Report

True vaginal metastasis of rectal cancer

G. Yagci, S. Cetiner, M. Dede1, O. Gunhan2
Departments of Surgery, 1Gynecology Obstetrics and 2Pathology, Gulhane Military Medical Academy, Etlik, Ankara, Turkey
For correspondence:
G Yagci, Department of Surgery, Gulhane Military Medical Academy, Etlik 06018, Ankara, Turkey. E-mail: gyagci@gata.edu.tr

Case

ABSTRACT
Vaginal metastasis from colonic cancer is an extreme case and often indicates a poor prognosis. More
frequently tumor cells from the colonic lesions spread out to vagina by direct contiguous way. We
present a case of rectal carcinoma with true metastasis to the vagina that was discovered after an
interval of 15 mounts when vaginal bleeding and discharge became evident. To our knowledge, there
are only a few other papers in the English language previously documenting this phenomenon.
Key words: Adenocarcinoma, rectal neoplasms, vaginal neoplasms
How to cite this article:
Yagci G, Cetiner S, Dede M, Gunhan O. True vaginal metastasis of rectal cancer. Indian J Surg 2005;67:270-2.

The first document in the literature regarding

to vaginal metastasis of colorectal cancer was
reported by Whitelaw[1] in 1956 when a vagi
nal lesion was found to be adenocarcinoma.
Further investigation of the patient showed
that primary tumor was originated from a mid
sigmoid tumor. In 1966, a series of four cases
of remote vaginal metastases from colonic car
cinoma was presented by Raider.[2] These le
sions were found between 4 and 41 months
after the initial colonic resection. In three of
the four cases other sites of metastasis were
also present with overall survival in these cases
being less than 40 months. Since that time,
however, there is only one other documented
report of this interesting phenomenon was
presented by Chagpar and Kanthan.[3] We re
port a rectal carcinoma case with true metas
tasis to the anterior wall of vagina.

CASE HISTORY
Fifty-four-year-old woman presented to our
clinic with left lower abdominal pain, rectal
bleeding, weight loose, night sweets and diz
ziness. She had no previous history of medi
cal illness. Physical examination revealed a
soft abdomen with a slightly tenderness in left
lower quadrant. Flexible recto-sigmoidoscop
ic examination showed a fragile tumor mass
Paper Received: March, 2005. Paper Accepted: April, 2005.
Source of Support: Nil.

270
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at 15 cm. And biopsy result of this lesion reported as

adenocarcinoma with high mitotic activity and signif
icant pleomorphism. Subsequent CT scan of the ab
domen and ultrasound demonstrated a surface-seated
liver nodule with diameters of 4.24.5 cm in segment
8 and a second small nodule in left lobe of liver with
diameters of 2.82.4 cm both showing target sign. In
the pelvic sections, there was thickening in the bowel
wall beginning from rectosigmoid junction.
Blood samples for tumor markers showed ten times
fold in CA-19-9 and three times fold in CEA levels.
Laparotomy with low anterior resection and tumorec
tomy of metastatic lesions in liver was performed. Post
operative period was uneventful and she was dis
charged without any complication. Pathology con
firmed a poorly differentiated adenocarcinoma of the
rectum invading the whole thickness of the bowel wall
with surrounding fatty tissue. Tumor was 2.5 cm in
diameter in the largest section invading a 6-cm long
bowel segment. The specimen was tumor free in both
resection borders. Tumor showed both lymphatic and
vascular invasion and two out of ten lymph nodes were
attacked by tumor cells. The patient was accepted as
stage-IV rectum carcinoma and given six cycles of post
operative adjuvant chemotherapy by Oncology depart
ment with 5-FU plus calcium leucovorin periodically.
During the follow-up period, she was admitted with
3 months intervals for the first year. Approximately
13 months after her first surgery, she came with bloody
vaginal discharge and pelvic examination confirmed a
3 x 5 cm friable mass in the anterior wall of vagina
[Figure 1]. Bimanual pelvic examination revealed that
Indian J Surg | October 2005 | Volume 67 | Issue 5

Remote vaginal metastases from rectal cancer

vulva, cervix, uterus and bilateral adnexal structures

are normal. Speculum examination showed a polypoid
mass 2 x 3 cm in diameter on the anterior wall of
vagina at fifth centimeter. Transabdominal pelvic ul
trasound reported that the uterus was
34 x 37 x 41 cm in diameter, with homogeneous
myometrium, indistinct endometrial echo pattern and
bilateral adnexal areas were normal.

only for approximately one percent of all malignant

neoplasms of the female genital tract. Squamous cell
carcinoma represents about 80% of malignant neo
plasms primary to the vagina. Although primary neo
plasms of the vagina are quite rare, secondary spread
of malignant neoplasms to the vagina by direct exten
sion or lymphatic or hematogenous metastasis is quite
common.[4]

Incisional biopsy was performed and reported as met

astatic infiltration of poorly differentiated adenocarci
noma. The histological appearance of the tumor was
similar to rectal carcinoma, which was diagnosed pre
viously in the patient [Figure 2]. The patient was then
treated with intracavitary radiation and chemothera
py for the control of bleeding.

