Open Access

Postoperation of cervical cancer with intestine metastasis: a case report and literature review

Contributed equally
World Journal of Surgical Oncology201614:2

https://doi.org/10.1186/s12957-015-0759-3

Received: 8 September 2015

Accepted: 30 December 2015

Published: 6 January 2016

Abstract

Background

Cervical cancer can infiltrate locally and directly spread to adjacent organs including the vagina, peritoneum, urinary bladder, ureters, rectum, and paracervical tissue, but the intestine metastasis from cervical cancer is extremely rare, which can easily be misdiagnosed.

Case presentation

Here, we report a case about a 45-year-old postoperative cervical cancer patient with metastases to small intestine and sigmoid colon who presented abdominal distention and dull pain due to intestinal obstruction. The patient underwent exploratory laparotomy, and two intestinal segments including the tumors were resected. The postoperative pathological diagnosis illustrated sigmoid colon and terminal ileum metastatic squamous cell carcinoma.

Conclusions

This case demonstrates that intestine metastasis must be considered in the differential diagnosis of acute abdomen in patients with cervical cancer even at an early tumor stage.

Keywords

Intestinal obstruction Cervical cancer Metastasis Ileum Sigmoid colon

Background

Cervical cancer is a worldwide disease which ranks as the second most common malignant disease and also the third most common cause of cancer death among women [1]. More than 90 % of cases are attributed to human papillomavirus (HPV) infection [2]. Most cases occur in developing countries, as no effective screening procedures are available [3]. Over the past decades, the survival of patients with cervical carcinoma has significantly improved attributing to early screening and the rapid development of concurrent cisplatin-based chemotherapy and radiotherapy [4, 5]. In spite of the prolonged survival, the patients are also at an increased risk of recurrence and metastases, which are the main causes of death. The primary routes in cervical carcinoma metastases are direct local extension and lymphatic dissemination, while hematogenous dissemination occurs infrequently, which usually occurs with advanced tumor or uncommon pathologic types, such as adenosquamous or neuroendocrine tumors. In general, cervical cancer can spread to adjacent organs including the vagina, peritoneum, urinary bladder, ureters, rectum, and paracervical tissue. Meanwhile, Common distant metastatic sites include the lungs, bones, and liver [6], but cervical cancer metastases to the small intestine and sigmoid colon are rare. Here, we present the first reported case of a cervical cancer patient with simultaneous metastases to the small intestine and sigmoid colon, based on our knowledge.

Case presentation

A 45-year-old woman was admitted to our department with a 5-day history of abdominal distention and dull pain, especially at the upper umbilical region, and vomiting of gastric content without passage of stools or flatus. She had an erect abdominal plain radiograph which showed intestinal obstruction in a local hospital previously.

A careful medical history was taken on admission. Three years ago, she suffered from cervical cancer and had a radical hysterectomy with adnexectomy. The postoperative pathological diagnosis is cervical moderately differentiated squamous cell carcinoma with its maximum diameter to 9 mm and infiltration depth to 2 mm. No lymph node metastasis was found in the bilateral pelvic and common iliac lymph node. It was diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IB1 cervical cancer. After the operation, she had a 3- to 6-month follow-up but did not have any radiotherapy or chemotherapy.

On physical examination, her vital signs were stable. There were no lesions in the oropharynx and nasopharynx. She had abdominal light distension and a loud gurgling sound. No abdominal tenderness and rebound tenderness were found. Rectal examination and bimanual vaginal examination had no obvious abnormalities including lump and bleeding. Analysis of blood tests was unremarkable except the elevating of squamous cell carcinoma antigen (SCCA) and CA125. An erect abdominal plain radiograph was rechecked, showing the upper left intestine expanding and fluid levels with a stepladder pattern. Abdominal contrasted computed tomography (CT) showed intestinal obstruction with a thickened bowel wall in the terminal ileum and upper sigmoid colon (Fig. 1a, b). Abdominal magnetic resonance imaging (MRI) indicated the same result (Fig. 1c, d) and an unremarkable uterus stump (Fig. 1e). Colonoscopy showed a narrowed sigmoid colon lumen with smooth mucosa, and the pathological results indicated mucosal chronic inflammation (Fig. 2). Chest CT and X-ray had no obvious abnormity.
Fig. 1

