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Research Article: Clinical Case Report

Primary vaginal squamous cell carcinoma with bladder involvement in uterine prolapsed patient

Case report

Fedus, Tadeusz MDa; Raś, Renata PhDb; Książek, Mariusz MDc; Filipowska, Justyna MDd; Kaznowska, Ewa MDc; Skręt, Andrzej MDb; Skręt-Magierło, Joanna MDe; Barnaś, Edyta PhDe,*

Editor(s): NA.,

Author Information
doi: 10.1097/MD.0000000000008993
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1 Introduction

Vaginal carcinoma is considered the rarest gynaecological neoplasm, accounting for only about 1% to 3% of all gynaecological malignancies.[1,2] Vaginal carcinoma with prolapse is very rare, but in elderly women 13.6% to 16.3% of total vaginal cancer coexist with prolapse.[3]

Some authors report the metastases of vaginal cancer coexisting with prolapse to the chest, nodes, liver, iliac bone.[3,4]

To the best of authors’ knowledge, there is no case description with bladder involvement.

The aim of this report is to present the case of primary vaginal squamous cell carcinoma (SSC) with bladder involvement in uterine prolapse.

2 Case report

A 69-year-old patient (G6 P6) (height, 155 cm; weight, 66 kg) reported vaginal prolapse for several years and incontinence, abdominal pain and hematuria. Comorbidities: type 2 diabetes for 20 years, circulatory failure, paroxysmal atrial fibrillation, anaemia, urinary tract infection, hypertension, chronic biliary gastritis, cervical osteoarthritis.

Physical examination on admission revealed anterior vaginal and uterine walls prolapse, with 8 cm in diameter large ulcerated lesion (Fig. 1) located on the anterior vaginal wall. Diagnostic biopsy of the lesion revealed squamous cell carcinoma (Fig. 2).

Figure 1:
Irreducible vaginal prolapse with vaginal squamous cell carcinoma. Ulcurated lesion involving almost entire anterial vaginal wall.
Figure 2:
Surgical diagnostic biopsy of prolapsed vagina: well-differentiated keratinizing squamous cell carcinoma of vagina (H&E, objective ×20).* keratin pearl formation in SCC.

Additional tests: hemoglobin 11.0 g/dL (12.0–16.0); hematocrit 33.9% (37.0–47.0); erythrocytes 4.34 × 106/uL (4.00–5.00); MCV 78.1 fL (80–94); MCH 25.3 pg (27.0–31.0); MCHC 32.4 g/dL 931.0–37.0); RDW-SD 48.3 fL (36.4–46.3); RDW-CV 17.7% (11.7–14.4); Blood Plate 296 × 103/Ul (140–400); plate distribution width (PDW) 11.6 fL (9.80–16.20); MPV 9.8 fL (9.40–12.50); platelet large cell ratio (P-LCR) 24.1% (19.10–46.60); WBC 8.12 × 103/ul (4.0–10.0); Macro R 6.7%; Micro R 7.9%; total protein 7.1 g/dL (range 6.3–8.2); chlorides 112.0 mmol/L (98.0–107.0); activated partial thromboplastin time (APTT) 29.0 s (25.9–36.6); prothrombin time 9.2 s (7.6–11.4); Prothrombin index 103.7% (80.0–120.0); INR 1.0 (0.9–1.3); D-dimer 2 208.8 ng/mL (<500.0); fibrinogen 503.9 mg/dL (180.0–400.0); glomerular filtration rate (GFR) 27 mL/min/1.73 m2 (>60.0); glucose 115 mg/dL (70–99); creatinine 1.85 mg/dL (0.52–1.04); urea 66 mg/dL (15–43); potassium 4.9 mmol/L (3.5–5.1); sodium 144.0 mmol/L (137.0–145.0); TSH 0.50 uIU/mL (0.27–4.20).

Sagittal pelvic CT showed protruded vagina, infiltrated bladder wall, uterus, and rectum. In frontal CT scan of abdomen, enlarged pelvic iliac nodes, hydronephrosis of the left kidney with left hydroureter, in the right kidney nephrostomic catheter were observed (Fig. 3).

Figure 3:
Sagittal pelvic computed tomography of the patient. In protruded vagina: bladder—B, rectum—R, carcinomatous ulceration—CU, uterus—U. Abdominal and pelvic frontal CT. PV—protruded vagina, LN—enlarged iliac nods, H—left kidney with hydronephrosis, C— nephrotomic catheter in right kidney.

Cystoscopy-mucosal lesions were found in the bladder (Fig. 4). The diagnostic biopsies were collected from the urethra and the bladder (Fig. 5).

