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Cerebral metastasis in cervical carcinoma
276
Communications
Cerebral cervical
metastasis carcinoma
HERBERT ALFRED
J. C.
September 15, 1972 Am. J. Obstet. Gynecol.
in brief
BUCHSBAUM, RICE,
Departments of Obstetrics and Radiology, University College of Medicine, Iowa
and confirmed by craniotomy. cal course and angiographic basis of this report.
in
M.D.
M.D. and Gynecology of Iowa, City, Iowa
C E R v I c A L carcinoma spreads primarily by local extension, with distant involvement a relatively late occurrence. The incidence of distant metastases is related to the stage of disease and is found most commonly with tumor involvement of the para-aortic nodes. Liver, lung, and bone are the most common extranodal sites of metastases from cervical carcinoma. Belmey,l in 1933, found no cerebral metastases at autopsy in 116 cases of advanced cervical carcinoma. Fifteen years later, Bnmschwig and Pierces failed to find a single brain metastasis in 65 cases. The antemortem diagnosis of cerebral metastasis was so rare as to warrant a case report.3 We are reporting upon a patient with Stage IB anaplastic carcinoma of the cervix with negative para-aortic lymph nodes and a brain metastasis. The brain lesion was diagnosed by physical examination, demonstrated by electroencephalogram, cerebral angiogram, and isotope scan,
Fig. and
1. Photomicrograph of cervical biopsy eosin. Original magnification x250.)
The unusual clinifindings form the
The 34-year-old, para 3-O-O-3 patient was admitted to the University of Iowa Hospitals with intermenstrual and postcoital bleeding and severe headaches and tinnitus. Neurological examination suggested a right hemisphere dysfunction. Pelvic examination revealed an irregular, granular lesion on the cervix which did not involve the fornices. The uterus was irregularly enlarged by myomas to 12 weeks’ gestational size. The paracervical areas were free of induration. Cervical and endometrial biopsies revealed anaplastic epidermoid carcinoma (Fig. 1) , and a metastatic tumor survey was negative. The patient’s disease was clinically staged as a Stage IB cervical carcinoma. An electroencephalogram was interpreted as abnormal, with diffuse and focal aspects, the latter implicating the right hemisphere. A technetium99m brain scan revealed a single large area of increased uptake over the right parietal-occipital region (Fig. 2). A right carotid angiogram showed a large round mass in the parietal cerebrum around which both arteries and veins were draped. There was a vascular stain around the periphery of the mass and signs of arteriovenous shunting. In the late venous phase, there was a paucity of contrast media in the center of the mass, indicative of either cystic or necrotic change. There was little space between the vascular stain and the draped vessels, indicating minimal edema. The mass was supplied by branches of both the anterior cerebral and middle cerebral arteries (Fig. 3). The radiographic diagnosis was glioblastoma multiforme.
showing
an anaplastic
carcinoma.
(Hematoxylin
Volume Number
114 2
Communications
One week after admission to the hospital, removal of a 5 by 5 cm. mass in the brain was carried out through a right parietal-occipital craniotomy. The histologic appearance of this lesion was similar to that of the tissue obtained at cervical biopsy: anaplastic epidermoid carcinoma. Three weeks later, the patient underwent laparotomy. The clinical stage of the carcinoma was confined by the absence of paracervical or parametrial induration. Several enlarged para-aortic lymph nodes were excised at the level of the third
Fig. 2. Data-averaged parietal
scintiscan
demonstrating
in brief
lumbar vertebra but failed to reveal metastatic tumor. Biopsy of an isolated and fixed pelvic lymph node revealed metastatic anaplastic carcinoma similar to the previous biopsies. The patient was started on cyclophosphamide in the postoperative period and was discharged approximately one month after admission. Improved control of
area
therapeutic the central
of abnormal
nuclide
techniques lesion has
activity
in
with better altered the
right
cerebrum.
