Locally advanced cervical cancer in a transgender man

Abstract

A 45-year-old transgender man presented to a gynecologist with a 2-year history of dysfunctional uterine bleeding. Vaginal bleeding had been occurring daily, small to moderate in volume, with periods of heavier irregular bleeding occurring without precipitating or alleviating factors. Additional symptoms included suprapubic discomfort managed with acetaminophen. The patient had attributed the cause of the persistent bleed to previous exogenous testosterone used for his hormonal gender confirmation, which he had stopped 18 months before presentation. Constitutional symptoms included a weight loss of 4.5 kg in the 4 months before initial assessment. The patient had been told that he did not require screening for cervical cancer because he had never had penetrative sexual intercourse with a male. He had never been pregnant.Pertinent medical history included a surgery for a double mastectomy. A hysterectomy had been planned 1 year before presentation because of a uterine fibroid (3 cm in diameter) that was identified on ultrasonography; however, the patient decided not to undergo the procedure.A speculum examination showed an abnormal mass located at the cervix that easily bled. A Papanicolaou smear confirmed a high-grade squamous intraepithelial lesion suspicious for invasion. A mass in the bladder (2.2 × 2.1 × 2.1 cm 3 in size) was identified on ultrasonography. Examination under anesthesia with cystoscopy showed an abnormal mass in the bladder at the trigone that was obstructing the right ureter. Gynecologic examination showed a friable mass (4 cm in diameter) in maximal dimension that had entirely replaced the normal cervical tissue. Biopsies of the bladder mass, endometrium and cervix confirmed squamous cell cervical carcinoma. The patient was referred to a regional cancer centre for further management.Staging investigations included a computed tomography scan of the chest, abdomen and pelvis, which did not identify regional adenopathy or metastatic disease. There was severe right-sided hydronephrosis secondary to ureteric obstruction. Magnetic resonance imaging of the pelvis confirmed a cervical mass (3.4 × 3.3 × 2.4 cm 3 in size) with indistinct margins, parametrial involvement and invasion into the right posterior wall of the bladder (Figures 1 and 2). The mass abutted but did not invade the anterior rectal wall. Final disease staging was International Federation of Gynecology and Obstetrics stage IVA cervical cancer.We started curative intent treatment with external beam radiotherapy and concurrent weekly radiosensitizing cisplatin chemotherapy, followed by high-dose-rate intracavitary brachytherapy. After chemoradiotherapy, there was an excellent local response with no evidence of residual tumour. Our patient remains disease-free 6 months posttreatment with five years of surveillance planned. DiscussionPap smears represent a major public health advancement for the detection of gynecologic neoplasia; increased participation in screening has resulted in a drastic decline in the incidence of and mortality from...

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