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Recurrent cervical cancer presenting as small bowel obstruction
GYNECOLOGIC
ONCOLOGY
22, 109-114 (1985)
Recurrent Cervical Cancer Presenting as Small Bowel Obstruction’ WAYNE Division
CHRISTOPHERSON, M.D., RICHARD VOET, AND HERBERT J. BUCHSBAUM, M.D.’
of Gynecologic Oncology; Department of Obstetrics and Gynecology; Pathology, Southwestern Medical School, University of Texas Health Dallas, Texas 75235
M.D., and Department Science Center,
of
Received July 10, 1984 A case report of a patient with recurrent squamous cell carcinoma of the cervix is presented in whom the recurrence was confined to the gastrointestinal tract and omentum in the upper abdomen. No evidence of recurrent disease was present in the pelvis or paraaortic lymph node bearing areas. Possible mechanisms for this unusual location of recurrence are discussed. o 1985 Academic press, IIIC.
Carcinoma of the cervix tends to spread in an orderly, predictable fashion. Early spread is by direct extension to the vagina and paracervical tissues. Lymphatic spread is initially to the pelvic lymph nodes, with later involvement of the paraaortic nodes. In recurrent disease, particularly following radiation therapy, the spread may be by aberrant routes to unusual sites. We are presenting a patient who was treated with radiation therapy for stage IIIB squamous cell carcinoma of the cervix. She later presented with intestinal obstruction, and was found to have recurrent carcinoma involving the greater curvature of the stomach, transverse colon, two loops of proximal ileum, and omentum, as well as the peritoneum and fascia of the anterior abdominal wall. All of these structures were involved in a single mass of metastatic squamous cell carcinoma, causing obstruction of the gastrointestinal tract. CASE REPORT L. A., a 42-year-old white female, presented in October of 1981 with postcoital bleeding. Physical examination was unremarkable with the exception of the pelvic examination which revealed a 5 to 6 cm exophytic, necrotic, tumor mass replacing the cervix and involving the vaginal fornices. The parametria were indurated bilaterally, with the induration extending to the right pelvic sidewall. A biopsy was obtained which revealed invasive epidermoid carcinoma of the cervix. A tumor survey consisting of a chest X ray, an intravenous pyelogram, cystoscopy, and proctoscopy was negative for metastatic disease. A pretreatment celiotomy ’ This work was supported in part by the American Cancer Society Clinical Fellowship. ’ To whom reprint requests should be addressed at: Department of Obstetrics and Gynecology, University of Pittsburgh, Magee-Womens Hospital, Pittsburgh, Pa. 15213. 109
0090-8258/85 $1.50 Copyright 0 1985 by Academic Press, Inc. All rights of reproduction in any form reserved.
110
CHRISTOPHERSON,
VOET,
AND
BUCHSBAUM
for evaluation of paraaortic lymph nodes was then performed. This revealed the omentum, bowel, and liver to be free of disease. The common iliac, paraaortic, and scalene lymph nodes were excised. Histologic examination of the retroperitoneal and scalene lymph nodes revealed reactive hyperplasia, with no evidence of metastatic carcinoma. Postoperatively she was treated with 5058 rad of external radiation and two radium applications. In January of 1984 she presented to the clinic with a l-month history of intermittent nausea and vomiting accompanied by upper abdominal pain. Physical examination revealed a 10 x 10 cm, firm, fixed epigastric mass which was tender to palpation. Bowel sounds were present and hyperactive. Pelvic examination revealed smooth induration in the parametrial and paracervical areas, with no evidence of recurrent disease. She was admitted to the hospital for further evaluation. An intravenous pyelogram, barium enema, and upper gastrointestinal series were performed. The pyelogram was unremarkable. The gastrointestinal studies revealed a mass in the upper abdomen compressing the stomach, circumferentially constricting the transverse colon, and obstructing the proximal ileum. A fine needle aspiration biopsy of the epigastric mass was performed which revealed squamous cell carcinoma. Because of her obstructive symptomatology, an exploratory laparotomy was performed. At surgery she was found to have a 10 x lo-cm mass in the epigastrium, involving the peritoneum and fascia of the anterior abdominal wall, the greater curvature of the stomach, the mid-portion of the transverse colon, two loops of proximal ileum, and the omentum. All of the above mentioned structures were involved in a single tumor mass. Examination of the remainder of the abdomen revealed both hemidiaphragms, the liver, the remainder of the small and large bowel, as well as the pelvic and paraaortic lymph node-bearing areas, to be free of disease. Examination of the paracervical and parametrial tissues revealed only radiation fibrosis. The tumor mass was resected in its entirety by excising the involved portion of the anterior abdominal wall, performing a partial gastrectomy, resecting the mid-segment of the transverse colon, and resecting the involved portions of the proximal ileum. Surgical staples were used for the gastric resection, as well as to reanastomose both large and small bowel. The abdominal wall defect was closed primarily. Histopathologic review of the surgical specimen revealed metastatic epidermoid carcinoma involving the above mentioned structures (Fig. lA-C). Postoperatively the patient was given nutritional support by intravenous hyperalimentation. She recovered uneventfully and was discharged on the 14th postoperative day, and is currently receiving chemotherapy. DISCUSSION
This patient is unusual in that she presented with a partial small bowel obstruction secondary to recurrent carcinoma of the cervix with the recurrence confined to the upper abdomen. At the time of exploration she was found to have a single mass involving the anterior abdominal wall, omentum, greater curvature of the stomach, transverse colon, and obstructing the proximal ileum.
CASE
REPORTS
IA-C. Photomicrographs demonstrating metastatic epidermoid carcinoma. FIG. 1A. Carcinoma (arrow) involving stomach wall from greater curvature.
FIGS.
111
112
CHRISTOPHERSON, VOET, AND BUCHSBAUM
FIG. IB.
Epidermoid
carcinoma (arrow) in submucosa of ileum.
CASE
FIG.
1C.
REPORTS
113
Colonic mucosa is seen at top, with metastatic tumor in bowel wall (arrow).
Bowel metastases from cervical carcinoma are relatively infrequent. Buchsbaum [l] reported bowel metastases in 12 of 115 patients with cervical carcinoma who underwent pretreatment celiotomy. Bowel metastases have been reported to occur in between 6.3 and 34.6% of autopsy cases [2,3]. The mechanism, or mechanisms, responsible for isolated gastrointestinal metastases in the upper abdomen is not clear. There are three possible explanations. (1) Hematogenous spread may account for this unusual site of recurrence. Spread by the hematogenous route in cervical carcinoma occurs in about 5% of cases, but only 8% of these hematogenous metastases involve the bowel 141. (2) A less likely explanation involves lymphatic dissemination of cervical malignancy to the upper abdominal wall. The lymphatics of the lower abdominal wall and paraumbilical regions normally drain in a caudad fashion toward the groins, while the lymphatic drainage of the upper abdomen is cephalad to the axilla. However, following obstruction of the pelvic lymphatics by tumor or radiation fibrosis, tumor emboli may travel in a retrograde fashion, cephalad through the lymphatics of the lower abdominal wall, and then proceed in an antegrade fashion into the upper abdomen [5]. (3) The third, and most likely, mechanism for spread of cervical carcinoma to the upper abdomen is by intraperitoneal seeding. Approximately 20% of patients with stage III cervical carcinoma will have positive peritoneal cytology [ 11. Spread by this mechanism is a distinct possibility when we consider that the omentum was probably the site of first involvement. This patient also demonstrates the importance of surgical exploration in recurrent
114
CHRISTOPHERSON,
VOET,
AND
BUCHSBAUM
cervical carcinoma. Not only was her bowel obstruction left free of clinical disease following surgery.
corrected,
but she was
REFERENCES 1. Buchsbaum, H. J. Extrapelvic Gynecol.
133, 814-824
lymph node metastases in cervical carcinoma, Amer.
J. Obsrer.
(1979).
2. Morris, J. McL., and Meigs, J. V. Carcinoma of the cervix: Statistical evaluation of 138 and results of treatment, Surg. Gynecol. Obsret. 90, 135-150 (1950). 3. Kelly, J. W. M., Parsons, L., Friedell, G. H., et al. A pathologic study in 55 autopsies radical surgery for cancer of the cervix, Surg. Gynecol. Obster. 110, 423-432 (1960). 4. Lifshitz, S. G., and Buchshaum, H. J. The spread of cervical carcinoma in Gynecology Obstetrics, Vol. 4 Gynecologic Oncology (J. Sciarra, Ed.), Harper and Row, Hagerstown, Ch. 6, p. 5 (1980). 5. Brown, R. C., and Buchsbaum, H. J. Lymphatico-peritoneal fistula. Obsret. Gynecol. 47, 485 (1976).
cases after and
Md., 482-
ONCOLOGY
22, 109-114 (1985)
Recurrent Cervical Cancer Presenting as Small Bowel Obstruction’ WAYNE Division
CHRISTOPHERSON, M.D., RICHARD VOET, AND HERBERT J. BUCHSBAUM, M.D.’
of Gynecologic Oncology; Department of Obstetrics and Gynecology; Pathology, Southwestern Medical School, University of Texas Health Dallas, Texas 75235
M.D., and Department Science Center,
of
Received July 10, 1984 A case report of a patient with recurrent squamous cell carcinoma of the cervix is presented in whom the recurrence was confined to the gastrointestinal tract and omentum in the upper abdomen. No evidence of recurrent disease was present in the pelvis or paraaortic lymph node bearing areas. Possible mechanisms for this unusual location of recurrence are discussed. o 1985 Academic press, IIIC.
Carcinoma of the cervix tends to spread in an orderly, predictable fashion. Early spread is by direct extension to the vagina and paracervical tissues. Lymphatic spread is initially to the pelvic lymph nodes, with later involvement of the paraaortic nodes. In recurrent disease, particularly following radiation therapy, the spread may be by aberrant routes to unusual sites. We are presenting a patient who was treated with radiation therapy for stage IIIB squamous cell carcinoma of the cervix. She later presented with intestinal obstruction, and was found to have recurrent carcinoma involving the greater curvature of the stomach, transverse colon, two loops of proximal ileum, and omentum, as well as the peritoneum and fascia of the anterior abdominal wall. All of these structures were involved in a single mass of metastatic squamous cell carcinoma, causing obstruction of the gastrointestinal tract. CASE REPORT L. A., a 42-year-old white female, presented in October of 1981 with postcoital bleeding. Physical examination was unremarkable with the exception of the pelvic examination which revealed a 5 to 6 cm exophytic, necrotic, tumor mass replacing the cervix and involving the vaginal fornices. The parametria were indurated bilaterally, with the induration extending to the right pelvic sidewall. A biopsy was obtained which revealed invasive epidermoid carcinoma of the cervix. A tumor survey consisting of a chest X ray, an intravenous pyelogram, cystoscopy, and proctoscopy was negative for metastatic disease. A pretreatment celiotomy ’ This work was supported in part by the American Cancer Society Clinical Fellowship. ’ To whom reprint requests should be addressed at: Department of Obstetrics and Gynecology, University of Pittsburgh, Magee-Womens Hospital, Pittsburgh, Pa. 15213. 109
0090-8258/85 $1.50 Copyright 0 1985 by Academic Press, Inc. All rights of reproduction in any form reserved.
110
CHRISTOPHERSON,
VOET,
AND
BUCHSBAUM
for evaluation of paraaortic lymph nodes was then performed. This revealed the omentum, bowel, and liver to be free of disease. The common iliac, paraaortic, and scalene lymph nodes were excised. Histologic examination of the retroperitoneal and scalene lymph nodes revealed reactive hyperplasia, with no evidence of metastatic carcinoma. Postoperatively she was treated with 5058 rad of external radiation and two radium applications. In January of 1984 she presented to the clinic with a l-month history of intermittent nausea and vomiting accompanied by upper abdominal pain. Physical examination revealed a 10 x 10 cm, firm, fixed epigastric mass which was tender to palpation. Bowel sounds were present and hyperactive. Pelvic examination revealed smooth induration in the parametrial and paracervical areas, with no evidence of recurrent disease. She was admitted to the hospital for further evaluation. An intravenous pyelogram, barium enema, and upper gastrointestinal series were performed. The pyelogram was unremarkable. The gastrointestinal studies revealed a mass in the upper abdomen compressing the stomach, circumferentially constricting the transverse colon, and obstructing the proximal ileum. A fine needle aspiration biopsy of the epigastric mass was performed which revealed squamous cell carcinoma. Because of her obstructive symptomatology, an exploratory laparotomy was performed. At surgery she was found to have a 10 x lo-cm mass in the epigastrium, involving the peritoneum and fascia of the anterior abdominal wall, the greater curvature of the stomach, the mid-portion of the transverse colon, two loops of proximal ileum, and the omentum. All of the above mentioned structures were involved in a single tumor mass. Examination of the remainder of the abdomen revealed both hemidiaphragms, the liver, the remainder of the small and large bowel, as well as the pelvic and paraaortic lymph node-bearing areas, to be free of disease. Examination of the paracervical and parametrial tissues revealed only radiation fibrosis. The tumor mass was resected in its entirety by excising the involved portion of the anterior abdominal wall, performing a partial gastrectomy, resecting the mid-segment of the transverse colon, and resecting the involved portions of the proximal ileum. Surgical staples were used for the gastric resection, as well as to reanastomose both large and small bowel. The abdominal wall defect was closed primarily. Histopathologic review of the surgical specimen revealed metastatic epidermoid carcinoma involving the above mentioned structures (Fig. lA-C). Postoperatively the patient was given nutritional support by intravenous hyperalimentation. She recovered uneventfully and was discharged on the 14th postoperative day, and is currently receiving chemotherapy. DISCUSSION
This patient is unusual in that she presented with a partial small bowel obstruction secondary to recurrent carcinoma of the cervix with the recurrence confined to the upper abdomen. At the time of exploration she was found to have a single mass involving the anterior abdominal wall, omentum, greater curvature of the stomach, transverse colon, and obstructing the proximal ileum.
