The Korean Journal of Helicobacter and Upper Gastrointestinal Research Vol. 12, No. 3, 207-211, September 2012 ∙ http://dx.doi.org/10.7704/kjhugr.2012.12.3.207
A Case of Metastatic Lymph Node of Invasive Cervical Cancer Diagnosed by Endoscopic Ultrasonography-Guided Fine Needle Aspiration Biopsy
Cervical cancer is the most common malignant gynecological cancer. The incidence and mortality of cervical cancer has been declining in developed countries, but it is still one of the most common cancers in women worldwide. Prognoses of cervical cancer are based on the stage, size, histologic grade 18 of a primary tumor and metastasis of lymph node. CT, MRI, and F-fluoro-2deoxyglucose (FDG) PET are widely utilized and effective for detecting early recurrence in cervical cancer. The lymph node metastasis of cervical cancer begins locally and spreads distantly. Metastasis of cervical cancer has been rarely assessed by means of EUS or EUS-guided fine needle aspiration biopsy (FNAB) as a form of subepithelial lesion of stomach. A 62-year-old female was referred to the department of gastroenterology for evaluation of a mass like gastric subepithelial tumor with high uptake of 18F-FDG in PET-CT. Four years ago, the patient underwent a total abdominal hysterectomy with bilateral salphingo-oophorectomy for invasive cervical cancer. The specimen obtained by EUS-FNAB appeared to be pus. Finally, the lesion was diagnosed as metastatic squamous cell carcinoma originated from the previous invasive cervical cancer. The patient completely recovered after systemic chemotherapy for the metastatic lesion. (Korean J Helicobacter Up Gastrointest Res 2012;12:207-211) Key Words: Uterine cervical neoplasms; Endosonography; Biopsy, Fine-needle
Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea Myung Jin Oh, Jung Soo Lee, Si Hyung Lee Received：June 4, 2012 Accepted：July 31, 2012 Corresponding author: Si Hyung Lee Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, 170 Hyeonchung-ro, Nam-gu, Daegu 705-717, Korea Tel: 053-620-3830 Fax: 053-654-8386 E-mail:
[email protected]
tologic grade of a primary tumor and metastasis of lymph 3 node. Most of metastasis begins in the surround lymph node,
INTRODUCTION
and common distant metastatic sites of cervical cancer are lung, Cervical cancer is the seventh most common cancer in
3 gastrointestinal tract, bone, and liver. Distant metastases can 4,5
CT
Korean women according to national cancer statistics in 2009.
be rarely developed in skin and central nervous system.
Human papillomavirus (HPV) infection is reported as the most
and MRI are useful in staging advanced disease and in monitor-
important risk factor in development of cervical neoplasms such
ing patients for recurrence of the disease. Recently,
as cervical cancer or cervical intraepithelial neoplasm. Because
ro-2-deoxyglucose (FDG) PET is widely utilized and effective
cervical cancer is one of the most common preventable cancers
for detecting early recurrence of cervical cancer. It can be also
by vaccination of HPV and health screening, its incidence and
a useful follow-up modality.
18
F-fluo-
6
mortality has been declining in developed countries, specifically
In general, pattern of lymph node metastasis is spread
in the United States, but it is still one of the most common
through regional lymph nodes to distant lymph nodes. Thus,
1,2
EUS or EUS-guided fine needle biopsy (EUS-FNAB) are less
Prognoses of cervical cancer are based on the stage, size, his-
used for detecting lymph node metastasis as a form of sub-
cancers in women worldwide, especially in developing countries.
207
208
Korean J Helicobacter Up Gastrointest Res：제 12 권 제 3 호 2012
epithelial tumor of stomach in invasive cervical cancer. Herein,
conducted annually for evaluation of recurrence and metastasis.
we report that a case of a 62-year-old female, who had a hyper-
After four years, the
18
18
F-FDG PET scan showed high uptake
18
F-FDG PET, was definitely
of F-FDG at ascending colon, and a mass-like lesion near the
diagnosed as metastatic lymph node through EUS-FNAB of the
gastrohepatic area (Fig. 1). A subsequent enhanced abdominal
lesion.
CT revealed segmental wall thickening of hepatic flexure, peri-
metabolic lymph node in serial
colic fat infiltration, multiple lymphadenopathies along the gastric antrum, and a 2.5 cm-sized non-enhanced mass in the gas-
CASE REPORT
troesophageal junction. A 62-year-old female was referred to the department of gas-
The patient complained of no clinical symptoms and sign.
troenterology for evaluation of a mass around cardia of stomach
Also, there was no abnormal finding in her physical exami-
18
with high uptake of F-FDG in PET-CT. Four years ago, the
nation. The initial vital sign was stable. Other chemical panels
patient underwent a total abdominal hysterectomy including bi-
except tumor markers were unremarkable. Tumor makers were
lateral salphingo-oophorectomy against invasive cervical can-
elevated to CA19-9: 46.48 U/mL (reference range＜37 U/mL),
cer. According to pathologic report, the tumor was invasive
CEA: 32.49 ng/mL (reference range＜5.0 ng/mL), and CA-125:
squamous cell carcinoma, and nonkeratinizing type. The post-
122.3 U/mL (reference range＜35 U/mL), respectively. First, on
operative final stage was International Federation of Gynecolo-
the suspicious lesions at large bowel, colonoscopy was conduc-
gy and Obstetrics (FIGO) stage IIA1, and TNM stage T2a1N0M0.
ted. The colonoscopic findings showed several diverticuli with-
Other postoperative modalities of treatment, such as radiation
out inflammation at ascending colon, and about 0.3 cm-sized
therapy or chemotherapy, were not applied. The patient had re-
single polyp at sigmoid colon. The pathologic result of polyp
ceived treatment by anti-hypertensive drug against essential
at sigmoid colon was revealed as tubular adenoma.
hypertension. After gynecology operation,
18
F-FDG PET was
On a lesion in the gastrohepatic area, esophagogastroduo-
Fig. 1.
18
F-FDG PET (Jan. 2010) revealed hypermetabolic lesion at asending colon, and a subepithelial tumor near the gastrohepatic area.
Fig. 2. Radial and linear endoscopic ultrasound images showed a hypoechoic, demarcated, and round-shaped mass.
Myung Jin Oh, et al：A Case of Metastatic Cervical Cancer Diagnosed by EUS-FNAB
Fig. 3. Gross finding of aspirated specimen appeared to be pus.
209
Fig. 4. Microscopic view of aspirated specimen. Malignant squamous cells with large pleomorphic nucleus congregated (H&E, ×100).
denoscopy was conducted initially. Endoscopic findings showed about 3 cm-sized bulging mucosa such as a subepithelial tumor
route to the paraaortic nodes. Distant metastasis without locore-
at cardia of stomach. Thereafter, EUS was taken, and EUS find-
gional lymph node metastasis is rare. Probability of metastatic
ings revealed a 3.1×2.0 cm-sized hypoechoic, demarcated, and
nodes in a patients with stage IIB or less is 18.6%, and those
round-shaped mass at cardia (Fig. 2). The extramural lesion was
7 of patients with higher stage is 44.3%. Despite of carefully
assumed to an enlarged lymph node or simple cyst. EUS-FNAB
planned and executed treatments, about 30% of cervical cancer
was performed for diagnosis of the subepithelial lesion. Turbid,
is known to eventually recur after treatment. In our case, the
yellowish discharge was aspirated by EUS-FNAB. The aspi-
patient was in FIGO stage IIA1 on initial cervical cancer
rated fluid seemed to be like pus forming an abscess (Fig. 3).
diagnosis. After five years of initial diagnosis and surgical treat-
The histopathologic result of aspirated specimen was confirmed
ment, lymph node metastasis around cardia of stomach was de-
as metastatic squamous cell carcinoma originated from the pre-
tected without locoregional lymph node metastasis. In general,
vious invasive cervical cancer (Fig. 4).
CT, MRI, and
18
F-FDG PET have been utilized as modalities
Systemic chemotherapy as a therapeutic strategy for the
for detecting metastatic lymph nodes. The accuracy of CT is
metastatic lesion was performed. Paclitaxel and carboplatin
between 65% and 80% for detection of metastatic involvement,
were administered intravenously after definite diagnosis and to-
and biopsy of suspicious nodes is necessary for confirmation.
tal six cycles of systemic chemotherapy were conducted. The
18
patient completely cured by means of the systemic chemo-
current cervical cancer, and its overall sensitivity is 86% and
therapy. Without recurrence of disease, the patient has been ex-
its specificity is 87%.
7,8
F-FDG PET is a useful imaging modality for detection of re9
18 amined at the outpatient clinic regularly. The last F-FDG PET
The metastasis of cervical cancer has been rarely evaluated
(Dec. 2011) also showed a complete remission of the metastatic
by EUS or EUS-FNAB, because there is seldom a case that
lesion.
metastatic lymph node is developed as a form of subepithelial tumor of stomach. This case is very significant in the aspect
DISCUSSION
that EUS-FNAB might be a useful technique for assessing distant metastatic lymph nodes in invasive cervical cancer.
Cervical cancer is the most common malignant gyneco-
EUS is one of the most accurate diagnostic tools for gastro-
logical cancer, and lymphatic metastasis is one of the most im-
intestinal malignancies and other malignancies with lymph node
portant metastasis routes of this cancer. Lymphatic spread goes
metastasis. Endosonographic features of malignant lymph no-
along external and internal iliac nodal chains and the presacral
des were reported as enlarged nodal size, hypoechoic echoge-
10
210
Korean J Helicobacter Up Gastrointest Res：제 12 권 제 3 호 2012 11
nicity, and sharply-demarcated borders.
12
Catalano et al.
re-
and serum WBC count was also normal. If the specimen was
ported that four specific criteria thought to be most important
regarded as simple pus forming abscess, it might be discarded
in determining metastatic disease. These criteria were (1) hypo-
or misinterpreted as a benign lesion. Therefore, in case of a
echoic structure, (2) sharply demarcated border, (3) round con-
clinical clue, EUS-FNAB should be actively recommended for
tour, and (4) larger than 10 mm in size. In our case, these four
a definitive diagnosis and any morphologic specimen obtained
criteria were all met as a result of examining the endosono-
by EUS-FNAB should be immediately sent to a pathologic lab-
graphic views. When all four criteria were met, this could pre-
oratory, and be analyzed.
12
A recent
In conclusion, most of patterns in metastasis of malignancy
study has demonstrated an accuracy of 80% when all criteria
are generally consistent, but some lymph node metastasis may
dict a malignant lymph node with 100% accuracy. 13
Other criteria that define benign or malignant lym-
be infrequently detected at unexpected sites. Further assess-
phadenopathy would be helpful in case of multiple lymph
ments including EUS or EUS-FNAB for a rare case of gastric
are met.
14
nodes. Sawhney et al. put forth opinion that intact vasculature
subepithelial lesion with likelihood of malignancy will be
through a lymph node should present benign nature. Some
needed. In addition, all the acquired specimens, irrespective of
study also reported that presence of intranodal vasculature was
nature of specimens, should be assessed in a laboratory without
11
universally associated with a benign diagnosis.
In this case,
any adjustments.
the vasculature of lymph node was not assessed. However, EUS findings related to malignant lymph node
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15,16
Vander Noot et al.17 reported
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