Journal of Obstetrics and Gynaecology, January 2014; 34: 101–113 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online
GYNAECOLOGY CASE REPORTS
Metastatic cervical carcinoma presenting as psoas abscess, after a radical total hysterectomy P. Chatzis1, A. Daniilidis1, N. Papathanasiou1, K. Lathouras1, P. D. Loufopoulos1 & N. Vrachnis2
J Obstet Gynaecol Downloaded from informahealthcare.com by York University Libraries on 02/01/15 For personal use only.
12nd Department of Obstetrics and Gynaecology, Aristotle University
of Thessaloniki, Hippokration Hospital, Thessaloniki and 22nd Obstetrics and Gynaecology Clinic, Areteio University Hospital, Athens, Greece DOI: 10.3109/01443615.2013.831042 Correspondence: A. Daniilidis, 2nd Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, 9 Smirnis, 56224, Evosmos, Thessaloniki, Greece. E-mail: [email protected]
was anaemic (haemoglobin 9.9%) and had a total white cell count of 11,000/μl (68% polymorphs). Fine-needle aspiration cytology (FNAC) was done under CT guidance (Figure 1b). Cytology was negative for malignancy. A ‘pigtail’ catheter was left in place for continuous drainage until 500 ml of whitish thick pus-like fluid (Figure 1c) had drained. Staining for aerobic and anaerobic bacteria was negative. A few days later, a repeat CT scan showed the collection to have increased again. The abscess cavity was incised and explored. The pus-filled mass was excised and histology revealed the presence of metastatic cervical carcinoma. She received radiotherapy and a combination of platinum-taxane postoperatively.
Discussion Psoas abscess-like metastasis from cervical carcinoma is a rare condition after a radical total hysterectomy and radiotherapy, especially in HIV-negative patients (Bar-Dayan 1997). Two case reports from Devendra and Tay (2003) and from Bar-Dayan et al. (1997),
Introduction Metastasis from cervical carcinoma mimicking psoas abscess in its presentation, is a rare condition. Although skeletal muscles account for nearly 50% of body weight, the total incidence of metastases in striated muscle is estimated to be ⬍ 1% of haematogenous metastases (Ferrandina et al. 2006). Muscles are highly resistant to primary or metastatic cancer. This is thought to be due to their contractile activity, pH, oxygenation, intramuscular blood pressure, local production of lactic acid, inhibition of cell invasion by protease inhibitors located in the basement membrane and the antitumour activity of lymphocytes and, or, natural killer cells within skeletal muscle (Sudo et al. 1993). We present an unusual case of an isolated metastatic cervical endometrioid adenocarcinoma imitating a psoas abscess, and a review of the current literature.
Case report Colposcopically-guided biopsies from a 40-year-old woman referred with abnormal smear, demonstrated the presence of endometrioid endocervical adenocarcinoma cells. On clinical examination and MRI imaging of her chest and abdomen, there was no evidence of distant metastases. The tumour’s diameter was ⬍ 4 cm. Serology for human immunodeficiency virus (HIV-1) was non-reactive, CEA, CA19-9 and CA125 markers within normal levels. Radical total hysterectomy with resection of the contiguous retroperitoneal lymph nodes was done. Histology reported endometrioid endocervical adenocarcinoma stage IB1. She was discharged home after 5 days and continued treatment with radiotherapy. Follow-up at 1, 6 and 12 months included clinical examination, laboratory tests and imaging investigations with ultrasound and CT. At 14 months after the operation, she developed reduced mobility of her right leg due to backache and persistent femoral pain. There was no improvement, despite non-steroidal antiinflammatory drugs (NSAIDs) and physiotherapy. Abdominal ultrasound examination showed a large mass on the right psoas, with appearances consistent with an abscess. Abdominal CT demonstrated a well-defined hypodense lesion in the right psoas muscle (Figure 1a). Erythrocyte sedimentation rate was 35 mm in the first hour, HIV-1 serology was negative, Mantoux was negative, biochemical investigations were essentially normal but she
Figure 1. (a) Well defined hypo-dense lesion in the right psoas muscle before the aspiration; (b) aspiration with a ‘pigtail’ catheter and (c) continues drainage.
J Obstet Gynaecol Downloaded from informahealthcare.com by York University Libraries on 02/01/15 For personal use only.
