|Year : 2015 | Volume
| Issue : 3 | Page : 653
Cervical Cancer as a silent killer: A rare case report with review of literature
Deeksha Pandey1, Jyothi Shetty1, Charudatt Sambhaji2, PU Saxena3, Dilip Mishra4, Arun Chawla4
1 Department of Obstetrics and Gynecology, Kasturba Medical College Manipal, Manipal University, India
2 Department of Radiodiagnosis, Kasturba Medical College Manipal, Manipal University, India
3 Department of Radiation Oncology, Kasturba Medical College Manipal, Manipal University, India
4 Department of Urology, Kasturba Medical College Manipal, Manipal University, India
|Date of Web Publication||9-Oct-2015|
Associate Professor (OBGYN), KMC, Manipal, MU Karnataka
Source of Support: None, Conflict of Interest: None
Advanced-stage cervical cancer almost always presents either with abnormal vaginal bleeding or with foul-smelling vaginal discharge. We present here a rare case, where a postmenopausal lady presented almost silently with stage IVA cervical cancer. Fortunately, timely referral, correct diagnosis, and multispecialty team work could save her life.
Keywords: Bladder growth, cervical cancer, hydronephrosis, nephrostomy, percutaneous, ureteric stenting
|How to cite this article:|
Pandey D, Shetty J, Sambhaji C, Saxena P U, Mishra D, Chawla A. Cervical Cancer as a silent killer: A rare case report with review of literature. J Can Res Ther 2015;11:653
|How to cite this URL:|
Pandey D, Shetty J, Sambhaji C, Saxena P U, Mishra D, Chawla A. Cervical Cancer as a silent killer: A rare case report with review of literature. J Can Res Ther [serial online] 2015 [cited 2019 Jan 22];11:653. Available from: http://www.cancerjournal.net/text.asp?2015/11/3/653/137997
| > Introduction|| |
Preinvasive as well as early invasive cervical cancer usually is asymptomatic and is detected during screening procedures. However, advanced-stage cervical cancer almost always presents with abnormal vaginal bleeding or foul-smelling vaginal discharge. In late stages, ureteric obstruction caused by parametrial spread of disease may lead to uremia which is the most common cause of death in cervical cancer. We report a very rare case of stage IV cervical cancer with atypical presentation.
| > Case report|| |
A 55-year-old menopausal lady presented with mild pain abdomen and frequency of micturition for 5 days. Ultrasound revealed a growth inside her urinary bladder. Patient was referred to us for cystoscopy and management.
She had no gynecological complaint. Her general examination was well within normal limits. On pelvic examination, vagina was stenosed in upper part, so cervix couldn't be visualized. Anterior wall of vagina was indurated. Rectal examination revealed right-sided parametrial induration up to pelvic wall. Ultrasound abdomen and pelvis showed a polypoidal thickening involving the bladder base and bilateral ureteric orifices causing proximal hydroureteronephrosis. Uterus was found to be normal and ovaries were not seen. Thus, a cystoscopy, biopsy, and ureteric stenting were planned. On cystoscopy, a bulge in the left lateral wall and base of the bladder with mucosal changes was noted. Biopsy was taken. Cystoscopy-guided biopsy report turned out to be infiltrating squamous cell carcinoma (large cell non-keratinizing type). Magnetic resonance imaging (MRI) was now done to have a more tangible look of the cervix. MRI revealed subtle thickening of the anterior lip of the cervix and circumferential enhancing wall thickening of proximal vagina and adjacent base of bladder with heterogeneous enhancement [Figure 1]a and b. It also showed parametrial invasion, metastatic lymphadenopathy (bilateral external and internal iliac, common iliac, obturator, and aotic), and bilateral hydroureteronphrosis [Figure 2]. Thus, the final diagnosis was squamous cell carcinoma of cervix, stage IVA.
|Figure 1: Magnetic resonance imaging showing subtle thickening of the anterior lip of the cervix and circumferential enhancing wall thickening of proximal vagina and the adjacent base of bladder with heterogeneous enhancement. (1a) T1-weighted (post contrast) axial view, (1b) T2-weighted (post contrast) mid sagittal view|
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|Figure 2: Magnetic resonance imaging showing large metastatic internal and common iliac group of lymph nodes (T2-weighted axial view)|
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She was planned for chemo-radiation using three-dimensional conformal radiation therapy (3D-CRT) to a total dose of 50 Gy in 25 fractions over five weeks with weekly cisplatin sensitizer, followed by 3 weekly ICR applications (700 cGy each) using high-dose rate brachytherapy (HDR Ir 192) remote after-loading source. After first weekly sensitizer, the patient showed worsening creatinine clearance, following which stenting of the ureters were attempted to relieve the obstruction but failed. So as the life-saving measure, she underwent ultrasonography-guided bilateral percutaneous nephrostomy (PCN). She was discharged after full course of external beam radiation with four doses of chemosensitizer. On follow up, as her renal failure settled with both Percutaneous nephrostomies draining, repeat Double J stenting was successfully attempted and both PCN tubes were removed. Afterwards, she received three fractions of intacavitary radiations (ICR) of 700 cGy each. Patient is symptom free at 12 months follow up.
