Metastatic tumor extending through the inferior vena cava into the right atrium: a case report of carcinoma of the uterine cervix with para-aortic lymph node metastases

Carcinoma of the uterine cervix with cardiac metastasis is not uncommon in autopsy cases. However, an intraatrial tumor extending through the inferior vena cava (IVC) from the site of para-aortic lymph node metastasis has never been reported. A 57-year-old Japanese woman was admitted to an emergency care unit complaining of mild chest pain and shortness of breath. She had progressive multiple lymphatic metastases of stage IIIB squamous cell carcinoma of the uterine cervix that had initially been treated with concurrent chemoradiation. Echocardiogram showed pedunculated tumor in the right atrium (RA), and computed tomography demonstrated multiple pulmonary tumor embolism. Surgical specimen from the RA showed squamous cell carcinoma resembling the primary cervical tumor, and the peduncle appeared to originate from within the IVC. Postoperative ultrasonography showed severe stenosis of the abdominal IVC due to the invasive growth of para-aortic lymph node metastases. The stalk of the tumor originated from this lesion. We present an extremely unusual case of intraatrial metastatic tumor originating from the para-aortic lymph nodes of cervical cancer.     

A benign-looking subcutaneous metastasis from squamous cell cervical carcinoma: A case report and review of the literature

Abstract. Kouvaris JR, Plataniotis GA, Floros DG, Sykiotis CA, Trakadas SJ, Vlahos LJ. A benign-looking subcutaneous matastasis from squamous cell cervical carcinoma: A case report and review of the literature.
A 30-year-old woman with a stage IIIB grade 3 squamous cell cervical carcinoma and pelvic lymph node metastases was treated with external beam radiotherapy and intracavitary brachytherapy. One month after the completion of the treatment, a rubbery, movable, and painless mass appeared in the lower third and outer aspect of her right thigh. The overlying epidermis was intact. The whole clinical picture and CT scan image indicated a benign tumor. Biopsy revealed a nonkeratinizing, grade 2–3, squamous cell carcinoma similar to the primary cervical tumor. She then received six cycles of chemotherapy (cis-platinum and 5-fluorouracil) with transient partial response. The patient died one year after the diagnosis of the disease. This is the 29th case of cutaneous metastasis from a cervical carcinoma, the seventh localized on the leg, but the first solitary one with a benign-looking appearance reported since 1855. The possible mechanism of this rare metastasis is debated and the literature is reviewed.     

Prognostic difference of surgical treatment of exophytic versus barrel-shaped bulky cervical cancer

OBJECTIVE: The aim of the study was to evaluate the prognostic significance of tumor geography, defined as exophytic or barrel-shaped growth, in bulky (>4 cm) cervical cancer. METHODS: Four hundred women with cervical cancer, treated by primary radical hysterectomy between January 1984 and November 2000, were followed in a prospective cohort study. Clinical and pathology data were stored in a databank and the clinical protocol was unchanged during the study except for the amendment of additional indications of postoperative radiation in 1997. The assessment of tumor geography was based on pelvic examination at the time of tumor staging or radical hysterectomy or from the pathology report. Survival probabilities were calculated by the Kaplan-Meier method and compared with the log-rank test. RESULTS: The mean age of the patients was 45 years and the mean follow-up duration 48 months. Tumors were of squamous cell type in 291 patients (73%). Lymph node metastases were present in 91 patients (24%) and postoperative radiation was given in 179 patients (45%). In 291 patients, tumor diameter was <4 cm; in 58 patients, the tumor was defined as bulky exophytic and in 51 patients as bulky barrel shaped. There were no differences among these three groups in terms of operating time, blood loss during surgery or complications at 3 or 6 months postoperatively. Bulky exophytic tumors had an identical overall survival as compared to small-diameter (<4 cm) tumors. The overall survival (OS) of bulky barrel-shaped tumors was significantly worse (P < 10(-4)). The same was found for disease-free survival (DFS). CONCLUSION: Bulky exophytic cervical cancer has an identical surgical morbidity, overall and disease-free survival as compared to nonbulky (<4 cm) cervical cancer. In view of these identical characteristics, primary surgical treatment should be considered for patients with bulky exophytic cervical cancer.     