Fig. 3. Right cerebral angiogram showing stain and draped vessels (double arrows). (anterior cerebral artery) and lower arrow
277
large round mass in parietal cerebrum with Double vascular supply is indicated by upper (middle cerebral artery).
tumor arrow
278
Communications
in
September Am. J. Obstet.
brief
natural history of cervical carcinoma. Fewer patients are now dying of obstructive uropathy. As the result of prolonged life, increased numbers will present with metastatic disease. A recent autopsy study of patients treated for cervical carcinoma reported a 3.2 per cent incidence of brain metastases,* representing a significant increase over previous reports. It becomes important, therefore, to utilize all available techniques for the detection of brain metastases in cervical carcinoma. The findings of a single large area of increased radionuclide activity in the right cerebrum and the angiographic characteristics in our patient were consistent with a primary cerebral neoplasm: glioblastoma multiforme. While primary cerebral neoplasm and metastatic lesions may have overlapping angioarchitectural features, the findings in our patient suggested a primary neoplasm, since metastatic lesions are usually characterized by: (1) vascular supply by single major cerebral vessels; (2) edema (in metastatic lesions, it is far greater than in primary tumors, resulting in vascular displacement) ; (3 ) lack of arteriovenous
15, 1972 Gynecol.
shunting (this is unusual in metastatic tumors) ; (4) lack of vascular aneurysmal dilatation (this is rare in metastatic lesions but common in glioblastomas) ; (5 ) central degeneration and necrosis (common in metastatic tumors). The early clinical stage, confirmed by laparotomy, and the absence of para-aortic nodal involvement make this case of cerebral metastasis secondary to cervical carcinoma unusual. The angiographic findings in this patient suggest that as experience with brain metastases secondary to cervical carcinoma increases the generally accepted criteria for metastatic brain lesions may have to be modified. REFERENCES
1. Behney, C. A.: AM. .T. OBSTET. GYNECOL. 26: 608, 1933. 2. Brunschwig, A., and Pierce, V.: AM. J. OBSTET. GYNECOL. 56: 1134. 1948. 3. Andrew, J. D.: J. Obstet. Gynaecol. Br. Emp. 60: 545, 1953. 4. Badib, A. O., Kurohara, S. S., Webster, J. H., and Pickren, J. W.: Cancer 21: 434, 1968.
Communications
Cerebral cervical
metastasis carcinoma
HERBERT ALFRED
J. C.
September 15, 1972 Am. J. Obstet. Gynecol.
in brief
BUCHSBAUM, RICE,
Departments of Obstetrics and Radiology, University College of Medicine, Iowa
and confirmed by craniotomy. cal course and angiographic basis of this report.
in
M.D.
M.D. and Gynecology of Iowa, City, Iowa
C E R v I c A L carcinoma spreads primarily by local extension, with distant involvement a relatively late occurrence. The incidence of distant metastases is related to the stage of disease and is found most commonly with tumor involvement of the para-aortic nodes. Liver, lung, and bone are the most common extranodal sites of metastases from cervical carcinoma. Belmey,l in 1933, found no cerebral metastases at autopsy in 116 cases of advanced cervical carcinoma. Fifteen years later, Bnmschwig and Pierces failed to find a single brain metastasis in 65 cases. The antemortem diagnosis of cerebral metastasis was so rare as to warrant a case report.3 We are reporting upon a patient with Stage IB anaplastic carcinoma of the cervix with negative para-aortic lymph nodes and a brain metastasis. The brain lesion was diagnosed by physical examination, demonstrated by electroencephalogram, cerebral angiogram, and isotope scan,
