Cunha, Teresa Margarida

Delgado, Lara

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Case 10912 Atypical presentation of a cervical cancerLara Delgado , Teresa Margarida Cunha  1 2 Genital (Female) Imaging Section: 2013, Sep. 9 Published: 35 year(s), femalePatient:Authors' Institution(1) Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal(2) Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, PortugalEmail: lara_sofia_81@hotmail.comClinical History35-year old woman underwent gynecologic examination one month after delivery which revealed acervical polyp. The polyp was removed and the pathological analysis was positive for malignancy.Magnetic resonance was made for local staging. Three months later radical hysterectomy wasperformed and a painful episiotomy scar nodule was also excised.Imaging FindingsA pelvic MR revealed high signal intensity tumor of the anterior cervix, surrounded by low signalintensity cervical stroma (FIGO IB1) and linear episiotomy perineal scar with low signal intensityon T2-weighted images and high on T1-weighted images with fat saturation (Figure 1).Three months later radical hysterectomy, bilateral adnexectomy and pelvic lymphadenectomy wereperformed. At the same surgical time a painful episiotomy scar nodule was also excised.One month after surgery there was a painful and fast growing perineal lesion at the episiotomy scarsite. MR was repeated and revealed an heterogeneous mass with cystic areas, casting the puborectalmuscle. The lesion had mainly intermediate signal intensity on T2-weighted images and low signalintensity on T1-weighted when compared to the adjacent muscles (Figure 2). Bilateral lymphoceles were noticed on axial and coronal T2-weighted images (Figure 3).Vaginal stump showed low signal intensity on T2-weighted images (Figure 2).DiscussionCervical carcinoma is the most common gynecologic malignancy worldwide [1]. It is the secondmost common cause of cancer related death in women, with the majority of affected women livingin third world countries [2]. Because of its epidemiological characteristics cervical carcinomacontinues to be staged at clinical examination.The revised FIGO staging system now recommends performing computed tomography or MRimaging when available [1].The most common histologic type of cervical carcinoma is squamous cell carcinoma (90%),followed by adenocarcinoma (5-10%). Other rare histologic types include small-cell carcinoma,adenosquamous carcinoma and lymphoma [3].Histological examination of cervical polyp and uterus revealed adenosquamous carcinoma. Theepisiotomy scar nodule was a metastasis. Cervical cancer is characterized by continuous invasive growth [2]. Metastatic disease occurstypically by local extension and lymphatic dissemination. Hematogenous metastases usually occurless frequently, mainly involving the liver, lung and bone. Previous reports have shown thatadvanced disease, bulky tumor, endometrial extension, and lymph node metastases are associatedwith an increased rate of distant metastases [5]. There are some rare cases of breast [4] , brain [5],bone [6], heart [7], soft tissue [8] and incisional site metastases [9].Symptoms are infrequent in the early stages of the disease, but post-coital bleeding, metrorrhagia,and diffuse pelvic pain are common symptoms in advanced disease [2]. In this patient cervicalcancer, was found during a routine medical appointment one month after delivery.MR is able to depict important prognostic findings, including tumor size, parametrial and pelvicsidewall invasion, bladder or rectal invasion, and lymph node metastases. Accurate riskstratification of patients with cervical carcinoma is used to determine the most appropriatemanagement pathway [1]. On T2-weighted images, cervical carcinoma appears as an intermediateto high signal intensity mass that replaces the low signal intensity cervical stroma [1].MR is the first-line modality for follow up after radiation therapy and whenever tumor recurrence issuggested by clinical or gynecological findings [2].Radiotherapy and chemotherapy were performed for the persistent perineal disease which grewaggressively and showed no therapeutic response; lesion progression resulted in the extension intothe root of the thigh and abdominal wall.This case illustrates a rare presentation of a rare histologic type of cervical cancer, with anaggressive behavior, and a histologically proven metastasis of the episiotomy scar.Unfortunately, the patient died one year after diagnosis, due to complications related to progressionof the perineal disease.Final DiagnosisCervical adenosquamous carcinoma, with