Figure 4:
The bladder wall infiltrated by squamous cell carcinoma (cystoscopic view).
Figure 5:
H&E, objective ×10. This diagnostic bladder biopsy shows unremarkable urothelial epithelium (top) with underlying, within submucosa, well-differentiated squamous cell carcinoma (buttom). Well-defined vascular invasion is seen.

Symptomatic treatment included: InsulinueGensulin R t.i.d. (2–6 units)sc, Amlodypinum 2 × 10 mg, 0.9%NaCl 2 × 500 ml iv., Clexan (Enoxaparinumnatricum) 2 × 0.6 sc, Ramiprilum 5 mg 1 × 1, Captoprilum 25 mg 1 × 1.

The patient was disqualified from surgery due to the severity of the disease, lymph node metastases, and coexisting comorbidities. Only palliative nephrostomy was performed.

The patient signed informed consents. In our case the patient accepted regular and proved diagnosis and therapy in Clinical Department of Urology, so the ethical approval was not necessary.

3 Discussion

The paper presents the vaginal cancer coexisting with ICS-IV prolapse in a 69-year-old woman. Other papers described vaginal carcinoma with coexisting prolapse stage III in ICS in 15 cases, while stage IV only in 3 cases. The age of the patients in 19 described cases was 44 to 83 years. The data from the literature is presented in Table 1.[1,3–14,15] In the available papers, only 3 publications reviewed the literature: both Ghosh and Wang analyze data from 5 papers,[10,13] while Kowalski analyzes 8 papers.[14] In the presented case bilateral hydronephrosis occurred. According to the literature, hydronephrosis may be due to profound static disorders.[16–19] In 5 papers (6 cases) of vaginal cancer and prolapse, hydronephrosis was also reported.[1,3–5,15] In our case, bladder involvement was diagnosed on the basis of the diagnostic biopsies collected in the cystoscopy. Bladder involvement in vaginal cancer qualifies the case as stage IVa FIGO.[20] In the studies on vaginal carcinoma without prolapse, the incidence of stage IVa is only estimated at 8.98%.[20] In our case, as in Sonkusare's case,[6] kidney failure has occurred. According to the author, this failure was due to prolonged prolapse and inferior obstruction.[6] In our case, the diabetologist suspected that renal failure was associated with diabetes, in the case described by Sonkusare diabetes was present, as in the present case, for more than 20 years.[6]

Table 1:
Review of the literature on vaginal cancer with pelvic organ prolapse.

In the presented case, squamous cell carcinoma was found in both vaginal and bladder wall specimens. Interestingly, the cases of reversed metastases from urogenital bladder cancer to the vagina have been reported in the literature.[21–26]

Considering the cause of hydronephrosis, the lower obstruction may be due to bladder involvement. Obstructions of this type are found in cervical carcinoma, where hydronephrosis qualifies cervical cancer cases to stage III FIGO.[27] Perhaps in our case this hydronephrosis may be caused by parallel bladder infiltration and prolapse. It cannot be ruled out that diabetes was involved in the development of renal failure.

Literature provides a variety of treatment options for vaginal cancer with prolapse including surgical treatment, radiotherapy, and palliative treatment (Table 1). It should be emphasized that radiotherapy alone in such cases is associated with the complications due to the exposure of hernia to radiation. Rao reports 2 cases of vesicovaginal fistula after radiotherapy,[3] while Howat describes the case in which stoma was necessary after radiotherapy.[7] Among the patients treated surgically, hysterectomy with adnexa and extensive vaginal excision was performed (Table 1).

In the present case due to the advanced stage, accompanying diseases, metastases, the usual, surgical treatment was abandoned and only palliative nephrostomy was used. In the literature only two cases were limited to palliative treatment.

4 Conclusion

In the case of coincidence of vaginal cancer and prolapse, there is possibility of bladder involvement and cystoscopic evaluation should be considered.

Coexisting hydronephrosis may be a result of prolapsed and/or bladder involvement.


