Abstract
Abstract
Introduction
Case
In September 2008, a 38-year-old woman presented to the outpatient clinic with complaints of irregular vaginal bleeding and foul-smelling vaginal discharge. Her general, physical, and abdominal examinations were unremarkable. Speculum examination revealed an ulceroproliferative growth of 3.5×1.5 cm replacing the anterior lip of the cervix. The vaginal walls were free of the growth. On bimanual pelvic examination, the cervical growth was irregular and friable, the uterus appeared to be normal size, there was no adnexal mass, and the bilateral parametria were smooth. The rectal mucosa was smooth and mobile and there were no palpable inguinal lymph nodes. A biopsy was obtained from the cervical growth, which, on histopathology, was reported as nonkeratinizing SCC.
On investigation, the patient's hemogram, blood biochemistry, and chest radiographs were within normal limits. An abdominopelvic contrast-enhanced CT (CECT) scan did not suggest any enlarged pelvic or para-aortic lymphadenopathy. The patient was therefore staged as cervical cancer FIGO stage IB1. She subsequently underwent radical hysterectomy with ovarian transpositon and pelvic lymphadenectomy. The histopathology revealed moderately differentiated nonkeratinizing SCC of the cervix. There was no lymphovascular invasion and pelvic lymph nodes (18/18) were free of tumor.
The patient had irregular follow-up visits with the radiation oncology department and presented again after 6 months with complaints of vaginal discharge. Pelvic examination revealed an ulcerative lesion in the vaginal vault and upper 3 cm of the anterior vaginal wall. Magnetic resonance imaging showed recurrence in the pelvis in relation to the vaginal vault with extension to the parametrium. The patient received concurrent chemoradiation with cisplatin injections of 50 mg weekly, and whole pelvic radiotherapy doses of 46 Gy/23/4.3 weeks by four-field box technique. After 2 weeks of completion of concurrent chemoradiation, the patient was scheduled for intensity modulated radiation therapy (IMRT) using simultaneous integrated boost (SIB) to the local site; as intravaginal brachytherapy could not cover the residual disease at the vault and anterior vaginal wall in the upper part. She received a dose of 35Gy/15/3 weeks to gross tumor volume (GTV), which included the whole of the vaginal vault, the upper 3 cm of the vagina, and the parametrial extension, and 30Gy/15/3weeks to planning target volume (PTV), which included GTV plus 1 cm margin all around except posteriorly, where a margin of 0.8 cm was given in order to minimize the dose to the rectum.
After a disease-free interval of 9 months, the patient noticed a nodule in the right edge of the transverse abdominal scar (Fig. 1). On examination, the nodule was found to be located in the subcutaneous region measuring 4×3×3 cm, non-tender, and freely mobile over the underlying rectus muscle sheath. Supraclavicular lymph nodes were not enlarged. Fine-needle aspiration cytology from this nodule was performed, which revealed metastatic non-keratinizing SCC. A metastatic workup was done; chest radiograph was negative; and an abdominopelvic CECT scan did not suggest any enlarged pelvic or para-aortic lymphadenopathy, except for a 4×3×3 cm subcutaneous nodule in the anterior abdominal wall, superficial to the rectus sheath, with no extension to any other organ, suggestive of metastatic cervical cancer. Fluoro-2-deoxy-glucose-positron emission tomography (FDG-PET) was done, which showed an increased uptake of FDG, suggestive of metastasis in this subcutaneous nodule. Wide local excision, with the patient under general anesthesia, was performed. Histopathologic examination of the nodule, which measured 6×4×3.5 cm, showed features of non-keratinizing SCC. Sections from the peripheral and deep resection margins were free of tumor.
Image showing metastatic growth with surrounding indurated area on the right edge of the hysterectomy incision.
Results
The wound healed well over 2 weeks. The patient did not receive any further therapy, and has been disease free for 7 months.
Discussion
Metastatic carcinoma to the skin is an uncommon occurrence, with incidence rates of ≤5%. 4 Common primary sites of patients with skin metastasis are the breast, large intestine, lung, and ovary; skin metastasis is not often seen in cervical cancer. 5 Most common sites include the anterior abdominal wall, vulva, and anterior chest wall. Metastatic carcinoma in an abdominal wall incision has been frequently reported in cancers of the colon, kidney, and bladder. 5
Metastasis to the skin occurs either by direct extension or tumor implantation via the bloodstream or by lymphatics. The mode of spread is mainly lymphatic in cancer of the cervix; therefore, it has been posited by some authors that skin metastasis occurs by retrograde spread of tumor secondary to lymphatic obstruction. 7 However, others suggest that tumor implantation of malignancy at the time of surgery as a mechanism for skin incision metastasis. 8
Incidence of skin metastasis has been reported in all clinical stages from I to IV, with its involvement increasing from 0.8% in stage I to 4.8% in stage IV. 9 Adenocarcinoma and undifferentiated carcinoma in carcinoma of the cervix are found to be more often associated with skin metastasis rather than is SCC. 6
It commonly presents as a nodular lesion, but can also develop as plaques or an inflammatory telangectatic lesion of the skin. 10 The most common site of skin metastasis in carcinoma of the cervix is the anterior abdominal wall (especially at the drain site), vulva, and anterior chest wall. 9 Incisional site recurrence is rare, as in the index case, who presented with a painless nodular lesion on the right edge of the incisional scar.
Cutaneous metastasis has been reported to occur up to 10 years after initial diagnosis, with the average being <2 years. Skin metastasis carries a poor prognosis with a mean survival of ∼ 3 months, and is considered to be a pre-terminal event. 9
The intent of treatment in advanced recurrent disease is palliation by surgery, chemotherapy, or radiation therapy alone and/or in combination. Concurrent cisplatin-based chemotherapy improves the chances of survival, radiation treats the primary tumor and adjacent tissues and lymph nodes, and chemotherapy acts as a radiation sensitizer and may also control distant disease. 11
This patient had pelvic recurrence 6 months after radical surgery, which was treated with concurrent chemo-radiation. She then had a disease-free interval of 9 months before the development of nodular lesion of the scar. Metastatic workup, including the FDG-PET scan, revealed no other metastatic lesions, hence the patient underwent wide local excision of the lesion.
Conclusions
We report an unusual site of recurrence, and although incisional-site skin metastasis in cervical cancer has been reported to have a mean survival of only ∼3 months and is considered to be a preterminal event, 9 the patient discussed in this Case Report was disease-free for more than 7 months follow-up after complete excision.
Footnotes
Disclosure Statement
No competing financial conflicts exist.