Abdominal computed tomography (CT) scan. CT scan revealed lower intestinal obstruction with a thickened bowel wall in the terminal ileum (solid yellow arrow in (a) and upper sigmoid colon (feint yellow arrow in (b). Abdominal magnetic resonance (MR) revealed a thickened bowel wall in the terminal ileum (solid yellow arrow in (c) and upper sigmoid colon (feint yellow arrow in d). MR imaging also showed an unremarkable uterus stump (solid yellow arrow in e)

Fig. 2

Colonoscopy and biopsy. Colonoscopy confirmed that the intestinal mucosa was smooth without ulcers or lumps (a) except sigmoid colon luminal narrowing (b). Pathology result of the narrowing site biopsy showed mucosal chronic inflammation (c)

The patient was fasted and received passive gastric decompression along with total parenteral nutrition on admission. Abdominal distention eased on the first day. In consideration of the patient’s condition and the imaging examination and colonoscopy results, exploratory laparotomy was performed. Widespread intestinal adhesion and two firm tumors (2*2 cm and 3*2 cm separately) with a local thickened intestine wall at the end of the ileum and upper sigmoid colon were noted. She underwent segmental intestine resection and had end-to-end anastomosis. The postoperative pathological diagnosis showed squamous cell carcinoma (Fig. 3). After the operation, up until now (4 months), the patient has been treated with four cycles of a docetaxel-cisplatin combination chemotherapy regimen (day 1, 75 mg/m2 docetaxel; days 1–3, 25 mg/m2 cisplatin, per 21 days).
Fig. 3

Postoperative pathological examination. Microscopic examination of the intestinal tumor demonstrated a full-thickness wall of sigmoid colon and serosa, and the muscular layer of the terminal ileum had metastatic squamous cell carcinoma. Cancer embolus was seen in the vessel, and the peri-intestine lymph node also had metastatic squamous cell carcinoma. a small intestine and b sigmoid colon (staining with hematoxylin and eosin, ×100 magnification)

Discussion

In the present case, the patient underwent segmental intestine resection, and the pathological result indicated squamous cell carcinoma. Excluding possible primary lesions like oropharynx, nasopharynx, lung, and esophagus cancer, with the characteristics of outside-to-inside invasion from the pathology result, indicating the primary lesion in the abdominal or pelvic cavity, cervical cancer with small intestine and sigmoid colon metastases was diagnosed.

After precise calculation, the 10-year incidence of distant metastases was 3 % for stage IA, 16 % for stage IB, 31 % for stage IIA, 26 % for stage IIB, 39 % for stage III, and 75 % for stage IVA in cervical cancer patients [7]. The most frequently observed metastatic sites were the lungs, bones, liver, supraclavicular nodes, and para-aortic nodes etc. (Table 1). Unusual metastases can be seen in the skin and soft tissues [8], breast [9], pericardium [10], umbilical region [11], labia and introitus area [12], thyroid gland [13], oral cavity [14], and skeletal muscle [15]. Cervical cancer metastatic to the intestine is a rare occurrence. Table 2 provides a comprehensive review of the published cases of intestine metastases from cervical cancer in the English literature dating back to 1976. Things did not go the way we thought because not only do cervical cancer metastases to the intestine occur at an advanced tumor stage, but they also occur at an early stage, even at stage IA. The case presented here is the first report of cervical cancer with simultaneous small intestine and sigmoid colon metastases.
Table 1

The main metastatic sites of cervical cancer

metastatic sitesa [26]

Percent

Nodes

8.6

Supraclavicular

3.0

Para-aortic

3.0

Inguinal

2.3

Mediastinal

1.7

Iliac

1.3

Cervical

0.8

Axillary

0.5

Other

1.8

Lung

5.7

Bone

3.8

Peritoneum

0.6

Liver

2.2

Gastrointestinal tract

8.0

Stomach [17]

<2.0

Ileum [27]

1.2–3.2

Spleen [28]

1.6–30.0

Ovary [29]

1.3–6.3

Heart [30]

1.2

Brain [31]

0.4–1.2

Skin and subcutaneous tissue [32]

0.1–2.0

aModified and updated from [26]

Table 2

Intestine metastases from cervical cancer as reported in the literature

No.

