Delayed Recurrence of Cervical Cancer After Radical Hysterectomy for Carcinoma In situ

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Cervical cancer is the leading gynecologic cancer in Taiwan. For the early stage of this cancer, aggressive treatment, i.e. radical hysterectomy, is performed with a very good prognosis. After years of promoting the necessity of Pap smear examinations, the early detection of high-grade squamous intraepithelial lesions (HSIL) has been made much easier, and the incidence of these cases has increased yearly. In this stage of disease, conservative treatment with a loop electrosurgical excision procedure (LEEP) or cold knife conization can eradicate the lesion successfully, with good control of the disease. However, 20–30 years ago, carcinoma in situ (CIS) was treated as an early stage of cancer, and simple abdominal hysterectomy, or even radical hysterectomy with pelvic lymph node dissection, was sometimes performed. Logically, it should result in a complete cure. However, we have a patient who had a recurrence of cervical cancer 27 years after an extended operation. This case is described below. A 71-year-old woman, gravida 6, para 4, abortus 2, was admitted to our hospital in November 2006 because of the finding of a vaginal cuff mass. This patient’s medical history revealed that she underwent a radical hysterectomy, bilateral salpingo-oophorectomy and bilateral pelvic lymph node dissection for cervical CIS at Taipei Medical University Hospital 27 years previously. After that, she received regular gynecologic follow-up. Her latest Pap smear was done at Mackay Memorial Hospital in December 2005, with normal cytopathologic findings. However, she had a small amount of whitish vaginal discharge for 1 month, but no unpleasant scent, bloody discharge or bowel/urinary problems were noted. By colposcopic examination, a vaginal cuff mass measuring about 2 cm in diameter was found. A vaginal cuff biopsy was done, revealing the presence of squamous cell carcinoma. Hence, with a diagnosis of vaginal cuff carcinoma and possible recurrence of her cervical cancer, she was admitted for further cancer work-up. Pelvic magnetic resonance image, cystoscopy and rectoscopy were performed. No bladder or rectal invasion was noted, but two ovoid, enhanced, welldefined solid tumors of 3.5 cm and 4.5 cm were located between the urinary bladder and rectum, in the left pelvic cavity. Laparotomy with partial vaginectomy for excision of the mass in the vaginal cuff was performed on November 16, 2006. The peritoneal cavity was explored thoroughly, and no metastatic tumor was found. The vaginal apex was exposed, and the mass was located at the vaginal apex, just between the bladder and the rectum. No serosal involvement was found (Figures 1 and 2). The whole mass with the surrounding tissue was grasped with Allis clamps and excised completely (Figure 3). The vaginal edges and the peritoneum were sutured with 2-0 Vicryl. After thorough hemostasis,