|Year : 2016 | Volume
| Issue : 2 | Page : 134-137
Unusual presentation of metastatic carcinoma cervix with clinically silent primary identified by 18 F-flouro deoxy glucose positron emission tomography/computed tomography
Raja Senthil1, Ranjan Kumar Mohapatra2, Shripriya Srinivas3, Mouleeswaran Koramadai Sampath4, Sumati Sundaraiya1
1 Department of Nuclear Medicine, Global Hospitals, Vadapalani, India
2 Department of Medical Oncology, SIMS Hospital, Vadapalani, India
3 Department of Radiology, Global Hospitals, Vadapalani, India
4 Department of Histopathology, Global Health City, Chennai, Tamil Nadu, India
|Date of Web Publication||9-Mar-2016|
Department of Nuclear Medicine, Global Hospitals, No. 439, Perumbakkam, Chennai - 600 100, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Carcinoma cervix is the most common gynecological malignancy among Indian women. The common symptoms at presentation include abnormal vaginal bleeding, unusual discharge from the vagina, or pain during coitus and postmenopausal bleeding. Rarely, few patients may present with distant metastases without local symptoms. We present two patients with an unusual presentation of metastatic disease without any gynecological symptoms, where 18 F-flouro deoxy glucose positron emission tomography/computed tomography helped in identifying the primary malignancy in the uterine cervix.
Keywords: 18 F-flouro deoxy glucose positron emission tomography/computed tomography, carcinoma cervix, unknown primary
|How to cite this article:|
Senthil R, Mohapatra RK, Srinivas S, Sampath MK, Sundaraiya S. Unusual presentation of metastatic carcinoma cervix with clinically silent primary identified by 18 F-flouro deoxy glucose positron emission tomography/computed tomography. Indian J Nucl Med 2016;31:134-7
|How to cite this URL:|
Senthil R, Mohapatra RK, Srinivas S, Sampath MK, Sundaraiya S. Unusual presentation of metastatic carcinoma cervix with clinically silent primary identified by 18 F-flouro deoxy glucose positron emission tomography/computed tomography. Indian J Nucl Med [serial online] 2016 [cited 2020 Aug 7];31:134-7. Available from: http://www.ijnm.in/text.asp?2016/31/2/134/178267
| Introduction|| |
Cervical cancer is the most common gynecological malignancy among Indian women; squamous cell carcinoma being the most frequent histological type (85%) with adenocarcinomas is representing most of the remaining types (15%). Cervical cancer spreads regionally by direct extension to contiguous structures or by lymphatic dissemination to regional nodes and rarely through hematogeneous route to distant organs.  Cervical cancers may remain undiagnosed in our country despite adequate screening and present at an advanced stage. Symptoms such as abnormal vaginal bleeding may not occur in early cervical cancers and few advanced cases.
We present two patients with an unusual presentation of metastatic disease without any gynecological symptoms, where 18 F-flouro deoxy glucose (FDG) positron emission tomography/computed tomography (PET/CT) helped in identifying the primary malignancy in the uterine cervix.
| Case Reports|| |
A 61-year-old postmenopausal female presented with swelling on the left side of the neck with intermittent fever for 1 year. On examination, there were multiple enlarged lymph nodes in bilateral neck and axillary regions. Both breasts were clinically unremarkable. CT chest showed multiple enlarged nodes in the mediastinal and bilateral axillary regions. Both lungs were unremarkable. In view of generalized lymphadenopathy, possibilities of lymphoma, infection, or metastasis were considered. Left cervical lymph node biopsy revealed metastatic squamous cell carcinoma [Figure 1]a-c. Probable primary in the head and neck region was excluded by clinical examination, nasal endoscopy, and indirect laryngoscopy. 18 F-FDG PET/CT was hence done in search of primary which revealed multiple intensely hypermetabolic lymphadenopathies in the cervical, supraclavicular, axillary, mediastinal, abdominal, retroperitoneal, mesenteric, and iliac regions. The largest node was located in the left external iliac region, involving the left ureter causing left hydroureteronephrosis. In addition, there was a focal hypermetabolic heterogeneously enhancing soft tissue lesion in the uterine cervix, which appeared bulky and abutted the posterior bladder wall [Figure 2]. Subsequent clinical examination revealed 3 cm × 3 cm infiltrative growth replacing the cervix with involvement of upper vagina, all fornices and parametrium (clinical stage II B disease). Biopsy from the cervical growth confirmed nonkeratinizing moderately differentiated squamous cell carcinoma [Figure 1]d.