102
Gynaecology Case Reports
describe primary manifestation of the psoas abscess with simultaneous cervical pathology. George and Lai (1996) reported a psoas abscess after radiotherapy treatment for cervical cancer, with no details about HIV status. Our case was diagnosed after the patient complained of a limp and backache. Immunosuppression and carcinoma differentiation seem to be the major reasons for such an aggressive manifestation (Singh et al. 1994). This case presented difficulties in the clinical differential diagnosis of psoas pathology, which can, in any event, be extremely difficult. Both suspicion and multiple investigations may be required (Williams et al. 1997). The differential diagnosis includes abscesses, tumours or haematoma, secondary intestinal disorders (Crohn’s disease, appendicitis, colorectal carcinoma) or other metastases from renal, adrenal, colon or prostate tumours. Kalra et al. (2009) reported a similar case, which was initially diagnosed as spinal tuberculosis in a 60-year-old woman with stage IIb cervical carcinoma, 2 years after radiotherapy. The final diagnosis of metastatic carcinoma of the cervix mimicking psoas abscess was reached after a two-step aspiration of the pus and isolation of squamous malignant cells (Ferrandina et al. 2006). In our case, the interval of 14 months after initial diagnosis is short in comparison with the case reported from Ferrandina et al. (2006), with a psoas metastasis after a 6-year interval in a 38-year-old woman. Skeletal muscle metastases are rare and there are no specific guidelines on appropriate therapeutic options. Surgical experience and radiotherapy seem to be the most significant factors in achieving an early diagnosis and effective treatment. We selected platinum-taxane combination because of the possible advantage of this treatment in comparison to monotherapy (Moore et al. 2004; Tinker et al. 2005). Our case is a reminder that an extremely rare complication of metastasis from cervical cancer might involve psoas muscle with difficult diagnosis and limited treatment options.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Bar-Dayan Y, Fishman A, Levi Z et al. 1997. Squamous cell carcinoma of the cervix with psoas abscess-like metastasis in an HIV-negative patient. Israel Journal of Medical Sciences 33:674–676. Devendra K, Tay SK. 2003. Metastatic carcinoma of the cervix presenting as a psoas abscess in an HIV-negative woman. Singapore Medical Journal 44:302–303. Ferrandina G, Salutari V, Testa A et al. 2006. Recurrence in skeletal muscle from squamous cell carcinoma of the uterine cervix: a case report and review of the literature. BMC Cancer 6:169. George J, Lai FM. 1996. Metastatic cervical carcinoma presenting as psoas abscess and osteoblastic and lytic bony metastases. Singapore Medical Journal 36:224–227. Kalra N, Aiyappan S, Nijhawan R et al. 2009. Metastatic carcinoma of cervix mimicking psoas abscess on imaging: a case report. Journal of Gynecologic Oncology 20:129–131. Moore DH, Blessing JA, McQuellon RP et al. 2004. Phase III study of cisplatin with or without paclitaxel in stage IV B, recurrent or persistent squamous cell carcinoma of the cervix: a gynaecologic oncology group study. Journal of Clinical Oncology 22:3113–3119. Singh GS, Aikins JK, Deger R et al. 1994. Metastatic cervical cancer and pelvic inflammatory disease in an AIDS patient. Gynecologic Oncology 54: 372–376. Sudo A, Ogihara Y, Shiokawa Y et al. 1993. Intramuscular metastasis of carcinoma. Clinical Orthopaedics 296:213–217. Tinker AV, Bhagat K, Swenerton KD et al. 2005. Carboplatin and paclitaxel for advanced and recurrent cervical carcinoma: the British Columbia Cancer Agency experience. Gynecologic Oncology 98:54–58. Williams JB, Youngberg RA, Bui-Mansfield LT et al. 1997. MR imaging of skeletal muscle metastases. American Journal of Roentgenology 168: 555–557.
AlloDerm graft mimicking uterine carcinosarcoma recurrence on PET/CT B. N. Adams1, F. B. Musa2, J. Taylor1 & K. Holcomb1 Departments of Obstetrics and Gynecology, 1New York Presbyterian Hospital – Weill Cornell Medical Center and 2New York University – Langone Medical Center, New York, NY, USA DOI: 10.3109/01443615.2013.841131 Correspondence: J. Taylor, Department of Obstetrics and Gynecology, New York Presbyterian Hospital – Weill Cornell Medical Center, 525 East 68th Street J-130, New York, NY 10021, USA. E-mail: [email protected]
Introduction Positron emission tomography/computed tomography (PET/CT) is a useful tool in the detection of recurrent gynaecological malignancies. Despite its relatively recent introduction into clinical practice, the technology is commonly used in the surveillance of patients with uterine cancer, with reported sensitivity and specificity of approximately 90% (Kitajima et al. 2009). In a Japanese study published in 2008, PET/CT results alone changed the clinical management of 42% of endometrial cancer patients studied (Kitajima et al. 2009). Despite its frequent use and proven utility, it is important to recognise the limitations of PET/CT with regard to specificity. Hypermetabolism, as indicated by increased uptake of (18)F fluorodeoxyglucose (FDG), may be seen in the presence of foreign bodies and inflammation, as well as malignancy.
Case report A 57-year-old woman with a recently diagnosed endometrial cancer was referred to our institution. Physical examination was significant with a 12 ⫻ 10 cm myomatous uterus with grade IV uterine prolapse and no evidence of extrauterine metastases. A preoperative CT scan of the abdomen and pelvis with intravenous contrast showed no evidence of metastatic disease. The patient had an uncomplicated exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node biopsies and omentectomy. No gross extrauterine disease was noted at the time of surgery, so the urogynaecologist performed an uncomplicated abdominal sacrocolpopexy utilising the AlloDerm graft. Histopathology described a stage IB tumour of the uterus with minimal myometrial invasion (3 mm/26 mm). No lymph–vascular space invasion was noted. A CT scan of the abdomen and pelvis done 6 weeks later to assess a palpable pelvic mass, demonstrated an area of linear enhancement with multiple infoldings anterior to the rectum and appearing to adjoin the peritoneum. This finding reflected the AlloDerm graft. Since there was no evidence of progressive disease, the patient proceeded with adjuvant external beam pelvic irradiation. At the 4-month follow-up visit, the physical examination was notable for left groin lymphadenopathy and an unchanged 5 cm, non-tender, immobile, solid mass in the left lower abdomen. A PET/CT revealed a hypermetabolic soft tissue density within the left pelvis (max SUV 10.0), posterior and superior to the urinary bladder, compatible with recurrent carcinoma (Figure 1). Due to the irregularity of the identified mass, no measurements were obtainable. CT-guided fine-needle aspiration (FNA) of the pelvic soft tissue density revealed acute inflammation without evidence of malignancy. The patient then completed her course of adjuvant external beam pelvic irradiation for a total of 25 doses, which had up to this point been delayed due to surgical wound separation requiring a wound vac. A repeat PET/CT scan 1 year after her operation showed the previously identified pelvic mass, yet the lesion was non-hypermetabolic. Repeat fine-needle aspirate of the left pelvic mass showed muscle with degenerative changes and hemosiderin-laden macrophages, compatible with radiation changes.
GYNAECOLOGY CASE REPORTS
Metastatic cervical carcinoma presenting as psoas abscess, after a radical total hysterectomy P. Chatzis1, A. Daniilidis1, N. Papathanasiou1, K. Lathouras1, P. D. Loufopoulos1 & N. Vrachnis2
J Obstet Gynaecol Downloaded from informahealthcare.com by York University Libraries on 02/01/15 For personal use only.
12nd Department of Obstetrics and Gynaecology, Aristotle University
of Thessaloniki, Hippokration Hospital, Thessaloniki and 22nd Obstetrics and Gynaecology Clinic, Areteio University Hospital, Athens, Greece DOI: 10.3109/01443615.2013.831042 Correspondence: A. Daniilidis, 2nd Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, 9 Smirnis, 56224, Evosmos, Thessaloniki, Greece. E-mail: [email protected]
was anaemic (haemoglobin 9.9%) and had a total white cell count of 11,000/μl (68% polymorphs). Fine-needle aspiration cytology (FNAC) was done under CT guidance (Figure 1b). Cytology was negative for malignancy. A ‘pigtail’ catheter was left in place for continuous drainage until 500 ml of whitish thick pus-like fluid (Figure 1c) had drained. Staining for aerobic and anaerobic bacteria was negative. A few days later, a repeat CT scan showed the collection to have increased again. The abscess cavity was incised and explored. The pus-filled mass was excised and histology revealed the presence of metastatic cervical carcinoma. She received radiotherapy and a combination of platinum-taxane postoperatively.
Discussion Psoas abscess-like metastasis from cervical carcinoma is a rare condition after a radical total hysterectomy and radiotherapy, especially in HIV-negative patients (Bar-Dayan 1997). Two case reports from Devendra and Tay (2003) and from Bar-Dayan et al. (1997),
Introduction Metastasis from cervical carcinoma mimicking psoas abscess in its presentation, is a rare condition. Although skeletal muscles account for nearly 50% of body weight, the total incidence of metastases in striated muscle is estimated to be ⬍ 1% of haematogenous metastases (Ferrandina et al. 2006). Muscles are highly resistant to primary or metastatic cancer. This is thought to be due to their contractile activity, pH, oxygenation, intramuscular blood pressure, local production of lactic acid, inhibition of cell invasion by protease inhibitors located in the basement membrane and the antitumour activity of lymphocytes and, or, natural killer cells within skeletal muscle (Sudo et al. 1993). We present an unusual case of an isolated metastatic cervical endometrioid adenocarcinoma imitating a psoas abscess, and a review of the current literature.
