Treatment of Cervical Cancer Complicated by Advanced Pelvic Organ Prolapse: A Case Based Review

Objectives: Concurrent cervical cancer with advanced pelvic organ prolapse (POP) is a rare occurrence and data are limited to guide management. Human papillomavirus (HPV) independent cervical cancer is also rare and less is known about the pathophysiology but it is hypothesized that chronic irritation, as with longstanding POP, may lead to malignant changes. The multidisciplinary care of two such cases is presented.

Methods: Two patients were referred to gynecologic oncology with cervical squamous cell carcinoma (SCC). Treatment planning was complicated by procidentia in both cases. Traditionally, primary radiation therapy (RT) with sensitizing chemotherapy would have been recommended for stage IB3 SCC. However, given mobility and externalization of target lesions, the potential for lack of anatomic reproducibility during treatment made RT less desirable. Therefore, these cases were reviewed in a multidisciplinary tumor board and referred to urogynecology for concurrent surgical treatment options. Both patients' preoperative PET scans were negative for nodal or distant metastases. Subsequently, they were treated by a multidisciplinary team (gynecologic oncology, urogynecology, radiation oncology) with primary surgical intervention. Due to negative radiologic evaluation and expected prolonged surgical time, lymphadenectomy was deferred for both patients. In planning for reconstruction, special consideration was taken accounting for each patient’s health status, preferences, desired sexual function, and possible future radiation.

Results: The first patient with >10 year history of POP and 5cm cervical mass was diagnosed with HPV-independent stage IB3 SCC (Table). Adjuvant RT was discussed as the patient did not have a surgical lymph node assessment, although preoperative PET was negative for metastasis. She elected to have adjuvant RT. The second patient with a >10 year history of POP and 7cm cervical mass was also diagnosed with HPV-independent stage IB3 SCC (Table). Adjuvant RT was recommended due to close margin (0.1mm) on final pathology. Both patients experienced postoperative urinary dysfunction. After failing voiding trials prior to hospital discharge and on postoperative day seven, both patients were instructed on clean intermittent catheterization (CIC) and continued to require some degree of CIC at twelve-week follow-up. Voiding dysfunction was felt to be multifactorial due to duration/degree of prolapse, radical hysterectomy, and extent of vaginal reconstruction. Both patients' 3-month post-RT PET scan and examination showed no evidence of disease and they were voiding spontaneously at 1-year follow up.

Conclusions: The development of HPV independent cervical SCC may be due to chronic mucosal irritation from long duration of POP as seen in these cases. This suggests that POP may have both contributed to and complicated the pathogenesis and management in these cases. Though rare, these case reports demonstrate the importance of multidisciplinary coordination in these complex clinical scenarios. This report adds to the body of knowledge around care and treatment planning for cervical cancer in the setting of advanced POP.