|Year : 2019 | Volume
| Issue : 6 | Page : 1415-1417
Peritoneal metastasis in Stage IB1 adenocarcinoma cervix: A rare entity
Seema Singhal1, Sunesh Kumar1, Dayanand N Sharma2, Sandeep Mathur3
1 Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Radiation Oncology, BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
3 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||05-Dec-2018|
|Date of Acceptance||14-Feb-2019|
|Date of Web Publication||24-Dec-2019|
Dr. Seema Singhal
Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
The presence of ovarian or peritoneal metastasis in early-stage cervical malignancy is a rare entity. It often poses a diagnostic challenge whether it is a synchronous primary tumor or a metastatic lesion. A 63-year-old postmenopausal woman presented with Stage 1B1 carcinoma cervix with ascites, and a 5.8 cm × 4.2 cm × 3.5 cm left solid adnexal mass. She underwent Type III radical hysterectomy, excision of peritoneal mass, with bilateral pelvic and paraaortic lymphadenectomy and infracolic omentectomy. On histopathology, cervix showed features of adenocarcinoma, and the peritoneal mass revealed similar histomorphology as cervical growth with metastatic tumor deposits in omentum. Immunohistochemistry (IHC) was utilized to determine the origin of mass. The early stage disease and histology may not always predict the distant metastasis. Therefore, a thorough pretreatment evaluation, meticulous intraoperative assessment, and IHC are mandatory for optimum management and prognostication.
Keywords: Cervical adenocarcinoma, immunohistochemistry, metastasis, peritoneal metastasis, prognosis
|How to cite this article:|
Singhal S, Kumar S, Sharma DN, Mathur S. Peritoneal metastasis in Stage IB1 adenocarcinoma cervix: A rare entity. J Can Res Ther 2019;15:1415-7
| > Introduction|| |
Ovarian metastasis in cervical malignancy is rare and is seen in 0%–1.3% cases of squamous cell carcinoma (SCC) and 1.7%–6.3% cases of adenocarcinoma.,, Peritoneal metastasis without ovarian involvement in carcinoma cervix is still rarer, and the exact incidence is not known. This poses a diagnostic challenge, whether it is a synchronous primary tumor or a metastatic lesion from the cervical disease. We report the presence of peritoneal metastasis in a case of early-stage endocervical adenocarcinoma cervix without any ovarian involvement and role of histomorphology and immunohistochemistry (IHC) as a useful adjunct to clinical and radiological evaluation.
| > Case Report|| |
A 63-year-old postmenopausal woman presented with a history of foul smelling vaginal discharge since 1 year. The general physical examination was normal. On per speculum examination, the cervix was flushed with vault with 1 cm × 1 cm ulcerative growth seen at nine o' clock position. On bimanual examination, the uterus was retroverted and normal size. A 5 cm × 5 cm firm to hard adnexal mass with restricted mobility was felt on the left side and rectal mucosa was free. Cervical biopsy revealed endocervical adenocarcinoma with positive carcinoembryonic antigen (CEA) and estrogen receptor (ER) negative on IHC. Contrast-enhanced magnetic resonance imaging showed moderate ascites, 4 cm × 3 cm × 2 cm heterogeneous cervical lesion extending into lower uterine cavity with no parametrial fat stranding and another 5.8 cm × 4.2 cm × 3.5 cm left solid adnexal mass was observed [Figure 1] and [Figure 2]. Bilateral kidneys were normal. Ultrasound-guided biopsy from mass was suggestive of high-grade surface epithelial tumor that was negative for WT1 and p53 (wild). Her CA-125 was 128.7 IU/ml, CEA was 44.6 ng/ml, and CA19.9 was <2 IU/ml. She was taken up for exploratory laparotomy. Intraoperatively, 150 ml mucinous ascetic fluid was present and collected for cytological evaluation. The systemic exploration of the abdomen revealed normal liver, diaphragm, porta-hepatis, omentum, bowel, mesentery, and appendix. Uterus and bilateral ovaries were healthy. A 6 cm × 5 cm tumor mass was present over the surface peritoneum of pelvis which was excised [Figure 3]. Peritoneal biopsies were taken. Type III radical hysterectomy with bilateral pelvic and paraaortic lymphadenectomy and infra colic omentectomy was done. Her postoperative period was uneventful.