Case report Colposcopically-guided biopsies from a 40-year-old woman referred with abnormal smear, demonstrated the presence of endometrioid endocervical adenocarcinoma cells. On clinical examination and MRI imaging of her chest and abdomen, there was no evidence of distant metastases. The tumour’s diameter was ⬍ 4 cm. Serology for human immunodeficiency virus (HIV-1) was non-reactive, CEA, CA19-9 and CA125 markers within normal levels. Radical total hysterectomy with resection of the contiguous retroperitoneal lymph nodes was done. Histology reported endometrioid endocervical adenocarcinoma stage IB1. She was discharged home after 5 days and continued treatment with radiotherapy. Follow-up at 1, 6 and 12 months included clinical examination, laboratory tests and imaging investigations with ultrasound and CT. At 14 months after the operation, she developed reduced mobility of her right leg due to backache and persistent femoral pain. There was no improvement, despite non-steroidal antiinflammatory drugs (NSAIDs) and physiotherapy. Abdominal ultrasound examination showed a large mass on the right psoas, with appearances consistent with an abscess. Abdominal CT demonstrated a well-defined hypodense lesion in the right psoas muscle (Figure 1a). Erythrocyte sedimentation rate was 35 mm in the first hour, HIV-1 serology was negative, Mantoux was negative, biochemical investigations were essentially normal but she
Figure 1. (a) Well defined hypo-dense lesion in the right psoas muscle before the aspiration; (b) aspiration with a ‘pigtail’ catheter and (c) continues drainage.
J Obstet Gynaecol Downloaded from informahealthcare.com by York University Libraries on 02/01/15 For personal use only.
102
Gynaecology Case Reports
describe primary manifestation of the psoas abscess with simultaneous cervical pathology. George and Lai (1996) reported a psoas abscess after radiotherapy treatment for cervical cancer, with no details about HIV status. Our case was diagnosed after the patient complained of a limp and backache. Immunosuppression and carcinoma differentiation seem to be the major reasons for such an aggressive manifestation (Singh et al. 1994). This case presented difficulties in the clinical differential diagnosis of psoas pathology, which can, in any event, be extremely difficult. Both suspicion and multiple investigations may be required (Williams et al. 1997). The differential diagnosis includes abscesses, tumours or haematoma, secondary intestinal disorders (Crohn’s disease, appendicitis, colorectal carcinoma) or other metastases from renal, adrenal, colon or prostate tumours. Kalra et al. (2009) reported a similar case, which was initially diagnosed as spinal tuberculosis in a 60-year-old woman with stage IIb cervical carcinoma, 2 years after radiotherapy. The final diagnosis of metastatic carcinoma of the cervix mimicking psoas abscess was reached after a two-step aspiration of the pus and isolation of squamous malignant cells (Ferrandina et al. 2006). In our case, the interval of 14 months after initial diagnosis is short in comparison with the case reported from Ferrandina et al. (2006), with a psoas metastasis after a 6-year interval in a 38-year-old woman. Skeletal muscle metastases are rare and there are no specific guidelines on appropriate therapeutic options. Surgical experience and radiotherapy seem to be the most significant factors in achieving an early diagnosis and effective treatment. We selected platinum-taxane combination because of the possible advantage of this treatment in comparison to monotherapy (Moore et al. 2004; Tinker et al. 2005). Our case is a reminder that an extremely rare complication of metastasis from cervical cancer might involve psoas muscle with difficult diagnosis and limited treatment options.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Bar-Dayan Y, Fishman A, Levi Z et al. 1997. Squamous cell carcinoma of the cervix with psoas abscess-like metastasis in an HIV-negative patient. Israel Journal of Medical Sciences 33:674–676. Devendra K, Tay SK. 2003. Metastatic carcinoma of the cervix presenting as a psoas abscess in an HIV-negative woman. Singapore Medical Journal 44:302–303. Ferrandina G, Salutari V, Testa A et al. 2006. Recurrence in skeletal muscle from squamous cell carcinoma of the uterine cervix: a case report and review of the literature. BMC Cancer 6:169. George J, Lai FM. 1996. Metastatic cervical carcinoma presenting as psoas abscess and osteoblastic and lytic bony metastases. Singapore Medical Journal 36:224–227. Kalra N, Aiyappan S, Nijhawan R et al. 2009. Metastatic carcinoma of cervix mimicking psoas abscess on imaging: a case report. Journal of Gynecologic Oncology 20:129–131. Moore DH, Blessing JA, McQuellon RP et al. 2004. Phase III study of cisplatin with or without paclitaxel in stage IV B, recurrent or persistent squamous cell carcinoma of the cervix: a gynaecologic oncology group study. Journal of Clinical Oncology 22:3113–3119. Singh GS, Aikins JK, Deger R et al. 1994. Metastatic cervical cancer and pelvic inflammatory disease in an AIDS patient. Gynecologic Oncology 54: 372–376. Sudo A, Ogihara Y, Shiokawa Y et al. 1993. Intramuscular metastasis of carcinoma. Clinical Orthopaedics 296:213–217. Tinker AV, Bhagat K, Swenerton KD et al. 2005. Carboplatin and paclitaxel for advanced and recurrent cervical carcinoma: the British Columbia Cancer Agency experience. Gynecologic Oncology 98:54–58. Williams JB, Youngberg RA, Bui-Mansfield LT et al. 1997. MR imaging of skeletal muscle metastases. American Journal of Roentgenology 168: 555–557.
AlloDerm graft mimicking uterine carcinosarcoma recurrence on PET/CT B. N. Adams1, F. B. Musa2, J. Taylor1 & K. Holcomb1 Departments of Obstetrics and Gynecology, 1New York Presbyterian Hospital – Weill Cornell Medical Center and 2New York University – Langone Medical Center, New York, NY, USA DOI: 10.3109/01443615.2013.841131 Correspondence: J. Taylor, Department of Obstetrics and Gynecology, New York Presbyterian Hospital – Weill Cornell Medical Center, 525 East 68th Street J-130, New York, NY 10021, USA. E-mail: [email protected]
Introduction Positron emission tomography/computed tomography (PET/CT) is a useful tool in the detection of recurrent gynaecological malignancies. Despite its relatively recent introduction into clinical practice, the technology is commonly used in the surveillance of patients with uterine cancer, with reported sensitivity and specificity of approximately 90% (Kitajima et al. 2009). In a Japanese study published in 2008, PET/CT results alone changed the clinical management of 42% of endometrial cancer patients studied (Kitajima et al. 2009). Despite its frequent use and proven utility, it is important to recognise the limitations of PET/CT with regard to specificity. Hypermetabolism, as indicated by increased uptake of (18)F fluorodeoxyglucose (FDG), may be seen in the presence of foreign bodies and inflammation, as well as malignancy.
Case report A 57-year-old woman with a recently diagnosed endometrial cancer was referred to our institution. Physical examination was significant with a 12 ⫻ 10 cm myomatous uterus with grade IV uterine prolapse and no evidence of extrauterine metastases. A preoperative CT scan of the abdomen and pelvis with intravenous contrast showed no evidence of metastatic disease. The patient had an uncomplicated exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node biopsies and omentectomy. No gross extrauterine disease was noted at the time of surgery, so the urogynaecologist performed an uncomplicated abdominal sacrocolpopexy utilising the AlloDerm graft. Histopathology described a stage IB tumour of the uterus with minimal myometrial invasion (3 mm/26 mm). No lymph–vascular space invasion was noted. A CT scan of the abdomen and pelvis done 6 weeks later to assess a palpable pelvic mass, demonstrated an area of linear enhancement with multiple infoldings anterior to the rectum and appearing to adjoin the peritoneum. This finding reflected the AlloDerm graft. Since there was no evidence of progressive disease, the patient proceeded with adjuvant external beam pelvic irradiation. At the 4-month follow-up visit, the physical examination was notable for left groin lymphadenopathy and an unchanged 5 cm, non-tender, immobile, solid mass in the left lower abdomen. A PET/CT revealed a hypermetabolic soft tissue density within the left pelvis (max SUV 10.0), posterior and superior to the urinary bladder, compatible with recurrent carcinoma (Figure 1). Due to the irregularity of the identified mass, no measurements were obtainable. CT-guided fine-needle aspiration (FNA) of the pelvic soft tissue density revealed acute inflammation without evidence of malignancy. The patient then completed her course of adjuvant external beam pelvic irradiation for a total of 25 doses, which had up to this point been delayed due to surgical wound separation requiring a wound vac. A repeat PET/CT scan 1 year after her operation showed the previously identified pelvic mass, yet the lesion was non-hypermetabolic. Repeat fine-needle aspirate of the left pelvic mass showed muscle with degenerative changes and hemosiderin-laden macrophages, compatible with radiation changes.