[1]. Begum S, Akhter R, Begum K. Primary vaginal carcinoma, tales of tragedy: case report. Chattagram Maa-O-Shishu Hospital Med Coll J 2013;12:64–6.
[2]. Rajaram S, Maheshwari A, Srivastava A. Staging for vaginal cancer. Best Pract Res Clin Obstet Gynaecol 2015;29:822–32.
[3]. Rao K, Kumar NP, Geetha AS. Primary carcinoma of vagina with uterine prolapse. J Indian Med Assoc 1989;87:10–2.
[4]. Kim HG, Song YJ, Jin Y, et al. A case of vaginal cancer with uterine prolapse. J Menopausal Med 2013;19:139–42.
[5]. Gupta N, Mittal S, Dalmia S, et al. A rare case of primary invasive carcinoma of vagina associated with irreducible third degree uterovaginal prolapse. Arch Gynecol Obstet 2007;276:563–4.
[6]. Sonkusare S, Shetty VJ, Harikumar S, et al. Primary vaginal cancer complicating massive uterine prolapse: a case report. J Cases Obstet Gynecol 2016;3:92–5.
[7]. Howat JM, Stassan L, Mohandas I, et al. Carcinoma of the vagina presenting as a ruptured procidentia with an entero-vaginal fistula and prolapse of the small bowel. Postgrad Med J 1984;60:435–6.
[8]. Berthelsen HG. Vaginal carcinoma associated with total prolapse; report of a case. Acta Obstet Gynecol Scand 1957;36:257–61.
[9]. Iavazzo C, Vorgias G, Vecchini G, et al. Vaginal carcinoma in a completely prolapsed uterus. A case report. Arch Gynecol Obstet 2007;275:503–5.
[10]. Ghosh SB, Tripathi R, Mala YM, et al. Primary invasive carcinoma of vagina with third degree uterovaginal prolapse: a case report and review of literature. Arch Gynecol Obstet 2009;279:91–3.
[11]. Batista TP, Morais JA, Reis TJ, et al. A rare case of invasive vaginal carcinoma associated with vaginal prolapse. Arch Gynecol Obstet 2009;280:845–8.
[12]. Kumar V, Ratna B. Primary vaginal carcinoma of lower one-third of posteriori vagina associated with third-degree prolapse: a rare case. J Obstet Gynecol India 2013;63:356–8.
[13]. Wang Y, Li Q, Du H, et al. Uterine prolapse complicated by vaginal cancer: a case report and literature review. Gynecol Obstet Invest 2014;77:141–4.
[14]. Kowalski J, Savage J, Bradley CS. Vaginal cancer in patient presenting with advanced pelvic organ prolapse: case report and literature review. Proc Obstet Gynecol 2015;5:3.
[15]. Karateke A, Tugrul S, Yakut Y, et al. Managment of case of primary vaginal cancer with irreducible Massie uterine prolapse: a case report. Eur J Gynaecol Oncol 2006;27:528–30.
[16]. Begliomini H, Begliomini BD. Bilateral hydronephrosis caused by vaginal prolapse. Int Braz J Urol 2003;29:243–4.
[17]. Constantini E, Lazzeri M, Mearini L, et al. Hydronephrosis and pelvic organ prolapse. Urology 2009;73:263–7.
[18]. Wee WW, Wong HF, Lee LC, et al. Incidence of hydronephrosis in severe uterovaginal or vault prolapse. Singapore Med J 2013;54:160–2.
[19]. Miyagi A, Inaguma Y, Tokoyoda T, et al. A case of renal dysfunction caused by pelvic organ prolapse. CEN Case Rep 2017;6:125–8.
[20]. Beller U, Benedet JL, Creasman WT, et al. Carcinoma of the vagina. FIGO 26th Annual Report on the Results of Treatment in Gynecological Cancer. Int J Gynaecol Obstet 2006;95(suppl 1):S29–42.
[21]. Kumar R, Kumar S, Hemal AK. Vaginal and omental metastasis from superficial bladder cancer. Urol Int 2001;67:117–8.
[22]. Mondaini N, Giubilei G, Raspollini MR, et al. Recurrence of vaginal implantation of transitional cell carcinoma of the urinary tract. Gynecol Oncol 2005;97:669–70.
[23]. Ohgaki K, Horiuchi K, Oka F, et al. vaginal metastasis of urothelial carcinoma fund incidentally Turing transurethral resection of bladder tumor. J Nippon Med Sch 2008;75:312–5.
[24]. Kaneko G, Kikuchi E, Hasegawa M, et al. Non-muscle invasive bladder cancer with concominant vaginal urotherial carcinoma: a case report and review of the literature. Int J Clin Oncol 2010;15:626–30.
[25]. Reyes MC, Park KJ, Lin O, et al. Urothelial carcinoma involving the gynecologic tract: a morphologic and immunohistochemical study of 6 cases. Am J Surg Pathol 2012;36:1058–65.
[26]. Aoun F, Kourie HR, El Rassy E, et al. Bladder and vaginal transitional cell carcinoma: a case report. Oncol Lett 2016;12:2181–3.
[27]. FIGO Committee on Gynecologic Oncology. FIGO staging for carcinoma of the vulva, cervix, and corpus uteri. Int J Gynaecol Obstet 2014;125:97–8.

bladder involvement; uterine prolapsed; vaginal cancer

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