Multidisciplinary Approach Enables Aggressive Treatment for Rare, Locally Advanced Cloacal Cancer

When a young patient with a rare congenital cloacal anatomy developed an aggressive cancer, the complexity of her disease required an equally comprehensive treatment strategy. A multidisciplinary team performed a pelvic exenteration — a form of multivisceral resection — to achieve complete tumor resection and provide the best opportunity for long-term disease control.

The case highlights the role of aggressive, multivisceral resections in carefully selected patients with locally advanced, non-metastatic cancers where achieving clear margins requires removal of multiple organs or surrounding structures. While highly complex, these procedures can offer a potentially curative approach for patients whose cancers cannot be adequately addressed with standard surgical strategies.

A unique presentation requiring advanced surgical planning

The patient was born with a cloaca, a congenital condition in which the vagina and rectum are fused into one opening. Throughout her life, she underwent multiple procedures to address the condition. The patient was diagnosed with advanced mucinous adenocarcinoma, an aggressive cancer subtype that can be particularly challenging due to its pattern of local spread.

“Mucinous adenocarcinomas can be particularly aggressive locally because the cancer produces mucous material that spills into surrounding tissue,” says Haniee Chung, MD, a colorectal surgeon at Cleveland Clinic.

Given the extent of disease, Dr. Chung performed a pelvic exenteration alongside reconstructive urologist Hadley Wood, MD. In this patient’s case, the procedure involved removing the involved pelvic structures, including the rectal and vaginal tissue affected by the tumor, as well as portions of bowel that were attached to the cancer.

Following removal of the tumor and involved tissues, plastic surgeon Steven Schulz, MD, reconstructed the patient’s perineum. Because pelvic exenteration can leave a significant defect, reconstruction often requires bringing healthy tissue into the area to close the defect for wound healing .

A central goal of pelvic exenteration is achieving an R0 resection, meaning all visible and microscropic cancer is removed with negative margins. In this case, the patient’s tumor involved surrounding structures, including portions of bowel that required removal. The surgical team also removed additional tissue for margins after the primary tumor was excised to ensure no residual disease remained.

“Basically, anything touched by the cancer that can safely be removed has to be removed,” Dr. Chung says.

Although the additional margins were negative, the team remained concerned about microscopic disease because the cancer had perforated. Radiation oncology was involved shortly after surgery, and the patient underwent postoperative radiation therapy.

“When cancer perforates, all bets are off,” Dr. Chung adds. “You can remove as much as you possibly can that is visible, but you might be leaving microscopic disease behind.”

Recovery and continued surveillance

Despite the complexity of the procedure, the patient recovered well after surgery. She required one additional operation for bowel-related issues but was able to leave the hospital approximately one week later without requiring rehabilitation or nursing care.

“She looked amazing immediately post-op,” Dr. Chung says. “She was able to get on to radiation treatment a few weeks post-op, which is pretty remarkable as far as how she recovered.”

The patient continues to undergo close surveillance because of the aggressive nature of her disease. While she has experienced complications related to radiation therapy that require additional management, there is currently no evidence of cancer recurrence.

“She is an incredibly inspiring patient, not only because of what she has been through, but because of the way she has faced it,” Dr. Chung shares.

Coordination across specialties is critical

Although this patient’s anatomy made the case especially uncommon, the broader principles apply to other patients being treated for locally invasive cancers, including colorectal, gynecologic, urologic and musculoskeletal malignancies involving the pelvis.

According to Dr. Chung, successful outcomes depend on early multidisciplinary collaboration, particularly because these operations often require multiple surgical teams working together. “One of the keys is getting the radiation oncologists and medical oncologists on board early to have discussions about whether a patient is a candidate for preoperative treatments before we even get to surgery. We rely heavily on our diagnostic colleagues in Pathology and Radiology, as well,” she says.

Planning among surgical teams is equally important. Depending on the organs involved, procedures may require colorectal surgeons, urologists, plastic surgeons, orthopedic oncologists and gynecological oncologists.

“It is also important to have really good communication between the surgical teams because, oftentimes, we are either operating at the same time or we are having to coordinate the order of events in a long operation,” Dr. Chung notes.

Reducing operative time is another important consideration because of the complexity and potential morbidity associated with these procedures. “Trying to minimize time in the operating room really comes down to good communication between surgeons and having a plan well ahead of the day of surgery to make sure everybody knows what they are doing and when,” she says.

The case underscores how coordinated, multidisciplinary care can expand treatment options for patients with some of the most challenging locally advanced cancers. Through careful patient selection, early planning and collaboration across specialties, surgical teams can tailor treatment strategies to each patient’s unique disease presentation and pursue the most effective approach for achieving durable outcomes.