Author [Ref.]

Year

Age

Pathologic type

Stage of SCCA of cervix at diagnosis

Previous treatment

Interval time

Symptom

Metastasis sites

Confirmation of diagnosis

Treatment

Outcome

1

Bradley Watson [27]

1976

47

Adenosquamous carcinoma

Stage IV

None

Synchronous

Intermittent central abdominal pain associated with vomiting

Small intestine

Laparotomy

Segmentary intestinal resection

NA

2

Gurian, L. [17]

1981

64

Squamous cell carcinoma

Stage IIIB

None

Synchronous

Occult bleeding

Duodenum

Endoscopy

Refused surgical intervention

Death

3

Mathur, S. K. [18]

1984

35

Squamous cell carcinoma

Stage IV

None

Synchronous

Central abdominal angina, persistent vomiting and constipation

Terminal ileum

Laparotomy

Right hemicolectomy

Recovery

4

Christopherson, W. [33]

1985

42

Squamous cell carcinoma

Stage IIIB

NA

2 years

Intermittent nausea and vomiting, upper abdominal pain

Ileum, transverse colon

Laparotomy

Segmentary intestinal resection

Recovery

5

Hulecki, S. J. [34]

1985

48

Squamous cell carcinoma

Stage IB

NA

7 years

Gross hematuria from the conduit

Ileum

Endoscopy

Laparotomy

Recovery

6

Misonou, J. [16]

1988

69

Squamous cell carcinoma

Stage IA

Hysterectomy

13 years

Sudden onset of pan-peritonitis

Small intestine

NA

NA

NA

7

Singla, M. [35]

2011

48

Squamous cell carcinoma

NA

Radiation therapy

2 years

Right hypochondrium pain

Hepatic flexure of colon

Laparotomy

Right extended hemicolectomy

Recovery for 2 years

8

Kanthan, R. [19]

2011

49

Squamous cell carcinoma

Stage IIA

Chemotherapy and radiation treatment

2 years

Upper-gastrointestinal bleeding

Duodenum

esophagogastroduodenoscopy

None

Died of multiple organ failure

9

Lee T.H. [36]

2011

50

Squamous cell carcinoma

Stage IIA

Hysterectomy with systemic chemotherapy

2 years

Epigastric pain

Ampulla of vater

Endoscopy

Chemotherapy

NA

10

Raphael, J. C. [37]

2011

57

Squamous cell carcinoma

Stage IV

None

Synchronous

Persistent epigastric pain and vomiting

Pyloroduodenal region

Endoscopy

chemotherapy

NA

11

Sugimoto, T. [38]

2013

84

Adenocarcinoma

Stage III

Radiation therapy

3 months

Epigastric pain

Ileum

Laparotomy

The necrotic part of the ileum resection

4 months survival

12

Joshi, S. R. [39]

2013

50

Squamous cell carcinoma

Stage II

Wertheim’s hysterectomy

5 months

Abdominal pain, vomiting and intermittent fever

Ileocaecal region

Laparotomy

Segmentary intestinal resection

NA

13

Datta, S. [40]

2013

55

Squamous cell carcinoma

Stage IIB

Chemoradiation

3.5 years

Abdominal pain, vomiting, constipation

Ileocaecal region

Laparotomy

Right hemicolectomy

NA

14

Barlin, J. N. [41]

2013

37

Adenosquamous carcinoma

Stage IB

Radical hysterectomy

1.5 years

Hematochezia

Sigmoid colon

Colonoscopy

Rectosigmoid resection

Recovery

15

Iliescu, L. [42]

2014

70

Squamous cell carcinoma

Stage IIA1

Radiation therapy followed by curative surgery

2 years

Intermittent subocclusive symptoms, fatigue, nausea

Terminal ileum

Laparotomy

Segmentary intestinal resection

NA

16

Debasish, B. [43]