an episiotomy scar metastasis.Differential Diagnosis ListPerineal myxoid stromal tumour, Malignant degeneration of endometriosis of the episiotomy scar,Adenoid cystic carcinoma of Bartholin\'s gland, Granular cell tumor of vulva on episiotomy scar,Neurinoma of the episiotomy scar, Endometriosis of the episiotomy scar, Abscess of the episiotomyscar, Foreign body in an episiotomy scarFiguresFigure 1 Pelvic MRT2-weighted image on sagittal plane shows an 3 x 1 cm, anterior cervical tumor (arrow). © Roque A, Department of Radiology, Centro Hospitalar de Lisbon Ocidental, Lisboa, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Staging;  Special Focus: Neoplasia; Axial oblique T2-weighted image shows a linear densification of the peri-rectal fat with lowsignal intensity on the episiotomy site (arrow). © Roque A, Department of Radiology, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal. Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Staging;  Special Focus: Neoplasia; Axial oblique T1-weighted whit fat saturation image shows a linear densification of theperi-rectal fat with high signal intensity on the episiotomy site (arrow). © Roque A, Department of Radiology, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal. Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Staging;  Special Focus: Neoplasia; Figure 2 Pelvic MRT1-weighted image on axial plane showing a low intensity mass (arrow) on the rightischiorectal fossa. © Cunha TM, Departement of Radiology, Instituto Português de Oncologia de Lisboa Francisco Gentil, LisboN, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Staging;  Special Focus: Neoplasia; T2-weighted images on axial plane showing an heterogeneous intermediate signal intensitymass with cystic areas (arrow) on the right ischiorectal fossa. © Cunha TM, Department of Radiology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Staging;  Special Focus: Neoplasia; T2-weighted images on coronal and sagittal planes showing an heterogeneous intermediatesignal intensity mass with cystic areas (arrow) on the right ischiorectal fossa and normalappearance of the vaginal stump after hysterectomy. © Cunha TM, Department of Radiology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Staging;  Special Focus: Neoplasia; Figure 3 Pelvic MRT2-weighted image on coronal plane showing bilateral high intensity signal lymphoceles(arrows). © Cunha T M, Department of Radiology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal Area of Interest: Genital / Reproductive system female;  Imaging Technique: MR;  Procedure: Staging;  Special Focus: Neoplasia; MeSH [C04.588.945.418.948.170]Cervix NeoplasmsTumors or cancer of the uterine cervix. [C04.697.700]Neoplasm, ResidualRemnant of a tumor or cancer after primary, potentially curative therapy. (Dr. Daniel Masys,written communication)References[1] Freeman SJ, Aly AM, Kataoka MY, Addley HC, Reinhold C, Sala E. (2012) The revised FIGOstaging system for uterine malignancies: implications for MR imaging Radiographics 32(6):1805-27[2] Hamm B, Forstner R, Baert A, Knauth M, Sartor K (2007) MR and CT of the Female PelvisSpringer-Verlag Berlin Heidelberg (121-123,126,164)[3] Sala E, Walkely S, Senior E, Lomas D (2007) MRI of malignant neoplasms of the uterinecorpus and cervix AJR Am J of Roentgenology 188(6):1577-87[4] Kumar L, Tanwar R, Karak P, Shukla N (1994) Breast metastasis from primary cervical cancerAsia Oceania J Obstet Gynaecol 20(4):345-8[5] Hwang JH, Yoo HJ, Lim MC, Seo SS, Kang S, Kim JY, Park SY. (2013) Brain metastasis inpatients with uterine cervical cancer J Obstet Gynaecol Research 39(1):287-91[6] Dewdney A, Selvarajah U. (2010) A 'hot' leg: a rare case of isolated long bone metastases fromcervical cancer Anticancer Research 30(7):2949-51[7] Jamshed A, Khafaga Y, El-Husseiny G, Gray AJ, Manji M. (1996) Pericardial metastasis incarcinoma of the uterine cervix Gynecologic Oncology 61(3):451-3[8] Kim CJ, Day S, Yeh KA. (2001) Metastatic soft tissue squamous cell carcinoma The AmericanSurgeon 67(2):111-4[9] Iavazzo C, Madhuri K, Tailor A, Butler-Manuel S. (2012) Incisional site metastasis in a patientwith cervical carcinoma: a case report and review of the literature Case Reports in Obstetrics andGynecology 2012: 593732CitationLara Delgado , Teresa Margarida Cunha  (2013, Sep. 9) 1 2 Atypical presentation of a cervical cancer {Online}URL: http://www.eurorad.org/case.php?id=10912

Atypical presentation of a cervical cancer

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Atypical presentation of a cervical cancer

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