only 58 (16%) of 355 inva sive carcinomas involving the vagina represented pri mary neoplasms. Spread from primary carcinoma of the cervix was most common (32%), followed by en dometrium (18%), colon and rectum (9%) ovary (6%), vulva (6%), and urinary tract (4%). Even among the squamous carcinomas found in the vagina, only a mi nority prove to be primary to this side. About 75% are secondary, arising in either cervix (79%) or vulva (14%). Generally the vagina is a site for metastases from other areas of the female genitourinary tract.[8] Other miscellaneous tumors that have been found to have vaginal metastases include adenocarcinoma of pancreas, trophoblastic neoplasms, and tumors of the urinary tract.[9–12]
Figure 2: Low differentiated adenocarcinoma consisted of pleomorphic atypical epithelial cells with superficial ulceration. Slide does not contain normal vaginal mucosal tissue. HE x 100
Indian J Surg | October 2005 | Volume 67 | Issue 5
When direct contiguous spread is not the case, it is speculated that remote vaginal metastasis may occur either through lymphatic or hematogenous routes. Lymphatics from the sigmoid may carry metastasis to the iliac and hypogastric nodes where there could be retrograde spread to the periurethral area and anterior vaginal wall. Alternatively venous channels may al low the tumor emboli to pass from the colon to the ovarian plexus or parametrial veins and then on to the vaginal veins. Disseminated metastatic disease is frequently present 271
Yagci G, et al.
in patients with vaginal metastases and the prognosis is extremely poor in these patients. In three of the four patients reported by Raider, there was evidence of widespread metastatic disease. In these patients over all survival ranged from 10 to 39 months after the di agnosis of vaginal metastasis. The one case that had no other metastatic involvement, however, remained alive and well 48 months after the vaginal lesion was treated with intracavitary radiation.[2] Although it is frequently associated with primary vag inal tumors, vaginal bleeding or discharge might be the first clinical manifestations of an occult carcino ma or clinical signs of a widespread metastatic dis ease. We present a case of rectal carcinoma with true metastasis to the vagina that was discovered after an interval of 15 mounts when vaginal bleeding and dis charge became evident. Intracavitary radiation and chemotherapy was effective for the control of bleed ing whereas angiographic embolization may be emerg ing as a successful procedure to control the severe hemorrhage.
REFERENCES 1.
272
Whitelaw GP LSPLSRP. Carcinoma of large bowel with
metastasis to genitalia: Report of two cases. AMA Arch Surg 1965;73:171-8. 2. Raider L. Remote vaginal metastases from carcinoma of the colon. Am J Roentgenol Radium Ther Nucl Med 1966;97:944 50. 3. Chagpar A, Kanthan SC. Vaginal metastasis of colon cancer. Am Surg 2001;67:171-2. 4. Zaino RJ, Robboy SJ, Kurman RJ. Diseases of the Vagina. In: Robert J Kurman, editor. Blaustein’s Pathology of the Female Genital Tract. New York: Springer-Verlag; 2002. p. 151-206. 5. Del Castillo H, Rubio PA, Farrell EM. Vaginal adenocarcinoma in a gravida with prenatal DES exposure. Int J Gynaecol Obstet 1978;16:271-3. 6. Poskanzer DC, Herbst AL. Epidemiology of vaginal adenosis and adenocarcinoma associated with exposure to stilbestrol in utero. Cancer 1977;39:1892-5. 7. Zhou XR, Du XG. [Secondary vaginal adenocarcinoma: a clinicopathologic study of 55 cases]. Zhonghua Fu Chan Ke Za Zhi 1994;29:289-91,318. 8. In: Fu YS, Reagan JW, editors. Pathology of the uterine cervix, vagina, and vulva. Philadelphia: Saunders; 1989. 9. Weitzner S, Dressner SA. Vaginal metastasis from adenocarcinoma of pancreas. Am Surg 1974;40:256-8. 10. Yingna S, Yang X, Xiuyu Y, Hongzhao S. Clinical characteristics and treatment of gestational trophoblastic tumor with vaginal metastasis. Gynecol Oncol 2002;84:416-9. 11. Sogani PC, Whitmore WF, Jr. Solitary vaginal metastasis from unsuspected renal cell carcinoma. J Urol 1979;121:95-7. 12. Kumar R, Kumar S, Hemal AK. Vaginal and omental metastasis from superficial bladder cancer. Urol Int 2001;67:117-8.
Indian J Surg | October 2005 | Volume 67 | Issue 5