HPV-related cervical disease and oropharyngeal cancer

Human papillomavirus (HPV), especially HPV 16, is associated with the development of both cervical and oral cancer. We show the case of a woman affected by HPV-related cervical disease and oropharyngeal squamous cell carcinoma (OPSCC). A 41-year-old woman arrived at our Colposcopy Center following an abnormal Pap smear result (ASC-H) and a diagnosis of moderate cervical dysplasia obtained by a cervical biopsy. She underwent a colposcopy that showed a cervical abnormal transformation zone grade 2. A laser conization was performed in November 2010. Histology reported a moderate/severe dysplasia. The cone resection margins were free. Follow-up colposcopy and cytology were negative. The HPV testing showed an infection by HPV 16. In October 2012, the patient presented to the Head–Neck ER after episodes of hemoptysis; a lesion was found in the left tonsillar lodge. A biopsy was performed with a result of squamous cell carcinoma with low-grade differentiation. The HPV testing detected a high-risk HPV and the immunohistochemical analysis was positive for p16. She was treated by chemotherapy and brachytherapy. She was followed at the head–neck center with monthly visits with oral visual inspection that showed complete absence of mucosal abnormalities. HPV-related OPSCC and cervical precancerous/cancerous lesions have significant similarities in terms of pathogenesis. They are both caused largely by HPV 16, as in the present case. In conclusion, because of this association found in literature and in our case, we think that women with HPV cervical lesions should have regular surveillance for oropharyngeal cancer, whereas women with OPSCC should be encouraged to have diligent cervical screening.     

Long-term follow-up after neoadjuvant chemotherapy for high-risk cervical cancer during pregnancy

BACKGROUND: We report on a patient with a high-risk cervical cancer during pregnancy treated with neoadjuvant chemotherapy (NACT) followed by radical surgery. CASE: A 38-year-old woman was diagnosed with FIGO stage IIA cervical cancer at 19 weeks' gestation. She received four cycles of cisplatin (50 mg/m2) and vincristine (1 mg/m2) at 3-week intervals starting at 23 weeks' gestation. A cesarean section with radical hysterectomy and pelvic lymphadenectomy was performed at 33 weeks, delivering a 1920 g male newborn. Histology showed a poorly differentiated squamous cell carcinoma with lymph vascular invasion and pelvic lymph node metastases. The patient received three further cycles of chemotherapy. Both mother and child are healthy at 80 months after the primary diagnosis. CONCLUSION: NACT followed by radical surgery may be effective in selected patients with invasive cervical cancer during pregnancy.     

Isolated cardiac metastasis of cervical carcinoma presenting as disseminated intravascular coagulopathy. A case report

BACKGROUND: An isolated cardiac metastasis from cervical carcinoma is very rare. This report describes the unusual presentation in a patient diagnosed and successfully treated for stage IB squamous cell carcinoma of the cervix, presenting six months later with disease metastatic to the heart. CASE: A 44-year-old woman presented with hand swelling and bruising. She had undergone successful surgical treatment of a stage IB squamous cell cervical carcinoma six months previously. Computed tomography revealed a large mass in the right ventricle, confirmed by echocardiography. The patient underwent surgery, where the mass was biopsied and debulked under a cardiopulmonary bypass. Frozen section confirmed metastatic squamous cell carcinoma. The patient was discharged with follow-up radiation and chemotherapy. CONCLUSION: All women with myocardial abnormalities and a history of squamous cell carcinoma of the cervix should be suspected of developing a myocardial metastasis until proven otherwise.     

Malignant Brenner Tumor Mimicking a Primary Squamous Cell Carcinoma of the Cervix

An 86-year-old female presented with a necrotic cervical mass that was biopsy-proven squamous cell carcinoma. She had an elevated CA-125 and a pelvic mass. At surgery, this mass was found to be of adnexal origin and contiguous with the cervix. Histology showed a malignant Brenner tumor with abundant squamous differentiation eroding the cervix and simulating a primary cervical malignancy. We describe this case and review the literature on metastatic tumors to the cervix.     

Case of uterine cervical carcinosarcoma

Carcinosarcoma (CS) is a rare neoplasm that is called a mixed epithelial and mesenchymal malignancy. CS of the uterine cervix is much less common than its counterparts in the uterine corpus. A 61-year-old, gravida 2, para 2 woman, who had undergone menopause 16 years prior to the presentation, was diagnosed with CS of the uterine cervix. A semiradical hysterectomy was carried out on the diagnosis of stage Ib1 cervical cancer. The patient underwent whole pelvic 45 Gy radiation as a postoperative additional treatment, but she died from multiple organ failure by metastasis 17 months after the operation. The tumor protruded from the cervix to the vagina and measured 4.5 x 3.0 cm. Histologically, the tumor was characterized as a squamous cell carcinoma and mesenchymal malignancy, represented by osteosarcomatous components. The stroma was largely composed of atypical spindle-shaped cells, which were immunohistochemically demonstrated to be of epithelial origin. Uterine cervical CS is one of the aggressive malignancies, and squamous cell carcinomas are common epithelial counterparts of cervical CS as well as adenocarcinomas.     

Preoperative chemotherapy with irinotecan and mitomycin for FIGO stage IIIb cervical squamous cell carcinoma: a pilot study

PURPOSE OF INVESTIGATION: Patients with FIGO Stage IIIb cervical cancer show cancer propagation to pelvic side walls from the uterus, and the tumors cannot be completely removed by radical hysterectomy. Here, we examined the effects of preoperative irinotecan HCl (CPT-11)-combined chemotherapy on patients with unresectable Stage IIIb cervical squamous cell carcinoma. METHODS: Eleven patients agreed to participate in the pilot study and received preoperative chemotherapy. RESULTS: Cervical tumors of all 11 patients showed partial responses in tumor reduction, and radical hysterectomy was successfully performed in ten patients treated with CPT-11 and mitomycin C (MMC). One patient treated with CPT-11 and cisplatin had a 68% reduction of the primary cervical lesion but could not undergo radical surgery because of retroperitoneal cancer progression during chemotherapy. CONCLUSION: These results indicate that chemotherapy with CPT-11 and MMC could be a useful preoperative treatment for unresectable Stage IIIb cervical squamous carcinoma.     

Cotyledonoid leiomyoma of the uterus: report of a case.

A 46-year-old woman presented with a pelvic mass. At the time of operation a large, exophytic, multinodular tumor extended into the peritoneal cavity and right broad ligament from a pedunculated attachment to the uterus in the region of the right cornu. On external examination the lesion had the appearance of cotyledonoid dissecting leiomyoma. On microscopic examination bulbous processes were composed of benign smooth muscle arranged in interlacing fascicles or swirls; there was focal hydropic degeneration. Significant nuclear atypia, mitotic activity, and coagulative tumor necrosis were not encountered. No intravascular involvement was present. There was no demonstrable parent leiomyoma or intramural dissecting component, and thus the case differed from previously reported cases of both cotyledonoid dissecting leiomyoma and intramural dissecting leiomyoma. This tumor represents another variation in the group of benign uterine smooth muscle tumors with unusual growth patterns.     

Primary choriocarcinoma of the uterine cervix in a postmenopausal patient: a case report

BACKGROUND: Primary cervical choriocarcinoma seen in a postmenopausal patient is a very rare entity. CASE: Primary choriocarcinoma of the uterine cervix was diagnosed in a 54-year-old woman. She had admitted to our clinic with vaginal bleeding and had been postmenopausal for 1 year at the time of diagnosis. A cervical tumoral mass was seen in her pelvic examination and cervical biopsy revealed squamous cell carcinoma of the cervix. Pelvic examination under anesthesia was done and patient was accepted as FIGO Stage IIA. Type III hysterectomy with bilateral salphingoopherectomy and bilateral pelvic-paraaortic lymph node dissection was carried out. Postoperative pathological evaluation of the surgical specimen showed that case was a primary choriocarcinoma of the cervix. CONCLUSION: This is one of the few reported cases of cervical choriocarcinoma in a postmenopausal patient. The most appropriate theory for the development of this tumor is metaplastic differentiation of the tumor from another histologic type.     

