Our patient is a 52-year-old female, known to have hepatitis B, married with six children with a single history of cesarean delivery, and non-smoker. In March 2017, she started to notice weight loss, loss of appetite, and alteration in bowel habits associated with minimal bleeding per rectum. A colonoscopy was ordered by her primary care physician, which showed a mass at 12 cm from the anal verge. Eight months later, she was referred to King Hussein Cancer Center (KHCC) for further management. Initial laboratory results showed hemoglobin (Hb) 9.4 g/dl, platelet 397 103/µl, white blood cell count (WBC) 10.1 103/µl, creatinine 0.7 mg/dl, and carcinoembryonic antigen level 5.36 ng/ml. Her physical examination showed a soft lax abdomen without any lymphadenopathy, and upon digital rectal examination (DRE) a mass 7 cm from the anal verge was palpated. Magnetic resonance imaging (MRI) study showed circumferential wall thickening of the upper rectum, 13.5 cm proximal to the anal verge, the involved segment measured approximately 7.0 cm in length, with severe stranding of perirectal fat and possible infiltration of the anterior aspect of the mesorectal fascia. In addition to multiple enlarged lymph nodes within the perirectal and presacral spaces, and along the course of the right internal iliac vessels (Fig. 1). Computed tomography (CT) whole-body scan was negative for metastatic disease. After counseling the patient and her family, a multidisciplinary clinic (MDC) decision was to go for low anterior resection, being staged T3N2. Under general anesthesia and via a lower abdominal vertical incision, the peritoneal cavity was reached, and meticulous search for metastasis in the liver, mesentery, omentum, and peritoneal surfaces was negative. The sigmoid colon was dissected from its lateral peritoneal attachment, followed by ligation of the inferior mesenteric artery and preservation of the left colic artery. The tumor was found to be adherent to the posterior vaginal wall, which necessitated gentle shaving of the tumor without violating the vaginal entity. Colo-rectal end-to-end primary anastomosis via gastro-intestinal endostapler (GIE) was performed; hemeostasis was secured, followed by drain insertion, closure, and dressing. The patient was monitored in the intermediate care unit (IMU) for 24 hours postoperatively, and then was transferred to the surgical ward. On postoperative day 3, the patient reported passage of gas from the vagina, and with further questioning; she admitted to having this complaint even before the surgery.
Bedside speculum examination revealed a fungating mass 2 × 3 cm in the middle of the posterior vaginal wall, 4 cm from the introitus, not limited to the vaginal mucosa. A biopsy was taken, and it came back with a diagnosis of metastatic colonic adenocarcinoma, based on the morphology and immunohistochemical stains (positive staining for CDX2 and negative staining for PAX8), (Fig. 2). The patient was discharged home without any complications. Final histopathological analysis of the resected specimen confirmed the diagnosis of moderately differentiated adenocarcinoma, stating that the tumor is 2 mm away from the anterior circumferential margin involvement and with negative resection margins (R0). After two months, the patient followed up with the gynecology clinic at KHCC, where she was re-evaluated and informed about the need to perform a wide local excision of the posterior vaginal wall with a potential risk of anal sphincter injury. In late February of 2018, the patient underwent wide local excision of the posterior vaginal wall with primary repair, approximately a 2.5 × 1.5 cm lesion was completely excised. The patient was discharged home the following day without any complications, and after one month, was started on adjuvant chemotherapy (10 cycles of Oxaliplatin, Leucovorin, and 5-Fluorouracil) and radiotherapy (25 fractions, 5000 cGy). The patient continued with regular follow-up at our clinics, and her most recent imaging studies, two years postoperatively, showed complete disease remission and no complications.