|Figure 1: Cervical lymph node biopsy shows metastatic squamous cell carcinoma and reactive lymphoid cells (a) with positivity for CK 19 (b) and P63 (c). Biopsy from cervical growth shows nonkeratinizing squamous cell carcinoma with large areas of necrosis (d)|
Click here to view
|Figure 2: 18F-flouro deoxy glucose positron emission tomography/computed tomography shows intensely hypermetabolic lymph nodes in the cervical, supraclavicular, axillary, mediastinal, abdominal, mesenteric, and iliac regions. The largest node in the left external iliac region involves the left ureter causing left hydroureteronephrosis (a-e) with a focal hypermetabolic heterogeneously enhancing soft tissue lesion (arrows) in the uterine cervix (f and g)|
Click here to view
A 45-year-old perimenopausal female presented with 1-year history of pain and swelling in the right hip. X-ray of right hip showed a large osteolytic lesion in the right ilium and acetabulum. Magnetic resonance imaging (MRI) of the pelvis was performed to further characterize the lesion which revealed a large 15 cm × 12 cm × 8 cm ill-defined destructive lesion arising from the right ilium with solid and cystic areas extending to the subarticular aspect of right acetabulum, right sacroiliac joint, and right side of sacrum [Figure 3]. Possibility of primary bone tumors such as giant cell tumor or telangiectatic osteosarcoma was considered based on clinical and radiological findings. However, Tru-cut biopsy from the mass showed metastatic keratinizing squamous cell carcinoma [Figure 4]a-c]. 18 F-FDG whole body PET/CT was performed to identify the primary malignancy, which showed intensely FDG avid destructive left iliac bone lesion (SUVmax: 13.2) with no other skeletal lesions. There was a focal hypermetabolic enhancing soft tissue lesion in the uterine cervix, raising suspicion of primary malignancy [Figure 5]. Review of MRI revealed an irregular T 2 hyperintense area in the anterior and posterior lips, predominantly in the right lateral aspect and reaching up to the lower uterine segment. Parametrium on both sides were clear (stage II A ). Papanicolaou smear forms the cervix showed high grade dysplastic squamous cells suggestive of squamous cell carcinoma [Figure 4]d.
|Figure 3: Magnetic resonance imaging study of pelvis (axial T2) shows a large destructive lesion arising from the right ilium with solid and cystic areas extending to the right acetabulum, right sacroiliac joint and right side of sacrum. (a) Axial T2 and sagittal short tau inversion recovery images show hyperintense area in the anterior and posterior lips of cervix predominantly involving right lateral aspect, reaching up to the lower uterine segment (b and c)|
Click here to view
|Figure 4: Tru-cut biopsy from the right iliac bone lesion shows a metastatic tumor with well-differentiated keratinizing squamous cells, keratin pearls, and hemorrhage (a-c). Papanicolaou smear from the cervix shows high grade dysplastic squamous cells suggestive of squamous cell carcinoma (d)|
Click here to view
|Figure 5: 18F-flouro deoxy glucose positron emission tomography/computed tomography shows solitary intensely 18F-flouro deoxy glucose avid extensive destructive left iliac bone lesion with solid cystic areas (a-c) with focal 18F-flouro deoxy glucose avid enhancing soft tissue lesion in the uterine cervix (d-g)|
Click here to view
| Discussion|| |
Cervical cancer, despite being potentially preventable with available screening methods, remains an important cause of morbidity and gynecological cancer deaths, particularly in developing countries such as India, where many patients present with advanced disease at the time of presentation. In the setting of carcinoma of unknown primary, the primary lesion is predominantly silent; hence, patients are asymptomatic. With recent advances in imaging technology, PET/CT as a single imaging modality plays an important and cost-effective role in the detection of unknown primary cancers. Available literature supports the role of PET in localizing primary site in just under half cases, mostly lung cancers.  However, except for sporadic reports, there are no data available regarding the incidence of primary gynecological malignancies identified by PET in patients with unknown primary. ,
Both cases presented above had an unusual clinical presentation for cancer cervix, who presented with metastases and no specific local symptoms such as abnormal vaginal bleeding. The first case of stage II B presented with generalized lymphadenopathy mimicking lymphoma or other infective causes. Two cases with similar nodal involvement have been previously reported, both cases of squamous cell carcinoma, with one of them being a human T-cell leukemia/lymphotropic virus type 1 carrier who also had metastases to other solid organs. , Supradiaphragmatic nodal spread particularly to supraclavicular and cervical regions is quite rare (0.1%), which indicates a high tumor burden and poor prognosis in patients with carcinoma cervix.  The distant nodal spread can be explained by the lymphatic drainage from the para-aortic nodes to the mediastinum and thoracic duct which communicates with the systemic venous system in the neck. 