Assessment of cervical cancer radioresponse by serum squamous cell carcinoma antigen and magnetic resonance imaging

OBJECTIVE: To investigate the possibility of objective clinical assessment of the radioresponse of cervical cancer via determination of serum squamous cell carcinoma antigen levels and magnetic resonance imaging (MRI)-based estimation of tumor shrinkage. METHODS:The cases of 60 patients undergoing definitive radiotherapy for cervical squamous cell carcinoma (stage I-II: n = 20; stage III-IV: n = 40) were reviewed. Measurements of serum squamous cell carcinoma antigen levels (n = 60), estimated tumor volume on preradiotherapy MRIs (n = 60), and evaluated tumor shrinkage on postradiotherapy MRIs available (n = 30) were taken. The relation between postradiotherapy squamous cell carcinoma antigen level 2 months after the start of radiotherapy and disease recurrence was investigated. Regression analysis of tumor volume measured on MRIs was used to estimate the extent of tumor shrinkage 2 months after the start of radiotherapy. RESULTS: Preradiotherapy squamous cell carcinoma antigen levels correlated significantly with preradiotherapy tumor volumes. Recurrence was identified in 27 patients as distant (n = 19), distant and local (n = 1), local (n = 5), or regional (n = 2). Of 51 patients with elevated preradiotherapy squamous cell carcinoma antigen levels, 33 achieved normalized levels after radiotherapy. Squamous cell carcinoma antigen normalization was associated with a higher recurrence-free survival rate at 2 years (74.3%) than that associated with nonnormalization of squamous cell carcinoma antigen (5.6%, P <.001). The extent of shrinkage ranged from 61% to 100%, and there was no local recurrence. CONCLUSION: Postradiotherapy squamous cell carcinoma antigen status is a useful indicator of clinical outcome, particularly about tumor recurrence. It is not, however, useful for assessing response to radiotherapy. Magnetic resonance imaging is useful for obtaining an objective assessment of radioresponse.     

Simultaneous diagnosis and therapy of invasive cervical carcinoma and invasive vulvar carcinoma. A case report

Invasive squamous cell carcinoma of the vulva is predominantly a disease of postmenopausal woman with a mean age of approximately 65 years. After treatment for cervical cancer patients have an increased risk of developing second squamous cell malignancy of the lower genital tract. This study reports the case of a patient with double malignancy—invasive cervical cancer and invasive vulvar cancer. She underwent radical hysterectomy, bilateral adnexectomy and pelvic bilateral lymphadenectomy and at the same time radical vulvectomy and bilateral inguinal lymphadenectomy. After surgery she was referred to radiotherapy. The postoperative course was uneventful and at 14 months of follow-up, the patient showed no evidence of recurrence.     

Immunosuppressive activity of proteases in cervical carcinoma

OBJECTIVE: The host immune response is essential for restraining both HPV infections and HPV-related cervical cancer. We previously reported a direct correlation between proteolytic activity and malignant progression from precursor lesions to invasive cervical carcinoma. The present study was undertaken to investigate whether proteinases from cervical carcinoma extracts and representative purified proteinases involved in tumor progression could regulate lymphocyte proliferation to phytohemagglutinin (PHA) mitogen. METHODS: Extracts were prepared from tissue samples obtained from patients with invasive cervical squamous carcinoma, squamous intra-epithelial lesions or women with normal cervix. Lymphocytes obtained from a single healthy donor were pre-incubated with one of these extracts in the presence or absence of proteinase inhibitors, and stimulated with PHA during 72 h. The proliferative response was measured using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide (MTT) method (re-validated with thymidine uptake). RESULTS: Lymphocyte proliferation was significantly decreased by cervical carcinoma extracts, while only slightly decreased by squamous intra-epithelial lesions or normal extracts. Inhibitor assays indicated that proteinases from cervical carcinoma were responsible for 53.30% of total suppressive activity. We found that purified enzymes such as trypsin, cathepsin B, uPA and type IV collagenase suppressed the proliferative response in a dose-dependent fashion. CONCLUSIONS: Our data suggest that in addition to the classic role in tumor invasion, proteases could represent an immune evasion mechanism in cervical carcinoma.     