Development of adenocarcinoma of the vagina in young

women has been reported associated with maternal
ingestion of diethylstilbestrol in utero with a rising
incidence. These women should be examined regular
ly after menarche for prompt evaluation and treatment
of precancerous lesions such as adenosis, cervical ero
sion or transverse ridges. Since most of these patients
are young, a conservative treatment is recommended.
Primary vaginal adenocarcinoma unrelated to intrau
terine hormone exposure is very uncommon.[5,6]

DISCUSSION
Primary malignant vaginal tumors are rare and account

Secondary vaginal adenocarcinoma represents 2.6%

of all gynecological adenocarcinomas while 92.5% of
apical lesions were metastasized from the upper geni
tal tract, and 90.0% of the posterior lesions were from
the gastrointestinal tract. About two-thirds of recur
rences or metastases were reported after removal of
primary lesions, and 80.8% occurred within first
3 years.[7]

Figure 1: Speculum examination in genu-pectoral position showed

a friable mass in the anterior wall of the vagina

Fu and Reagan found that only 58 (16%) of 355 inva

sive carcinomas involving the vagina represented pri
mary neoplasms. Spread from primary carcinoma of
the cervix was most common (32%), followed by en
dometrium (18%), colon and rectum (9%) ovary (6%),
vulva (6%), and urinary tract (4%). Even among the
squamous carcinomas found in the vagina, only a mi
nority prove to be primary to this side. About 75% are
secondary, arising in either cervix (79%) or vulva
(14%). Generally the vagina is a site for metastases from
other areas of the female genitourinary tract.[8]
Other miscellaneous tumors that have been found to
have vaginal metastases include adenocarcinoma of
pancreas, trophoblastic neoplasms, and tumors of the
urinary tract.[912]

Figure 2: Low differentiated adenocarcinoma consisted of

pleomorphic atypical epithelial cells with superficial ulceration.
Slide does not contain normal vaginal mucosal tissue. HE x 100

Indian J Surg | October 2005 | Volume 67 | Issue 5

When direct contiguous spread is not the case, it is

speculated that remote vaginal metastasis may occur
either through lymphatic or hematogenous routes.
Lymphatics from the sigmoid may carry metastasis to
the iliac and hypogastric nodes where there could be
retrograde spread to the periurethral area and anterior
vaginal wall. Alternatively venous channels may al
low the tumor emboli to pass from the colon to the
ovarian plexus or parametrial veins and then on to the
vaginal veins.
Disseminated metastatic disease is frequently present
271

Yagci G, et al.

in patients with vaginal metastases and the prognosis

is extremely poor in these patients. In three of the four
patients reported by Raider, there was evidence of
widespread metastatic disease. In these patients over
all survival ranged from 10 to 39 months after the di
agnosis of vaginal metastasis. The one case that had
no other metastatic involvement, however, remained
alive and well 48 months after the vaginal lesion was
treated with intracavitary radiation.[2]
Although it is frequently associated with primary vag
inal tumors, vaginal bleeding or discharge might be
the first clinical manifestations of an occult carcino
ma or clinical signs of a widespread metastatic dis
ease. We present a case of rectal carcinoma with true
metastasis to the vagina that was discovered after an
interval of 15 mounts when vaginal bleeding and dis
charge became evident. Intracavitary radiation and
chemotherapy was effective for the control of bleed
ing whereas angiographic embolization may be emerg
ing as a successful procedure to control the severe
hemorrhage.

REFERENCES
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272

Whitelaw GP LSPLSRP. Carcinoma of large bowel with

metastasis to genitalia: Report of two cases. AMA Arch Surg

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2. Raider L. Remote vaginal metastases from carcinoma of the
colon. Am J Roentgenol Radium Ther Nucl Med 1966;97:944
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3. Chagpar A, Kanthan SC. Vaginal metastasis of colon cancer.
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Robert J Kurman, editor. Blausteins Pathology of the Female
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8. In: Fu YS, Reagan JW, editors. Pathology of the uterine cervix,
vagina, and vulva. Philadelphia: Saunders; 1989.
9. Weitzner S, Dressner SA. Vaginal metastasis from
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10. Yingna S, Yang X, Xiuyu Y, Hongzhao S. Clinical characteristics
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11. Sogani PC, Whitmore WF, Jr. Solitary vaginal metastasis from
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