Presentation
The patient presented to her primary obstetrics and gynaecology physician with left lower quadrant abdominal pain and intermittent spotting.
Patient Data
Due to the patient's presentation, a Pap test was performed, with results suggestive of cervical cancer. Subsequently, cervical/endometrial biopsies and dilation & curettage samples were taken, revealing the presence of invasive, moderately differentiated, non-keratinising squamous cell carcinoma, which was consistent with cervical cancer. The patient was referred to radiation oncology and completed definitive chemoradiation therapy and high-dose-rate (HDR) brachytherapy for approximately three months.
FDG PET-CT from the time of presentation showed left hydronephrosis and increased FDG avidity at the level of the cervix. Note normal adjacent bladder FDG activity.
Despite appropriate treatment, a monitoring FDG PET-CT taken five years later showed supraclavicular, hilar, and pelvic lymphadenopathy. Shortly after, the patient underwent six cycles of Carboplatin and Paclitaxel (Carbo/Taxol). A follow-up FDG PET-CT four months later demonstrated further disease progression, with a new lumbosacral spinal mass and a new paraoesophageal mass. A lumbar MRI helped elucidate the location of the spinal mass.
The patient underwent an OGD to rule out intra-oesophageal mass and extrinsic compression of the oesophagus was observed.
Right paravertebral soft tissue mass extending from L4-S1, contiguous with the medial aspect of the right psoas muscle. There is an osseous metastatic lesion involving the L5 vertebral body and signal abnormality extending into the right sacral ala.
Case Discussion
Upon reviewing the patient’s history of present illness, radiographic imaging, and relevant laboratory/pathology assessment, a diagnosis of metastatic cervical cancer with spine and paraoesophageal metastasis was made. Cervical cancer was confirmed via dilation & curettage, cervical and endometrial biopsies, and Pap smear test. The biopsies revealed invasive, moderately differentiated, non-keratinising squamous cell carcinoma, which is consistent with cervical cancer. The paraoesophageal mass and spinal mass biopsies revealed metastatic carcinoma originating from the primary cervical lesion.
A follow-up FDG PET-CT completed four months after six cycles of chemotherapy demonstrated cervical cancer metastases with a new lumbosacral spinal mass and a new para oesophageal mass. A lumbar MRI helped elucidate the location of the mass, showing that the mass originates from the right aspect of the L5 vertebral body with a soft tissue component that extends from the level of L4-S1, contiguous with the medial aspect of the right psoas muscle. The patient opted for palliative radiation therapy of the metastatic paraoesophageal lymph node for dysphagia with improvement in the ability to swallow solids.
Cervical cancer is ranked as the 4th most common cancer among women worldwide and results in over 300,000 deaths a year globally 1. It demonstrates an indolent course, beginning as a precancerous condition known as cervical intraepithelial neoplasia, which can become cervical cancer and metastatic if not detected and treated early 3. Persistent infection of human papillomavirus (HPV) strains 16/18 and smoking are established contributors to carcinogenesis in the cervix 4. Therefore, screening via HPV testing, Pap smear test, and encouraging smoking cessation and safe sexual practices using barriers are worthwhile pursuits in preventing and/or halting the progression of cervical cancer. Additionally, Gardasil, a high-risk HPV vaccine, was approved to be administered to men and more diverse age groups, not only young women. In this case, the patient had a history of HPV infection, tobacco smoking, and had not received the HPV vaccine, putting her at increased risk of developing cervical cancer. The patient’s cervical cancer at diagnosis was stage IIIB and obstructed her left ureter, indicating its size and invasion of nearby structures. Cervical cancer staged III or IV using FIGO staging has a higher likelihood of metastasising and increased risk of recurrence, with rates being close to 70% 2.
Case co-authors:
Shalom Mammen
Dr. Ellen Harris
Dr. Bhishak Kamat
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