Laparoscopic port-site recurrence following surgery for a stage IB squamous cell carcinoma of the cervix with negative lymph nodes

BACKGROUND: Port-site metastases are commonly reported after laparoscopic surgery for ovarian cancer, but have also been reported in patients with cervical or endometrial cancer with positive lymph nodes. Recently, a case of port-site recurrence after laparoscopic surgery for a patient with node-negative early-stage adenocarcinoma of the cervix was reported. We report the first case of port-site metastasis in a patient with stage IB squamous cell carcinoma of the cervix with negative lymph nodes. CASE: A 31-year-old woman had a laparoscopy for pelvic pain. Under anesthesia, she was noted to have a grossly abnormal-looking cervix and a biopsy revealed squamous cell carcinoma. She was referred to a gynecological oncologist and underwent radical hysterectomy and pelvic lymph node dissection through a transverse lower abdominal incision 6 weeks later. Nineteen months postoperatively, she presented with a soft tissue mass in a suprapubic laparoscopic trocar site. CONCLUSION: It is postulated that cells dislodged at the time of cervical manipulation and biopsy may have passed through the fallopian tubes and implanted in the laparoscopic port site due to the "chimney effect" caused by the pneumoperitoneum.     

Projectile vomiting as presentation of duodenal intramural metastasis from cervical cancer

ObjectiveTo report a case and review literature of bowel metastases from cervical squamous cell carcinoma.Case ReportA 49-year-old woman with a history of FIGO 2013 stage IVB cervical squamous cell carcinoma presented with refractory nausea, projectile vomiting, anorexia, postprandial abdominal pain, and significant weight loss for six months. Restaging images didn't reveal viable tumors but thickened duodenal wall indicating gastric outlet obstruction. Initially, the etiology was masked by chronic erosive duodenitis and mistreated as a duodenal ulcer. After repeated gastrointestinal endoscopic biopsy confirming intramural duodenal metastasis from cervical squamous cell carcinoma, the patient was treated successfully by gastrojejunostomy and adjuvant chemotherapy. She has remained asymptomatic and disease-free for more than 12 months since the surgical metastasectomy.ConclusionIntestine metastasis from cervical cancer is a rare cause that may present as projectile vomiting due to gastric outlet obstruction. Prompt recognition and surgical intervention may provide good outcomes despite the metastatic nature.     

Radiochemotherapy for patients with locally advanced cervical cancer: early results

PURPOSE: Radiotherapy is the standard treatment for locally advanced cervical cancer. Recent results of the prospective randomized trials have shown an overall survival and local control advantage for cisplatin-based therapy given concurrently with radiation therapy. Thirty-nine patients who received concurrent chemoradiation between October 1999 and December 2000 were evaluated for treatment response, local control and toxicity. MATERIALS AND METHODS: Thirty-nine patients with Stage IB through IVA cervical carcinoma received weekly cisplatin (40 mg/m2) concurrent with radiotherapy. Thirty-two patients received both external and intracavitary radiotherapy and seven patients received only external radiotherapy because of insufficient tumor response for intracavitary application. Total external radiotherapy dose was 64.8 Gy with 1.8 Gy daily fractions in patients who received only external radiotherapy. Midline shielding was performed at 50.4 Gy in patients who were going to receive brachytherapy and the total external radiotherapy dose was 54-59.4 Gy. Brachytherapy was performed with a Rotterdam applicator via the microSelectron HDR machine. A total dose of 8.5-18 Gy was applied to point A. RESULTS: Median age was 55. Distribution by stages were as follows: Stage IB 5.1%, IIA 28.2%, IIB 43.6%, IIIA 7.7%, IIIB 12.8% and IVA 2.6%. Histologically 33 (84.6%) were epidermoid carcinoma, one was adenocarcinoma, two were undifferentiated carcinoma, one was malignant epithelial tumor. In two patients histological type could not be specified. The median duration of follow-up was 20 months. Four patients had local recurrence and three developed distant metastases. Thirty patients (76.9%) had complete response, eight had (20.5%) partial response and one had (2.6%) stable disease. During or after radiochemotherapy 46.2% of the patients developed toxicity due to chemotherapy. Early and late radiation morbidity rates were 66.7% and 71.8%, respectively. No grade III-IV toxicity was observed. CONCLUSION: Concurrent chemoradiation for locally advanced cervical cancer is the treatment of choice in suitable patients providing high response rates with acceptable toxicity.     

