Endocervical adenocarcinoma

Question:
46 years old woman
October 2002: heterogeneous mass in Douglas sac infiltrating one third of vagina. Biopsy revealed endometrioid adenocarcinoma in vagina from metastatic origin. Ultrasound showed ovaries increased in size.

Neoadjuvant Carboplatin Paclitaxel x 4 cycles followed by:

February 2003: hysterectomy, bilateral salpingo-oophorectomy and vaginal end of 1 cm removed. Pathology report: endocervical adenocarcinoma moderate differentiation infiltrating vagina, affected margin, metastasis in right ovary.

April 2003: endovaginal brachytherapy (25Gy) was administered.

June 2003: Pelvic radiotherapy (45Gy)

February 2005: relapse in anterior vaginal wall, external third next to urethral meatus with biopsy. Pathology report: endocervical papilar carcinoma Grade 2. On CT scan no distant relapse was observed. Treated with interstitial brachytherapy Ir-192 (28Gy) finished on May 2005 with complete response.

April 2009: second local relapse MRI showed mass 2x2 cm in middle third of vagina without plan de clivage in posterior wall of urethra; bilateral lymphnodes. PET scan is normal, CT scan confirms MRI findings.

May 2009: exploration under anesthetia shows exophytic tumor 3x3 cm occupies anterior vaginal wall from 8 mm of meatus and extends to the end of vagina. Cystoscopy shows no affected bladder or urethra; negative biopsy of mucosal urethral.

Bilateral inguinal biopsy: adenocarcinoma metastatic in both sides.
Any indication for surgery???

Thank you for your help
Best

Andres Poveda


 
Response # 1:
Surgery will not help this patient, only systemic treatment.
 
How is the ER status?
 
Hormonal treatment may be an option.
 
In case of ER negative I would give palliative chemotherapy.
 
Best regards
 
Gunnar Kristensen
 
Response # 2:
With disease confined to pelvis, I would certainly consider Anterior Exenteration with continent conduit and vaginal reconstruction using a myocutaneous flap. One could try to salvage bladder and posterior vaginal wall, but I would be concerned about 1) recurrence and 2) bladder dysfunction because of extensive mobilization.
 
William J Hoskins
 
Response # 3:
Chemotherapy and exenteration (preferred choice)  or exenteration followed by chemotherapy are the only options in my view

Nick Reed
 

Response # 4:
Yes.  For a young woman with no known metastatic disease, I think exenterative surgery may be indicated.

Dave Gaffney
 

Response # 5:
Surgery alone for recurrent vaginal tumor and bilateral inguinal nodes would be very morbid and would still require post operative radiotherapy (leading to further morbidity)  for it's long term control.

I would use concurrent cis platin (40 mg...al la cervix protocol), use a combination of electrons (for inguinal nodes) and involved field photon EBRT with 2 cm margin around vaginal disease and give about 45 - 54 in 1.8 Gy Fx to this volume matching with previous radiotherapy field etc. Would accept overlap in vaginal field. In short to medium term this will be the least toxic and best palliation available to her. If inguinal disease remains under control for the next 2 years (she seem to have indolent disease), she may well recur in vagina and if that be the only site of disease at that time, then exentration at that time could be considered.

Presently, surgery done with a curative intent would require ant exent. and bilateral groin dissection which will be very morbid and still would not guarantee cure. I have seen patients cured with ant exent but never seen gross bilateral nodal disease being cured by surgery alone!
 
Regards,
Kailash Narayan
 

Response # 6:
 
We just discussed a rather similar patient in our hospital and decided, because of the lymphogene spread not to start an excenterative procedure.

Regards,
Els Witteveen