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Journal of Cancer Research and Therapeutics, Vol. 7, No. 2, April-June, 2011, pp. 183-184 Case Report Squamous cell carcinoma cervix with metastasis to pyloroduodenal region Jomon C Raphael1, Thomas Samuel Ram1, Simon Pavamani1, Lisa Choudharie2, PN Viswanathan1 1 Department of Radiation Oncology, Christian Medical College, Vellore, Tamilnadu, India Code Number: cr11042 PMID: 21768708 Abstract Metastatic squamous cell carcinoma in the pyloroduodenal region is uncommon. Cases have been reported where carcinoma of the lung has presented with metastasis to the duodenum. We present here the case of a 57-year-old lady who was found to have a metastasis in pyloroduodenal region while on treatment for carcinoma cervix. The patient developed features of intestinal obstruction and endoscopy showed a growth extending from pyloric antrum to first part of duodenum up to the junction of first and second part. A biopsy was taken from the duodenal area and it was reported as metastatic squamous cell carcinoma. This is one of the few reported cases of hematogenous visceral metastasis from carcinoma cervix. Since the disease was found to be advanced and her performance status was poor, she was provided best supportive care. Keywords: Carcinoma cervix, duodenum, pylorus, squamous cell carcinoma Introduction Metastatic squamous cell carcinoma in the pyloroduodenal region from carcinoma cervix is an extremely rare presentation. Most of the reported cases of squamous cell carcinoma in the pyloroduodenal region are from lung primary. [1] Although carcinoma cervix is known to spread locally and to the regional lymph nodes, hematogenous spread of tumor is comparatively rare. We are reporting a case of carcinoma cervix, which developed features of intestinal obstruction while on treatment and on subsequent evaluation was found to have metastatic squamous cell carcinoma extending from pyloric antrum to the first part of duodenum. Case Report A 57-year-old postmenopausal lady presented to the outpatient department of our institution with complaints of bleeding and white discharge per vagina of 2-month duration. She also gave history of lower abdominal pain, abdominal distension, and occasional vomiting. On clinical examination, she was found to have an exophytic growth arising from the cervix involving all the vaginal fornices and extending to lower third of vagina along the posterior vaginal wall. Both parametrium were infiltrated by the tumor up to pelvic side wall. Rectal mucosa was free of tumor. Her chest x-ray and ultrasound scan of abdomen were negative for metastasis. However, there was bilateral moderate hydroureteronephrosis. Cystourethroscopy was normal. Computed tomography scan chest, abdomen, and pelvis were not performed as it is not part of our standard institutional protocol. The biopsy from the exophytic growth in cervix was reported as a moderately differentiated squamous cell carcinoma. According to the current standard of care, she was started on external radiotherapy and concurrent chemotherapy with cisplatin. [2] External radiotherapy was delivered using four field box technique, using Cobalt 60 beam (Theratron 780C) at 2 Gy per fraction, 5 days in a week. During the third week of her treatment, she had developed recurrent vomiting and constipation. Since clinically she had no signs of intestinal obstruction and her plain X-ray of abdomen did not show features of obstruction, she was managed symptomatically and conservatively. Subsequently, she complained of persistent epigastric pain and vomiting with few episodes of coffee-colored vomitus, so she was admitted in the hospital and evaluated. Her ultrasound abdomen did not show any features of intestinal obstruction or mass lesion. She underwent an upper gastrointestinal (GI) scopy. Her upper GI scopy revealed an eccentric growth extending from the pyloric antrum to the first part of duodenum along the anterior wall and medial part of the junction of first and second part of duodenum. A biopsy was taken from the duodenal lesion and it was reported as metastatic squamous cell carcinoma [Figure - 1]. In view of the metastatic disease and deteriorating general condition, radiation therapy was discontinued and she was planned for best supportive care. A nasojejunostomy tube was introduced under endoscopic guidance and jejunostomy feeding started. Patient tolerated jejunostomy feeds and she was discharged from the hospital. Further option of oncological treatment of palliative chemotherapy was being planned after improving general condition. Discussion Carcinoma cervix is the most common malignancy in Indian women, with an incidence of 19 to 44 per 100 000 women. [3] A multivariate analysis of factors influencing the incidence of distant metastases showed clinical stage, endometrial extension noted by dilatation and curettage prior to therapy, and pelvic tumor control within each stage to be significant indicators of distant dissemination. [4] Metastases from carcinoma cervix are predictable and well studied. [4] Apart from local spread, the disease goes to the pelvic and para-aortic lymph nodes and then by hematogenous route to the supra- and infradiaphragmatic viscera. Pyloroduodenal metastasis is an uncommon presentation. The common malignancies which cause stomach or duodenal metastasis are malignant melanoma, renal cell carcinoma, colon, lung, and genitourinary carcinoma. [5] Most of the metastases from these sites were adenocarcinoma. Squamous cell carcinoma metastasizing to the pyloroduodenal region is extremely rare. The available case reports [1],[6] show that non-small-cell carcinoma of the lung is one of the primary sites which produces squamous cell metastasis to duodenum. So far, to the best of our knowledge, there is only one published case report of a cervical cancer metastasizing to the duodenum. [7] More than the rarity of the presentation, pyloroduodenal metastasis is always a difficult clinical situation to manage. Most of the cases presented with GI obstruction and bleeding. [5] It also shows the nature of advanced stage of the disease. Only supportive measures are the best therapeutic option in these kinds of situations. In the present case, a nasojejunostomy tube was introduced and nutritional support was restarted. A definite oncological therapy was difficult to initiate because of the poor performance status of the patient. Measures to address the hematogenous metastasis are one of the possible best therapeutic options for this type of situations. Conclusion Squamous cell carcinoma cervix with pyloroduodenal metastasis is an extremely rare presentation. This case report and literature review elucidates the possibilities of such a rare distant metastasis from the carcinoma cervix. There is a need to identify molecular markers of systemic relapse in cervical cancer. This will thus help in identifying the patients at risk of systemic relapse and justify the option of offering adjuvant systemic therapy despite aggressive locoregional treatment. References
Copyright 2011 - Journal of Cancer Research and Therapeutics The following images related to this document are available:Photo images[cr11042f1.jpg] |
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