CASE
REPORTS
IA-C. Photomicrographs demonstrating metastatic epidermoid carcinoma. FIG. 1A. Carcinoma (arrow) involving stomach wall from greater curvature.
FIGS.
111
112
CHRISTOPHERSON, VOET, AND BUCHSBAUM
FIG. IB.
Epidermoid
carcinoma (arrow) in submucosa of ileum.
CASE
FIG.
1C.
REPORTS
113
Colonic mucosa is seen at top, with metastatic tumor in bowel wall (arrow).
Bowel metastases from cervical carcinoma are relatively infrequent. Buchsbaum [l] reported bowel metastases in 12 of 115 patients with cervical carcinoma who underwent pretreatment celiotomy. Bowel metastases have been reported to occur in between 6.3 and 34.6% of autopsy cases [2,3]. The mechanism, or mechanisms, responsible for isolated gastrointestinal metastases in the upper abdomen is not clear. There are three possible explanations. (1) Hematogenous spread may account for this unusual site of recurrence. Spread by the hematogenous route in cervical carcinoma occurs in about 5% of cases, but only 8% of these hematogenous metastases involve the bowel 141. (2) A less likely explanation involves lymphatic dissemination of cervical malignancy to the upper abdominal wall. The lymphatics of the lower abdominal wall and paraumbilical regions normally drain in a caudad fashion toward the groins, while the lymphatic drainage of the upper abdomen is cephalad to the axilla. However, following obstruction of the pelvic lymphatics by tumor or radiation fibrosis, tumor emboli may travel in a retrograde fashion, cephalad through the lymphatics of the lower abdominal wall, and then proceed in an antegrade fashion into the upper abdomen [5]. (3) The third, and most likely, mechanism for spread of cervical carcinoma to the upper abdomen is by intraperitoneal seeding. Approximately 20% of patients with stage III cervical carcinoma will have positive peritoneal cytology [ 11. Spread by this mechanism is a distinct possibility when we consider that the omentum was probably the site of first involvement. This patient also demonstrates the importance of surgical exploration in recurrent
114
CHRISTOPHERSON,
VOET,
AND
BUCHSBAUM
cervical carcinoma. Not only was her bowel obstruction left free of clinical disease following surgery.
corrected,
but she was
REFERENCES 1. Buchsbaum, H. J. Extrapelvic Gynecol.
133, 814-824
lymph node metastases in cervical carcinoma, Amer.
J. Obsrer.
(1979).
2. Morris, J. McL., and Meigs, J. V. Carcinoma of the cervix: Statistical evaluation of 138 and results of treatment, Surg. Gynecol. Obsret. 90, 135-150 (1950). 3. Kelly, J. W. M., Parsons, L., Friedell, G. H., et al. A pathologic study in 55 autopsies radical surgery for cancer of the cervix, Surg. Gynecol. Obster. 110, 423-432 (1960). 4. Lifshitz, S. G., and Buchshaum, H. J. The spread of cervical carcinoma in Gynecology Obstetrics, Vol. 4 Gynecologic Oncology (J. Sciarra, Ed.), Harper and Row, Hagerstown, Ch. 6, p. 5 (1980). 5. Brown, R. C., and Buchsbaum, H. J. Lymphatico-peritoneal fistula. Obsret. Gynecol. 47, 485 (1976).
cases after and
Md., 482-