The patient was born with a cloaca, a congenital condition in which the rectum, vagina, and urinary tract drain through a single opening. She had already undergone multiple procedures over her life to correct it. Then, while still young, she was diagnosed with advanced mucinous adenocarcinoma in that same reworked anatomy.
Cleveland Clinic surgeons described the case in the institution's clinical publication on Aug. 13. Treating her required a pelvic exenteration, a multivisceral resection in which surgeons remove the involved pelvic organs together rather than piece by piece.
Cloacal malformations are rare, occurring in roughly 1 in 50,000 live births and seen exclusively in females. Cancer arising later in that reconstructed anatomy is rarer still, and it strips away the landmarks surgeons normally rely on.
A Tumor Type That Spreads by Leaking
Mucinous adenocarcinoma is not simply an aggressive cancer. It is aggressive in a specific and inconvenient way.
"Mucinous adenocarcinomas can be particularly aggressive locally because the cancer produces mucous material that spills into surrounding tissue," said Haniee Chung, MD, the colorectal surgeon who performed the operation.
That behavior matters enormously in a pelvis where the urinary, reproductive and gastrointestinal systems already converge, and where a congenital malformation and years of reconstructive surgery have further scrambled the tissue planes.
Chung operated alongside reconstructive urologist Hadley Wood, MD. The team removed the rectal and vaginal tissue involved by the tumor along with portions of bowel that had become attached to it. Plastic surgeon Steven Schulz, MD, then reconstructed the perineum, since an operation of this scale leaves a defect too large to simply close.
Reconstruction is not cosmetic here. Bringing healthy tissue into a pelvis that has been emptied is what allows the wound to heal at all, and it is a major determinant of whether a patient recovers well enough to continue cancer treatment.
The Standard Is Total Removal, Not Partial
The operative goal in these cases is an R0 resection, meaning no cancer remains at the margins, visible or microscopic.
"Basically, anything touched by the cancer that can safely be removed has to be removed," Chung said.
After excising the primary tumor, the team took additional tissue for margins. Those margins came back negative. The team was not reassured.
The reason was that the cancer had perforated. When a tumor breaks through its own boundary, cells can escape in a way no surgical margin can account for.
"When cancer perforates, all bets are off," Chung said, adding that a surgeon can remove everything visible and still leave microscopic disease behind. Radiation oncology was brought in shortly after surgery, and the patient received postoperative radiation therapy.
An Unexpectedly Fast Recovery
Given the scale of the operation, the recovery is the part of the case that reads least predictably.
The patient needed one additional operation for bowel-related issues but left the hospital roughly a week later, without requiring rehabilitation or nursing care. She began radiation a few weeks after surgery.
"She was able to get on to radiation treatment a few weeks post-op, which is pretty remarkable as far as how she recovered," Chung said.
She has had complications related to the radiation that require ongoing management, and she remains under close surveillance because of how aggressive her cancer was. As of the Cleveland Clinic account, there is no evidence of recurrence.
Pelvic exenteration is not a routine cancer operation and should not be read as one. It is reserved for carefully selected patients with locally advanced or recurrent disease that cannot be cleared by surgery alone, and it carries substantial, permanent consequences. Adults born with cloacal anomalies already face long-term urinary, bowel, and gynecological challenges, which complicate both the surgery and the recovery.
What the Case Says About Everyone Else
Chung argues the broader lesson is not about anatomy at all. It is about sequencing.
Successful outcomes in locally invasive pelvic cancers, in her account, depend on getting radiation and medical oncologists involved early enough to determine whether preoperative treatment is appropriate before surgery is even on the table. Pathology and radiology carry heavy weight in that planning.
The surgical choreography matters too. Depending on which organs are involved, a case may require colorectal surgeons, urologists, plastic surgeons, orthopedic oncologists and gynecologic oncologists, sometimes operating simultaneously and sometimes in a specific order.
Reducing time in the operating room is itself a safety measure in procedures with this much potential morbidity, which Chung attributes largely to communication and planning well before the day of surgery.
That argument is not new to the field. Because cloacal malformations occur so rarely, most pediatric surgeons and urologists encounter only a handful in their entire careers, which is precisely why protocol-driven, referral-based care was developed around them in the first place. The same principles, Chung notes, apply to colorectal, gynecologic, urologic and musculoskeletal cancers involving the pelvis, none of which are rare.
Patients facing complex pelvic cancer decisions should discuss surgical options, including expected effects on continence and sexual function, directly with their care team.
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Key Questions Answered
What is a cloaca?
A congenital condition in which the rectum, vagina and urinary tract share a single common channel and opening. It occurs only in females and typically requires surgical reconstruction in childhood.
How rare is it?
About 1 in 50,000 live births, though the true figure may be higher because some cases are misdiagnosed as a rectovaginal fistula.
What kind of cancer was it?
Advanced mucinous adenocarcinoma, a subtype that produces mucous material capable of spreading into surrounding tissue.
What is pelvic exenteration?
A multivisceral operation removing the involved pelvic organs together is used for locally advanced or recurrent pelvic cancers when narrower surgery cannot clear the disease.
Why did she need radiation after surgery?
The tumor had perforated, raising concern about microscopic disease that surgery could not reliably remove.
How did she recover?
She required one additional operation for bowel-related issues and left the hospital in about a week without rehabilitation or nursing care.
Does the case have wider relevance?
Yes. The team says the same multidisciplinary planning applies to more common pelvic cancers involving multiple organ systems.
