The tell-tale heart: A case of recurrent vulvar carcinoma with cardiac metastasis and review of literature

Biventricular cardiac metastasis from vulvar squamous cell carcinoma

Vulvar cancers make up just 3% to 5% of all gynecological cancers, and they are most typically found in postmenopausal women. Vulvar cancer distant metastases are uncommon and usually arise late. Only six cases of vulvar cancer metastasizing to the heart have been reported in the literature, and none of them included both the left and right ventricles. We describe the case of a 68-year-old patient diagnosed with vulvar cancer arising from lichen sclerosus, initially localized, treated with chemotherapy, surgery, and radiation therapy. Less than two months after the end of the treatment sequence, the patient returned to our clinic with bone pain. Imaging investigations have shown multiple disseminated metastases, but not in the heart at that moment. Chemotherapy was initiated, and after two cycles, the patient developed an arrhythmia (atrial fibrillation with rapid ventricular rate), which was later determined to be caused by cardiac metastases discovered by echocardiography and computed tomography. Vulvar cancer metastatic to the heart represents a rare clinical condition, requiring multidisciplinary care. The case's uniqueness is the biventricular metastasis, which resulted in STEMI despite angiographically normal epicardial coronary arteries

What to do when nothing else is left to be done - metastatic non-HPV vulvar squamous cell carcinoma with multiple lines of chemotherapy

Recurrent vulvar squamous cell carcinoma with multiple site metastases is a rare entity – (up to 14.2% of the total number of recurrences), with a poor prognosis (only 15% of the patients alive at 5 years). Due to its “hard to find” character, there are no standardized guidelines available and the treatment is extrapolated from advanced cervical carcinoma, anal carcinoma and other squamous cell carcinomas. Immunotherapy has shown some positive results in vulvar carcinoma with PD-L1 positive, high TMB, high MSI or with MMR deficiency. An alternative for selected cases without therapeutic resources could be the HPV vaccine. We present the case of a 64-year-old woman diagnosed in 2014 with vulvar squamous cell carcinoma stage II for which she underwent radical vulvectomy with bilateral inguinal lymphadenectomy followed by external radiotherapy. In 2019 she developed local recurrence associated with lung, pleural, lymph nodes and subcutaneous metastasis, treated with three lines of chemotherapy: paclitaxel/carboplatin followed by cisplatin/5-fluorouracil and carboplatin/gemcitabine. The patient’s general health status altered progressively, and she died after the 4^th cycle of carboplatin/gemcitabine. This case’s management could be a starting point for the vulvar carcinoma cases where the standard therapeutical options do not represent a choice anymore, providing the necessary example on how to approach it.

A Case of Recurrent Vulvar Carcinoma With Cardiac Metastasis: Case Report and Review of the Literature

A 67-yr-old female patient was diagnosed with squamous cell vulvar carcinoma and treated with a radical vulvectomy and bilateral sentinel lymphadenectomy. Three months after the surgery, the patient presented with local recurrence and underwent surgical excision of the mass, followed by chemotherapy. Eight months later, the patient was admitted due to weakness and pleural effusion. The patient underwent a chest computed tomography and echocardiogram, which revealed a large mass in the right ventricle penetrating into the pericardium and an additional mass residing on the tricuspid valve. She underwent a pericardial biopsy, and the pathology revealed a moderately differentiated squamous cell carcinoma metastasis. The patient was admitted thereafter in the oncological department for additional chemotherapy treatment. Because of a rapid deterioration in the patient's condition, only palliative treatment was given, and the patient died shortly after. Secondary cardiac tumors are very rare and have not been extensively studied in oncology. Therefore, optimal management is not entirely clear. It is extremely rare for vulvar cancer to metastasize to the heart, and only a handful of cases have been reported in the literature.

Left-Sided Intracardiac Tumors in a Case of Widespread Vulvar Cancer

Metastatic cardiac tumors associated with gynecological malignancies are rare. This report describes the case of stage-4 vulvar carcinoma that metastasized to the left ventricle of the heart. (Level of Difficulty: Intermediate.)

HPV16 viral characteristics in primary, recurrent and metastatic vulvar carcinoma

Vulvar carcinoma is the fourth most common gynecological malignancy. Two separate carcinogenic pathways are suggested, where one is associated with the human papillomavirus (HPV) and HPV16 the most common genotype. The aim of this study was to evaluate HPV-markers in a set of primary tumors, metastases and recurrent lesions of vulvar squamous cell carcinomas (VSCC). Ten HPV16-positive VSCC with metastatic regional lymph nodes, distant lymphoid/hematogenous metastases or local recurrent lesions were investigated for HPV genotype, HPV16 variant, HPV16 viral load, HPV16 integration and HPV16 E2BS3 and 4 methylation. In all 10 analyzed case series, the same HPV genotype (HPV16), HPV16 variant and level of viral load were detected in all lesions within a patient case. Primary tumors with a high E2/E6 ratio were found to have fewer vulvar recurrences and/or metastases after diagnosis and treatment. Also, a significantly lower viral load was evident in regional lymph nodes compared to primary tumors. The data presented strengthens the evidence for a clonal HPV-induced pathway for vulvar carcinoma.