| > Discussion|| |
Advanced-stage cervical cancer presents mostly with abnormal vaginal bleeding. This is a rare case of stage IV cervical cancer without complaints of vaginal bleeding or discharge. Duration of her complaints (pain abdomen and frequent micturition) was only 5 days and within 3 weeks of presentation, patient started going into uremia. PCN was life saving for her. As per our knowledge, there are only three other cases reported in the literature, presenting silently in stage IV of cervical cancer.
In 2001, a case was reported from USA, where a 60-year-old lady with right upper quadrant pain, diarrhea, and urinary incontinence was found to have stage IV B cervical cancer. Here, CT scan clinched the diagnosis.  Another case was of a 51-year-old lady who was referred to ENT department with a 2-week history of a lump on the right side of her neck. On routine examination, cervix appeared normal to the naked eye and cervical smear was normal. MRI revealed a highly abnormal cervix, diffusely infiltrated by an intermediate to high T2 signal intensity mass measuring approximately 3 × 4 × 3.5 cm.  An interesting case was of cervical adenocarcinoma who presented primarily as advanced ovarian malignancy with the primary site totally silent. Here, a 47-year-old lady presented with vague abdominal pain for 2 months. Initial imaging with USG and CT suggested right ovarian dermoid cyst. Serum CA 125 was normal. Right salpino-ovariotomy was done and the histology confirmed dermoid cyst. Follow up after 5 months showed a markedly elevated CA 125 (1,594 U/ml) and a negative cervical smear. Exploratory laparotomy was done with the intent to progress to total abdominal hysterectomy, left salpingo-oophorectomy, and omentectomy with staging. Surprisingly, histologic features of the specimen obtained at laparotomy were consistent with a moderately differentiated cervical adenocarcinoma with metastases to corpus uterus, left ovary, fallopian tube, and omentum. 
There have been reports of some other cases with atypical presentation of cervical cancer. However, all of these were either diagnosed or treated cases of cervical cancer. Six cases of duodenal metastasis have been reported in literature.  In another report, a known case of cervical cancer had severe facial erythematous swelling and telangiectasia. A skin biopsy specimen revealed widespread intravascular tumor emboli.  An unusual case of cervical cancer was reported by Harvey et al. In this case, 6 months after diagnosis and treatment of squamous cell carcinoma of cervix (stage IB), patient presented with disease metastatic to the heart. Histology confirmed metastatic squamous cell carcinoma.  In another report a 43-year-old woman treated for stage IB squamous cervical carcinoma presented with optic neuropathy and her cerebral spinal fluid was positive for squamous cells carcinoma. 
Though we feel that over the years we have been able to understand each and every aspect of cervical cancer from its etiological agent Human Papillomavirus to pathogenesis to its metastatic pathways, still this cancer as mentioned above has posed challenges for the clinicians with its unusual recondite presentations. These cases highlight the importance of out-of-the-box thinking and joining the blocks of history, imaging, and histology together to reach the diagnosis for an accurate management.
| > References|| |
Shah M, Moogerfeld MS, Ahmed J, Mughal M, Aziz K. Metastatic cervical cancer with unusual presentation: A case report. Conn Med 2001;65:523-5.
Manoharan M, Satyanarayana D, Jeyarajah AR. Cervical lymphadenopathy-An unusual presentation of carcinoma of the cervix: A case report. J Med Case Rep 2008;2:252.
Abdulhathi MB, Al-Salman S, Kassis A, Ghazal-Aswad S. Unusual presentation of cervical cancer as advanced ovarian cancer. Arch Gynecol Obstet 2007;276:387-90.
Kanthan R, Senger JL, Diudea D, Kanthan S. A review of duodenal metastases from squamous cell carcinoma of the cervix presenting as an upper gastrointestinal bleed. World Journal of Surgical Oncology 2011;9:113.
Yang HI, Lee MC, Kuo TT, Hong HS. Cellulitis like cutaneous metastasis of uterine cervical carcinoma. J Am Acad Dermatol 2007;56 Suppl 2:526-8.
Harvey RL, Mychaskiw G 2 nd
, Sachdev V, Heath BJ. Isolated cardiac metastasis of cervical carcinoma presenting as disseminated intravascular coagulopathy. A case report. J Reprod Med 2000;45:603-6.
Portera CC, Gottesman RF, Srodon M, Asrari F, Dillon M, Armstrong DK. Optic neuropathy from metastatic squamous cell carcinoma of the cervix: An unusual CNS presentation. Gynecol Oncol 2006;102:121-3.
[Figure 1], [Figure 2]