The lumbar spine and pelvic bones are commonly involved by cervical cancers, either by direct parametrial extension or by hematogeneous dissemination via Batson's plexus.  Our second patient with stage II A disease had uninvolved parametrium, excluding the likelihood of direct involvement of the pelvic bone. Moreover, the lesion presented as an expansile lytic lesion with solid cystic areas mimicking a primary bone tumor such as malignant giant cell tumor, telangiectatic osteosarcoma, and Paget disease with osteosarcomatous malformation. As the biopsy from this lesion revealed a metastatic tumor with well-differentiated keratinizing squamous cells, the clinical impression of a primary bone tumor was changed to bone metastasis. The lesion in the cervix was the only additional finding in the whole body 18 F-FDG PET/CT, hence raised possibility of a primary malignancy, which was confirmed by papanicolaou smear. There are few case reports showing isolated skeletal metastases from cervical cancer in both axial and appendicular skeleton. , Although the site was not unusual, the radiological appearances of the bone lesion were unusual for metastasis arising from cervical cancer, probably by hematogeneous spread.
To conclude, 18 F-FDG PET/CT was helpful in identifying the clinically unsuspected primary site in both cases of squamous cell carcinoma who presented with metastasis (only nodal spread in the former and isolated bone metastasis in the later) indicating an aggressive behavior. By virtue of its whole body imaging, PET helped in the identification of primary in the cervix. Our findings also reiterate that classical clinical symptoms related to the primary may not always be present even at the advanced stage of the disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Senapathy JG, Umadevi P, Kannika PS. The present scenario of cervical cancer control and HPV epidemiology in India: An outline. Asian Pac J Cancer Prev 2011;12:1107-15.
Wang G, Wu Y, Zhang W, Li J, Wu P, Xie C. Clinical value of whole-body F-18 fluorodeoxyglucose positron emission tomography/computed tomography in patients with carcinoma of unknown primary. J Med Imaging Radiat Oncol 2013;57:65-71.
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.
Dandapani SV, Mhawech-Fauceglia P, Palmer S, Senikowich M, Lin YG. Lower extremity pain as initial presentation of cervical cancer. Gynecol Oncol Case Rep 2013;5:13-5.
Taguchi H, Daibata M, Kitagawa T, Kubonishi I, Asai M, Sagara Y, et al.
Generalized lymph node metastasis of early uterine cancer in an HTLV-I carrier. Cancer 1988;62:2614-7.
Henriksen E. The lymphatic spread of carcinoma of the cervix and of the body of the uterus; a study of 420 necropsies. Am J Obstet Gynecol 1949;58:924-42.
Tunio MA, Al Asiri M, Mohamed R, Al-Dandan S. Supraclavicular lymphadenopathy: Initial manifestation of metastasis in carcinoma of cervix. Case Rep Obstet Gynecol 2013;2013:409196.
Ratanatharathorn V, Powers WE, Steverson N, Han I, Ahmad K, Grimm J. Bone metastasis from cervical cancer. Cancer 1994;73:2372-9.
Pasricha R, Tiwari A, Aggarwal T, Lal P. Carcinoma of uterine cervix with isolated metastasis to fibula and its unusual behavior: Report of a case and review of literature. J Cancer Res Ther 2006;2:79-81.
Malek M, Kanafi AR, Pourghorban R, Nafisi-Moghadam R. Isolated humeral metastasis in uterine cervical cancer: A rare entity. J Clin Imaging Sci 2012;2:80.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]