Modified radical hysterectomy for early Ib cervical cancer.

A total of 39 patients with selected early Ib cervical cancer were treated with modified radical hysterectomy (MRH) and compared with 102 patients with nonbulky Ib cervical cancer treated with radical hysterectomy (RH). Postoperative voiding difficulty (15.4 vs 46%) and constipation (43.6 vs 74.5%) were significantly less after MRH than after RH. All patients with MRH were followed uneventfully and the 3-year survival rate is 100%. No recurrence or persistence of disease was noted. It is suggested that patients with exophytic squamous cell carcinoma of the cervix less than 2 cm in diameter and invading less than 10 mm, as diagnosed by conization, may be effectively treated with MRH, resulting in less morbidity.     

Effective chemoradiotherapy protocol with 5-fluorouracil for cervical squamous cell carcinoma in vitro

PURPOSE OF INVESTIGATION: 5-Fluorouracil (5FU) is frequently used in concurrent chemoradiotherapy for patients with advanced cervical cancer, although its optimal chemoradiotherapy protocol has not yet been established. In search of an optimal chemoradiotherapy protocol, some in vitro experiments were carried out. METHODS: The radiosensitive human cervical squamous cell carcinoma cell line ME180 was examined to investigate the effects of 5FU on radiosensitivity and the effects of irradiation on 5FU-sensitivity. RESULTS: 5FU dose-dependently enhanced cellular radiosensitivity at therapeutic concentrations. Although high doses of y-ray irradiation significantly reduced the 5FU-sensitivity, a low dose of irradiation at therapeutic doses (< 2.5 Gy) had no effect on 5FU-sensitivity of the irradiated cells. Cells pretreated with 5FU eight hours before irradiation showed significantly higher 5FU-sensitivity than cells concurrently treated with 5FU and irradiation. In contrast, cells treated with 5FU eight hours after irradiation showed significantly lower 5FU-sensitivity than cells concurrently treated with 5FU and irradiation. Moreover, all four post-irradiation surviving subclones obtained from repeatedly irradiated ME180 cells showed significantly lower 5FU-sensitivity than the non-irradiated parent cells. CONCLUSION: 5FU acts as a radiosensitizer for cervical squamous cell carcinoma and 5FU-sensitivity is reduced in irradiated cells. Therefore, 5FU administration immediately before irradiation may be a more effective treatment than concurrent chemoradiotherapy or post-irradiation chemotherapy with 5FU.     

Case-control study of the effectiveness of mass screening in reducing invasive cervical cancer

A case-control study was conducted in Miyagi Prefecture, Japan, to evaluate the effectiveness of mass screening for invasive cervical cancer. The Papanicolaou (Pap) smear histories of 109 cases with invasive cervical cancer diagnosed in the years 1984-1989 were compared with those of 218 age (+/- 3 years)- and area-matched controls. Fifty-five percent of 109 cases were screened at least once, while for the controls the figure was 85.5%. Compared with women who were never screened, the odds ratio of invasive cervical cancer for women screened at least once was 0.16 [95% confidence interval: 0.090-0.278]. The odds ratio for 98 cases with squamous cell carcinoma for screened versus never screened women was 0.14 [0.080-0.253]. The Pap smear was less effective as a screening procedure for adenocarcinoma of the cervix than for squamous cell carcinoma. Of 11 cases with adenocarcinoma, 81.8% were screened, compared with 90.9% of controls. The odds ratio was 0.45 [0.054-3.719]. It showed that the odds ratio for the 1-year interval between last normal smear and diagnosis was 0.11 [0.061-0.196] and that for the 2-year intervals was 0.33 [0.157-0.714]. From the results of our study, it can be concluded that mass screening is effective for invasive cervical cancer.