Fig. and
1. Photomicrograph of cervical biopsy eosin. Original magnification x250.)
The unusual clinifindings form the
The 34-year-old, para 3-O-O-3 patient was admitted to the University of Iowa Hospitals with intermenstrual and postcoital bleeding and severe headaches and tinnitus. Neurological examination suggested a right hemisphere dysfunction. Pelvic examination revealed an irregular, granular lesion on the cervix which did not involve the fornices. The uterus was irregularly enlarged by myomas to 12 weeks’ gestational size. The paracervical areas were free of induration. Cervical and endometrial biopsies revealed anaplastic epidermoid carcinoma (Fig. 1) , and a metastatic tumor survey was negative. The patient’s disease was clinically staged as a Stage IB cervical carcinoma. An electroencephalogram was interpreted as abnormal, with diffuse and focal aspects, the latter implicating the right hemisphere. A technetium99m brain scan revealed a single large area of increased uptake over the right parietal-occipital region (Fig. 2). A right carotid angiogram showed a large round mass in the parietal cerebrum around which both arteries and veins were draped. There was a vascular stain around the periphery of the mass and signs of arteriovenous shunting. In the late venous phase, there was a paucity of contrast media in the center of the mass, indicative of either cystic or necrotic change. There was little space between the vascular stain and the draped vessels, indicating minimal edema. The mass was supplied by branches of both the anterior cerebral and middle cerebral arteries (Fig. 3). The radiographic diagnosis was glioblastoma multiforme.
showing
an anaplastic
carcinoma.
(Hematoxylin
Volume Number
114 2
Communications
One week after admission to the hospital, removal of a 5 by 5 cm. mass in the brain was carried out through a right parietal-occipital craniotomy. The histologic appearance of this lesion was similar to that of the tissue obtained at cervical biopsy: anaplastic epidermoid carcinoma. Three weeks later, the patient underwent laparotomy. The clinical stage of the carcinoma was confined by the absence of paracervical or parametrial induration. Several enlarged para-aortic lymph nodes were excised at the level of the third
Fig. 2. Data-averaged parietal
scintiscan
demonstrating
in brief
lumbar vertebra but failed to reveal metastatic tumor. Biopsy of an isolated and fixed pelvic lymph node revealed metastatic anaplastic carcinoma similar to the previous biopsies. The patient was started on cyclophosphamide in the postoperative period and was discharged approximately one month after admission. Improved control of
area
therapeutic the central
of abnormal
nuclide
techniques lesion has
activity
in
with better altered the
right
cerebrum.
Fig. 3. Right cerebral angiogram showing stain and draped vessels (double arrows). (anterior cerebral artery) and lower arrow
277
large round mass in parietal cerebrum with Double vascular supply is indicated by upper (middle cerebral artery).
tumor arrow
278
Communications
in
September Am. J. Obstet.
brief
natural history of cervical carcinoma. Fewer patients are now dying of obstructive uropathy. As the result of prolonged life, increased numbers will present with metastatic disease. A recent autopsy study of patients treated for cervical carcinoma reported a 3.2 per cent incidence of brain metastases,* representing a significant increase over previous reports. It becomes important, therefore, to utilize all available techniques for the detection of brain metastases in cervical carcinoma. The findings of a single large area of increased radionuclide activity in the right cerebrum and the angiographic characteristics in our patient were consistent with a primary cerebral neoplasm: glioblastoma multiforme. While primary cerebral neoplasm and metastatic lesions may have overlapping angioarchitectural features, the findings in our patient suggested a primary neoplasm, since metastatic lesions are usually characterized by: (1) vascular supply by single major cerebral vessels; (2) edema (in metastatic lesions, it is far greater than in primary tumors, resulting in vascular displacement) ; (3 ) lack of arteriovenous
15, 1972 Gynecol.
shunting (this is unusual in metastatic tumors) ; (4) lack of vascular aneurysmal dilatation (this is rare in metastatic lesions but common in glioblastomas) ; (5 ) central degeneration and necrosis (common in metastatic tumors). The early clinical stage, confirmed by laparotomy, and the absence of para-aortic nodal involvement make this case of cerebral metastasis secondary to cervical carcinoma unusual. The angiographic findings in this patient suggest that as experience with brain metastases secondary to cervical carcinoma increases the generally accepted criteria for metastatic brain lesions may have to be modified. REFERENCES
1. Behney, C. A.: AM. .T. OBSTET. GYNECOL. 26: 608, 1933. 2. Brunschwig, A., and Pierce, V.: AM. J. OBSTET. GYNECOL. 56: 1134. 1948. 3. Andrew, J. D.: J. Obstet. Gynaecol. Br. Emp. 60: 545, 1953. 4. Badib, A. O., Kurohara, S. S., Webster, J. H., and Pickren, J. W.: Cancer 21: 434, 1968.