|Figure 1: Pelvic magnetic resonance imaging T1 weighted sagittal images showing 3 cm × 4 cm heterogeneous endocervical lesion|
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|Figure 2: Pelvic magnetic resonance imaging axial images showing 3.5 cm × 5.8 cm × 4.2 cm left solid adnexal mass in the pouch of douglas|
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|Figure 3: Cut section of radical hysterectomy specimen showing 5.5 cm × 4.3 cm ulceroproliferative endocervical growth involving isthmic endometrium along with grossly normal bilateral Fallopian tube More Detailss and ovaries. Also showing the excised pelvic mass that was overlying peritoneal surface|
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On cut section, an ulceroproliferative growth measuring 5.5 cm × 4.3 cm seen in endocervical canal extending into endometrial cavity with a depth of infiltration of 1.1 cm. The peritoneal mass had mucoid appearance with papillary projections over surface, and bilateral tubes and ovaries were normal.
On histopathologic evaluation, cervical growth disclosed features of endocervical adenocarcinoma. The tumor cells contained intracellular mucin and were positive for p53, CEA, and CK7, whereas negative for ER, Vimentin, CK20, and WT1. The tumor involved isthmic endometrium and infiltrated >50% of cervical stroma. Ascitic fluid, peritoneal biopsies, bilateral parametria, vaginal cuff, and lymph nodes were free of tumor. The separate mass from peritoneal surface revealed similar histomorphology and IHC. Sections from omentum showed metastatic tumor deposits. The tubes were extensively sampled, and no luminal or mucosal tumor was identified.
The patient was given three cycles of cisplatin and paclitaxel-based chemotherapy followed by concurrent chemoradiation (CCRT), 50.4 Gy in 28 # and intravaginal brachytherapy (3#) followed by three cycles of chemotherapy. She is under follow-up and disease free after 6 months of follow-up.
| > Discussion|| |
The usual sites of distant metastasis from cervical malignancy are lung, liver, bone, and supraclavicular lymph nodes but other rare sites such as ovary, peritoneum have also been reported., The possible mechanism for peritoneal metastasis includes direct, hematogenous, lymphatic, or transtubal implantation of malignant cells.,, The concomitant involvement of fallopian tube or peritoneum supports the hypothesis of spillage of malignant cells through the tubes.,
The incidence of finding ovarian metastasis in women with cervical malignancy was high in cases having deep myometrial invasion, lymph-vascular space invasion, and lymph node metastasis. The presence of disease in ovarian hilus without any surface disease support the hematogenous or lymphatic spread to the ovary. In the present case, the lack of such an association and presence of peritoneal surface disease highlights the probability of tubal spillage of malignant cells.
Human papillomavirus (HPV)-related metastatic ovarian tumor from cervical malignancy are usually multicystic or solid-cystic and may be unilateral or bilateral. Majority were endometrioid or mucinous type with varied degree of differentiation. Microscopically atypical, hyperchromatic, elongated nuclei with numerous mitotic figures, situated in apical portion of the mucinous cytoplasm without destructive stromal invasion are specific characteristics of HPV-related neoplasms. These tumors are usually endometrioid, mucinous or mixed type. The presence of morphologically identical tumors in endocervix and ovary should be considered as metastatic unless proved otherwise. Metastatic ovarian neoplasm from adenocarcinoma cervix usually exhibits identical HPV subtypes, p16 positivity, and lack of hormone receptors expression., In our case, ovaries and fallopian tubes were normal and the tumor was WT1 and ER negative, this practically excluded primary ovarian or peritoneal malignancy.
The prognosis of isolated ovarian metastasis remains good if appropriate surgical management is done. On the other hand, the presence of peritoneal metastasis carries a poor prognosis. Purkayastha et al. reported a young woman with recurrent SCC cervix after definitive CCRT for stage 1B2 disease. She had malignant ascites and multiple peritoneal deposits. The patient received palliative external beam radiotherapy and paclitaxel and Carboplatin-based combination chemotherapy but did not respond and eventually died. Conversely, another case of Stage IVA SCC cervix during definitive CCRT treatment presented with suspected tubo-ovarian abscess. The patient was taken up for laparoscopy and intraoperatively metastatic disease was seen on omentum that was adherent with bladder mimicking tubo-ovarian mass on imaging. The ovaries were normal. Laparoscopic excision of mass was done followed by definitive CCRT. After 50 months of follow-up, the patient was disease free. Thus, the outcome of patients with peritoneal metastasis largely depends on the stage of primary disease, extent of metastasis, adequacy of excision, and adjuvant therapy.
The early stage disease and histology may not always predict distant metastasis. Meticulous pretreatment and intraoperative assessment along with IHC are essential for optimum management.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]