Metastatic Cervical Cancer s/p Radiation Therapy, Radical Hysterectomy and Attempted Modified Internal Hemipelvectomy

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1 Metastatic Cervical Cancer s/p Radiation Therapy, Radical Hysterectomy and Attempted Modified Internal Hemipelvectomy Sarah Hutto,, MSIV Marc Underhill, M.D. January 27, 2009

2 Past History 45 yo female with history of metastatic cervical cancer s/p radiation treatment and hysterectomy is asked to obtain CT chest, abdomen and pelvis with contrast prior to consideration for modified internal hemipelvectomy due to developing mass in pelvic sidewall Pertinent Negatives: Patient denies pain with flexion, extension, abduction or adduction of the hip

3 Past Images

4 Past Images

5 Differential Diagnosis: Cervical Cancer Since we already know the diagnosis of this patient, we will look for signs of recurrence or extension of the cervical cancer. However, initially the patient would have had a differential diagnoses including: Endometrial Carcinoma Cervical Leiomyoma Cervicitis Pelvic Inflammatory Disease Uterine Cancer Vaginitis

6 Symptoms of Cervical Cancer Abnormal vaginal bleeding, especially postcoital Vaginal discomfort Malodorous discharge Dysuria If extension to pelvic wall: constipation, hematuria,, leg edema, leg pain

7 Pathogenesis of Cervical Cancer HPV infection including, especially including Types 16, 18, 31, 33 and 45 Smoking Immunosuppression Chlamydia infection Diet low in fruits and vegetables OCP use Multiple pregnancies Low SES DES exposure Family history of Cervical Cancer

8 Discussion Cervical Cancer Staging Stage 0: Carcinoma in situ Stage 1: Cervical carcinoma confined to the uterus Stage II: Cervical carcinoma invades beyond uterus but not to pelvic wall or to lower third of vagina Stage III: Tumor extends to the pelvic wall and/or involves the lower third of the vagina and/or causes hydronephrosis or nonfunctioning kidney Stage IVA: Spread to adjacent organs (bladder, rectum, or both) Stage IVB: Distant metastasis

9 Radiologic Findings in Cervical Cancer CT scanning is the imaging modality that is most commonly used in clinical practice to evaluate the extent of spread of cervical cancer The intravenous injection of contrast material is particularly useful in increasing the visualization of the cervical tumor and in facilitating the evaluation of the parametria and the pelvic sidewalls.

10 Radiologic Findings in Cervical Cancer The pitfalls and limitations of CT scanning in staging cervical cancer include the following: Understaging of cancers with microscopic tumor spread Overlap with the appearances of other malignant cervical or uterine masses and leiomyomata Misinterpreting normal parametrial vessels and/or uterine ligaments as evidence of parametrial tumor invasion Similarity in the appearances of the irregular cervical margins and adjacent soft- tissue stranding due to parametrial tumor invasion and due to parametritis that is secondary to surgical biopsy, cervical conization,, uterine curettage, or infection of the primary tumor Inability to exclude metastasis in normal-sized lymph nodes Inability to differentiate lymph node enlargement due to metastasis sis from that which results from benign causes Difficulty in definitively detecting tumor extension to the bladder der or rectal mucosa

11 Discussion, continued 5-year survival rates Stage I: >90% Stage II: 60-80% Stage III: 50% Stage IV: <30%

12 Discussion, continued Common sites of distant metastasis of cervical cancer Extrapelvic lymph nodes Liver Lung Bone

13 Current history Patient is asked to obtain CT study for surveillance purposes after an attempt at modified internal hemipelvectomy was aborted due the inability to free the neurovascular bundles in the pelvis due to large amounts of fibrosis. It was determined that the tumor was unresectable and attempt at surgery would cause compromise to the patient s s limb and/or life.

14 Findings: Current Images There is callus formation of the right pubic ramus fracture previously seen which designates healing There is a soft tissue mass extending from the right pelvic wall into the right hip joint

15 Findings In the follow-up surveillance CT of pelvis, it is noted that there is a hazy appearance of the area adjacent to the right sacroiliac joint. This could suggest a possible fracture. There is a lack of fatty replacement within the bone marrow in this area which would be expected if these changes were caused by known radiation therapy. This makes the possibility of a metastatic lesion more likely.

16 Follow-up The patient will be getting an MRI of the pelvis with gadolinium to further assess the right SI joint.

17 References Emedicine.. Cervical Cancer. overview Emedicine.. Cervix, Cancer: Imaging. imaging American Cancer Society. Detailed Guide: Cervical Cancer. g&dt=8 Pannu HK, Corl FM and EK Fishman. CT evaluation of Cervical Cancer: Spectrum of Disease. Radiographics. 2001;21: