Acta Obstet Gynecol Scand 1990; 69: 265266
OVARIAN METASTATIC CARCINOMA PRESENTING AS A PRIMARY CERVICAL CARCINOMA Peter J. Danielian From the Department of Obstetrics and Gynecology, Westminster Hospital, London SWl, England
Abstract. A case of an ovarian carcinoma presenting a s a primary cervical carcinoma
is described. Although a rare event, this must be considered whenever the clinical or histological findings are unusual. The importance of careful histological review of all specimens in cases such a s this is emphasized.
CASE REPORT A 63-year-old woman presented with a single episode of postmenopausal bleeding. She had had three children, was a nonsmoker and had undergone the menopause at an age of 48 years. She had no other gynecological or medical history of relevance. A cervical smear was taken which was reported as negative, and the patient was admitted for a formal dilatation and curettage (D & C) and examination under anesthetic. This revealed an atrophic vagina and a hard, irregular cervix which bled on contact. The uterus was bulky, irregular and retroverted and the cavity was sounded to 7 cm. There was clinical thickening of the left parametrial tissues and the left uterosacral ligament. The D & C was performed and a cervical biopsy taken. The endometrial curettings aroused suspicion of malignancy, and the clinicians made a diagnosis of stage IIB carcinoma of the cervix. Histological examination of the specimens revealed undifferentiated carcinoma, and the patient was referred for radiotherapy. On further examination it was felt that there was a pelvic mass posteriorly, separate from the cervix and computerized axial tomography was performed. This showed an extensive pelvic mass extending from the Pouch of Douglas into the rectum. This was thought to be a probable carcinoma of the ovary. Ascitic fluid and left paraaortic lymphadenopathy were also present. A second cervical smear was reported to show malignant squamous cells consistent with invasive squamous cell carcinoma of the cervix. A chest Xray and intravenous pyelogram showed no abnormalities. Full blood count, serum electrolytes, serum urea, creatinine and hepatic enzyme levels were all within normal limits. A second examination under anesthesia was then performed. The cervix was found destroyed by growth and further biopsies were lsent for histological examination. The cervical canal was obliterated and the uterine cavity was therefore not explored. The uterus was felt to be enlarged and fixed, and a mass was palpable in the posterior fornix. The other findings were unchanged from the earlier examination. Histologically the cervical biopsies showed extensive infiltration by poorly differentiated carcinoma. There were squamoid features consistent with primary cervical car-
cinoma, but there were also foci of papillary growth and it was felt that the possibility of a poorly differentiated ovarian metastasis could not be excluded. In view of these findings, a laparotomy was performed. Both ovaries were frankly malignant and adherent to the pelvic walls and small bowel. The uterus was fixed to the rectum and bladder. Ascites was present, and there were secondaries in the bladder wall and the omentum. The liver, spleen, and paraaortic nodes were clinically normal. Bilateral salpingooophorectomy and omentectomy were performed; hysterectomy was considered to be inadvisable due to the fixation of the uterus and the involvement of the rectum and bladder in the tumor mass. Histology of the specimens revealed that both ovaries were replaced with poorly differentiated adenocarcinoma with focal papillary patterns. Some areas resembled endometrioid carcinoma. Carcinoma was present on the surfaces of both lovaries. Deposits of similar appearance were found in the omentum, and on further review of the previous slides. this tumor was felt to be identical with the most recent cervical biopsies. Postoperative recovery was uneventful and the patient received initial treatment of carboplatin, which was well tolerated.
DISCUSSION Ovarian carcinoma metastatic to the uterine cervix is an unusual event, and rarely presents clinically as a primary carcinoma of the cervix as in this case. Way reported 2 cases presenting in a similar manner, in a review of 8 cases of tumors in various sites metastasizing to the cervix, encountered over a period of 30 years(1). The carcinoma of the cervix in these cases is rarely a separate metastasis from the ovary, although one such case has been reported(2).More commonly there is continuity of tumor from the ovary to the cervix via Acta Obsiet Gynecol Scand 69 (1990)
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the Fallopian tubes and the corpus uteri, as seems been believed correct, and the patient treated errolikely to have occurred in the case reported here. Ob- neously with radiotherapy alone. In summary, an ovarian tumor presenting as a priviously the presence or absence of benign tissue between the cervical and uterine corpus lesions cannot be mary cervical carcinoma is a rare event, but must be ascertained without a hysterectomy specimen, and this considered whenever the clinical or histological findwas not obtained in this case, for surgical reasons. ings are unusual. The relatively high reported coincidence of ovarian Endometrioid carcinoma, as was eventually found in this case, can exist in both the ovary and the cervix; tumors with adenocarcinoma of the cervix should also a previous study found that 4 (7%) of 54 cases of en- be borne in mind when treating such cases, especially dometrioid adenocarcinomas of the cervix had coexis- as the incidence of adenocarcinoma of the cervix is tent or subsequent endometrioid carcinoma of the reportedly now increasing. The need for histological ovary, but no distinction was made between direct ex- review of all specimens in the light of unusual clinical findings is emphasised. tension of the tumor and true metastasis(3). Multiple primary neoplasia of the female genital tract has also been reported. A patient with simulACKNOWLEDGEMENT taneous and discrete squamous cell carcinoma of the The author is grateful to Mr J. Moir Shepherd, for his permiscervix, microinvasive squamous cell carcinoma of the sion to present the case and for his help in preparing the endometrium, squamous cell carcinoma in situ of the manuscript. Fallopian tubes and endometrioid carcinoma of the ovary has been described(4). This was thought to represent a case of diffuse Mullerian neoplasia; the en- REFERENCES dometrial, cervical and tuba1 epithelia and the surface 1. Way S. Carcinoma metastatic in the cervix. Gynecol Oncol 1980;9:298302. epithelium of the ovary have common Mullerian 2. McComas B C, Farnum J B, Donaldson R C. Ovarian origins and could therefore respond simultaneously or carcinoma presenting as a cervical metastasis. Obstet asynchronously in the same manner to a carcinogenic Gynecol D 1984;63:5936. stimulus. 3. Kaminski P F, Norris H J. Coexistence of ovarian neoplasms and endocervical adenocarcinoma. Obstet The histopathology of this case is also of interest. Gynecol 1984; 64: 5536. The original cervical biopsy specimen and the en4. Buckley C H, Fox H, Donnai P. Multiple primary dometrial curettings were both reported to be consisneoplasms of the female genital tract: Diffuse Mullerian tent with a primary squamous cell carcinoma of the neoplasia. Obstet Gynecol 1982;2:1756. cervix. Subsequent review of the histology and the second cervical biopsy showed papillary foci, thereby raising the possibility of an ovarian tumor, but this was Submitted for publication February 1, 1989 when changed clinical findings had suggested a pelvic Accepted April 11, 1989 mass, a computerized tomography report had also suggested an ovarian tumor, and with the benefit of hind- Peter J. Danielian Dept. of Obstetrics & Gynaecology sight. If a pelvic mass had not been suspected clinic- Westminster Hospital ally, then the original diagnosis of a stage IIB primary London SW14 squamous cell carcinoma of the cervix would have England
Acta Obstet Gyneeol Seand 69 (1990)
OVARIAN METASTATIC CARCINOMA PRESENTING AS A PRIMARY CERVICAL CARCINOMA Peter J. Danielian From the Department of Obstetrics and Gynecology, Westminster Hospital, London SWl, England
Abstract. A case of an ovarian carcinoma presenting a s a primary cervical carcinoma
is described. Although a rare event, this must be considered whenever the clinical or histological findings are unusual. The importance of careful histological review of all specimens in cases such a s this is emphasized.
CASE REPORT A 63-year-old woman presented with a single episode of postmenopausal bleeding. She had had three children, was a nonsmoker and had undergone the menopause at an age of 48 years. She had no other gynecological or medical history of relevance. A cervical smear was taken which was reported as negative, and the patient was admitted for a formal dilatation and curettage (D & C) and examination under anesthetic. This revealed an atrophic vagina and a hard, irregular cervix which bled on contact. The uterus was bulky, irregular and retroverted and the cavity was sounded to 7 cm. There was clinical thickening of the left parametrial tissues and the left uterosacral ligament. The D & C was performed and a cervical biopsy taken. The endometrial curettings aroused suspicion of malignancy, and the clinicians made a diagnosis of stage IIB carcinoma of the cervix. Histological examination of the specimens revealed undifferentiated carcinoma, and the patient was referred for radiotherapy. On further examination it was felt that there was a pelvic mass posteriorly, separate from the cervix and computerized axial tomography was performed. This showed an extensive pelvic mass extending from the Pouch of Douglas into the rectum. This was thought to be a probable carcinoma of the ovary. Ascitic fluid and left paraaortic lymphadenopathy were also present. A second cervical smear was reported to show malignant squamous cells consistent with invasive squamous cell carcinoma of the cervix. A chest Xray and intravenous pyelogram showed no abnormalities. Full blood count, serum electrolytes, serum urea, creatinine and hepatic enzyme levels were all within normal limits. A second examination under anesthesia was then performed. The cervix was found destroyed by growth and further biopsies were lsent for histological examination. The cervical canal was obliterated and the uterine cavity was therefore not explored. The uterus was felt to be enlarged and fixed, and a mass was palpable in the posterior fornix. The other findings were unchanged from the earlier examination. Histologically the cervical biopsies showed extensive infiltration by poorly differentiated carcinoma. There were squamoid features consistent with primary cervical car-
cinoma, but there were also foci of papillary growth and it was felt that the possibility of a poorly differentiated ovarian metastasis could not be excluded. In view of these findings, a laparotomy was performed. Both ovaries were frankly malignant and adherent to the pelvic walls and small bowel. The uterus was fixed to the rectum and bladder. Ascites was present, and there were secondaries in the bladder wall and the omentum. The liver, spleen, and paraaortic nodes were clinically normal. Bilateral salpingooophorectomy and omentectomy were performed; hysterectomy was considered to be inadvisable due to the fixation of the uterus and the involvement of the rectum and bladder in the tumor mass. Histology of the specimens revealed that both ovaries were replaced with poorly differentiated adenocarcinoma with focal papillary patterns. Some areas resembled endometrioid carcinoma. Carcinoma was present on the surfaces of both lovaries. Deposits of similar appearance were found in the omentum, and on further review of the previous slides. this tumor was felt to be identical with the most recent cervical biopsies. Postoperative recovery was uneventful and the patient received initial treatment of carboplatin, which was well tolerated.
DISCUSSION Ovarian carcinoma metastatic to the uterine cervix is an unusual event, and rarely presents clinically as a primary carcinoma of the cervix as in this case. Way reported 2 cases presenting in a similar manner, in a review of 8 cases of tumors in various sites metastasizing to the cervix, encountered over a period of 30 years(1). The carcinoma of the cervix in these cases is rarely a separate metastasis from the ovary, although one such case has been reported(2).More commonly there is continuity of tumor from the ovary to the cervix via Acta Obsiet Gynecol Scand 69 (1990)
266
I? 1 Danieiian
the Fallopian tubes and the corpus uteri, as seems been believed correct, and the patient treated errolikely to have occurred in the case reported here. Ob- neously with radiotherapy alone. In summary, an ovarian tumor presenting as a priviously the presence or absence of benign tissue between the cervical and uterine corpus lesions cannot be mary cervical carcinoma is a rare event, but must be ascertained without a hysterectomy specimen, and this considered whenever the clinical or histological findwas not obtained in this case, for surgical reasons. ings are unusual. The relatively high reported coincidence of ovarian Endometrioid carcinoma, as was eventually found in this case, can exist in both the ovary and the cervix; tumors with adenocarcinoma of the cervix should also a previous study found that 4 (7%) of 54 cases of en- be borne in mind when treating such cases, especially dometrioid adenocarcinomas of the cervix had coexis- as the incidence of adenocarcinoma of the cervix is tent or subsequent endometrioid carcinoma of the reportedly now increasing. The need for histological ovary, but no distinction was made between direct ex- review of all specimens in the light of unusual clinical findings is emphasised. tension of the tumor and true metastasis(3). Multiple primary neoplasia of the female genital tract has also been reported. A patient with simulACKNOWLEDGEMENT taneous and discrete squamous cell carcinoma of the The author is grateful to Mr J. Moir Shepherd, for his permiscervix, microinvasive squamous cell carcinoma of the sion to present the case and for his help in preparing the endometrium, squamous cell carcinoma in situ of the manuscript. Fallopian tubes and endometrioid carcinoma of the ovary has been described(4). This was thought to represent a case of diffuse Mullerian neoplasia; the en- REFERENCES dometrial, cervical and tuba1 epithelia and the surface 1. Way S. Carcinoma metastatic in the cervix. Gynecol Oncol 1980;9:298302. epithelium of the ovary have common Mullerian 2. McComas B C, Farnum J B, Donaldson R C. Ovarian origins and could therefore respond simultaneously or carcinoma presenting as a cervical metastasis. Obstet asynchronously in the same manner to a carcinogenic Gynecol D 1984;63:5936. stimulus. 3. Kaminski P F, Norris H J. Coexistence of ovarian neoplasms and endocervical adenocarcinoma. Obstet The histopathology of this case is also of interest. Gynecol 1984; 64: 5536. The original cervical biopsy specimen and the en4. Buckley C H, Fox H, Donnai P. Multiple primary dometrial curettings were both reported to be consisneoplasms of the female genital tract: Diffuse Mullerian tent with a primary squamous cell carcinoma of the neoplasia. Obstet Gynecol 1982;2:1756. cervix. Subsequent review of the histology and the second cervical biopsy showed papillary foci, thereby raising the possibility of an ovarian tumor, but this was Submitted for publication February 1, 1989 when changed clinical findings had suggested a pelvic Accepted April 11, 1989 mass, a computerized tomography report had also suggested an ovarian tumor, and with the benefit of hind- Peter J. Danielian Dept. of Obstetrics & Gynaecology sight. If a pelvic mass had not been suspected clinic- Westminster Hospital ally, then the original diagnosis of a stage IIB primary London SW14 squamous cell carcinoma of the cervix would have England
Acta Obstet Gyneeol Seand 69 (1990)
