Entero-Vascular Fistula Following Radiotherapy in a Patient with Recurrent Cervical Cancer Post-Pelvic Exenteration: a case report

Background Total pelvic exenteration (PE) is a surgical resection of all pelvic organs used as a palliative treatment for locally advanced or recurrent pelvic malignancies. This case report describes an entero-vascular fistula as a severe complication following radiotherapy in a patient with recurrent cervical cancer who underwent PE. Case presentation We present the case of a 47-year-old woman who was diagnosed with cervical cancer at the age of 43 years, classified as FIGO stage IIB. She underwent a radical hysterectomy followed by concurrent chemoradiotherapy (CCRT). In 2023, she developed a recto-urethral fistula and subsequently underwent PE. In March 2024, she was admitted for right buttock and leg pain. An evaluation revealed bone metastasis in the lumbar vertebrae, left iliac bone, and sacrum, for which local radiotherapy was administered. Later, she complained of bloody discharge from a sacral fistula and upper abdominal pain. Her blood pressure was 105/65 mmHg, heart rate 75 beats per minute (BPM), and hemoglobin level was 7.8g/dL, prompting an emergency blood transfusion. Abdomino-pelvic computed tomography (APCT) scan and esophagogastroduodenoscopy (EGD) revealed a large amount of bloody fluid in the stomach and suggested communication with the bowel loop. CT angiography showed contrast extravasation from the left external iliac artery and a large hematoma. A stent graft was inserted at the site of the entero-vascular fistula to achieve embolization. Conclusion This case highlights an entero-vascular fistula as one of the severe complications following PE and radiotherapy for recurrent cervical cancer. Patients who have undergone multimodal treatment, including PE, may have a pelvic condition that is more vulnerable to radiation. Therefore, the complications that may arise from radiation therapy, such as fistula formation, could be higher compared to patients who have not undergone PE.