2014

43

Squamous cell carcinoma

NA

Total abdominal hysterectomy

8 months

Symptoms of chronic intestinal obstruction

Terminal ileum

Laparotomy

Right hemicolectomy

NA

17

Nagarekha, K. [44]

2014

50

Squamous cell carcinoma

NA

Hysterectomy with bilateral salpingo-oophorectomy

3 months

Vomiting and abdominal pain

Jejunum

Laparotomy

Segmentary intestinal resection

NA

18

Hui Qiu [45]

2015

46

Squamous cell carcinoma

Stage IIB

Chemoradiotherapy

4 years

Acute abdominal pain

Ileocaecal region

Laparotomy

Segmentary intestinal resection

Recovery for 2 years

NA not available from original literature

The intestine metastases usually occur through the lymphatics to the bowel serosa and less commonly via intraperitoneal dissemination, direct spread, and hematogenous spread [1618]. As for the present case, another explanation is surgical factor, for tumor dissemination may be caused by reckless operation. Although the possible metastatic route is distinct, the rarity of intestine metastases is still unclear now [19]. Sigmoid colon metastases are rarely seen and may be because of the relatively short intestinal segment. While small intestine accounted for a large space in the enterocelia. So, the low incidence rates of small intestine metastases are notable, and several associated mechanisms have been raised as follows [2024]: (1) the intestine has abundant immune protection with numerous lymphoid cells and large secretions of IgA in the mucosa and submucosa of the intestine; (2) a rapid refresh rate of small intestinal mucosa may inhibit the tumorigenesis; (3) liquefied chyme may cause less mucosal irritation, then reduces mechanical injury and inflammation [19].

In general, a small intestine and sigmoid colon metastatic tumor indicates a poor prognosis. Bleeding and obstruction, as well as non-specific symptoms such as abdominal discomfort, gas distension, and vomiting, are common clinical features. Some reasons may cause a misdiagnosis and delay the treatment: (1) non-specific gastrointestinal symptoms may easily be seen as a symptom of tumor progression or adverse drug reaction; (2) lack of awareness of metastatic tumor; (3) ordinary CT scanners cannot find minimal lesions, especially in the small intestine. Once intestine metastasis is suspected, contrast-enhanced CT, endoscope, and even exploratory laparotomy should be operated. Typical features of intestinal metastases include intestinal wall thickening and stiffness, submucosal spread, and ulcers. Typically, metastases are submucosal or subserosal, which make the primary and secondary tumors easily distinguishable; besides, cytokeratin immunohistochemistry may help to differentiate the two. Metastatic cervical carcinoma is usually positive for CK7, epithelial membrane antigen, and CK5/6 and negative for CK20 [25]. The treatment for a small intestine and sigmoid colon metastatic tumor from cervical squamous cell carcinoma remains debatable because of the lack of enough cases to compare the efficacy of different treatments. Laparotomy seems to be the common choice if the patients are physically capable (Table 2). Chemotherapy could also be employed as a palliative treatment.

Conclusions

This report presents a rare case of small intestine and sigmoid colon metastases of cervical cancer that caused obstruction. Clinicians should be aware that intestine metastasis must be considered in the differential diagnosis of acute abdomen in patients with cervical cancer even at an early tumor stage.

Consent

Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. This report adhered to the tenets of the Declaration of Helsinki.

Notes

Abbreviations

CT: 

computed tomography

FIGO: 

International Federation of Gynecology and Obstetrics

MRI: 

magnetic resonance imaging

SCCA: 

squamous cell carcinoma antigen

Declarations

Acknowledgements

The authors would like to thank the members of the group for useful discussions and Dr. Dang Wu for language assistance.

The work was supported by grants from the Zhejiang Provincial Natural Science Foundation of China (No. Y15H160095). Written consent was obtained from the patient for publication of the study.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, Zhejiang University School of Medicine
(2)
Department of Surgical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine
(3)
Department of Gynecology, The Second Affiliated Hospital, Zhejiang University School of Medicine

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© Yu et al. 2016

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