Description

Pelvic organ prolapse and carcinoma of the cervix are common entities but their association is rare. In more than 60% of the cases, the uterine prolapse is present for at least 10 years.1

The displacement of the uterine cervix from the natural environment of the vagina is thought to explain a lower risk of cervical cancer due to viral infection in uterine prolapse. Nevertheless, the continuous injury of the cervical epithelium may favour the neoplastic process.2 The best treatment approach in this clinical setting is not clearly defined and vary considerably among authors.3 We present a case of a 74-year-old woman, Gesta 3 Para 3, with a 9 years history of an uterine prolapse that presented in our department. The reasons for medical visit were the onset of vaginal bleeding and increasing genital prolapse size. The patient had no prior cervical cancer screening. Physical examination revealed a complete and irreducible fourth-degree urogenital prolapse with induration of the entire vaginal mucosa, inflammatory signs and ulcerated lesions that made impossible to clearly identify the cervix (figure 1). No evidence of bladder or rectum involvement were present. Biopsies were performed and histopathology revealed squamous-cell cervical carcinoma. A pelvic MRI described a fibromatous uterus measuring 15×7, 8×10 cm, large ptosis of the uterus and bladder, bilateral parametrial invasion and hydronephrosis (figure 2). CT of the thorax and abdomen revealed no distant metastasis. She was staged according to the 2009 International Federation of Gynecology and Obstetrics staging system as at least FIGO IIIA. Radiotherapy was considered but the risk of visceral injury was high due to the volume of externalised prolapse and associated cystocele. After a multidisciplinary board meeting, given the locally advanced stage, the volume of externalised prolapse and the poor clinical status, the patient was referred to end-life care measures, regarding her comfort. The patient underwent rapid deterioration of her general condition manifested by increasing asthenia, cachexia, nausea and vomiting episodes. One month after the initial presentation, the patient died.

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Figure 1

Complete genital prolapse and externalised cervix cancer of the case reported.

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Figure 2

Coronal (A), axial (B) and sagittal (C) T2-weighted images show massive anterior and middle compartment pelvic prolapse (cystocele, peritoneocele and utero-vaginal prolapse). Also note cervical tumour, better depicted in the coronal plane (asterisk in A) with extensive invasion of the vagina, better seen in sagittal postcontrast images (arrows in C and D). There is also bilateral ureteral dilatation (B) suggesting ureteric obstruction, most likely from the prolapse.