Presentación inusual de compromiso metastásico cutáneo por carcinoma escamocelular de cuello uterino / Unusual presentation of metastatic skin involvement in a patient with squamous cell carcinoma of the cervix: Case report

Resumen El cáncer de cuello uterino ocupa el cuarto lugar dentro de las neoplasias de origen ginecológico a nivel global, representando un 85% de los casos en países en vías de desarrollo. Las metástasis cutáneas de origen ginecológico son altamente infrecuentes, observándose con mayor frecuencia en las neoplasias malignas de ovario, seguidas del adenocarcinoma endometrial y de cuello uterino y, menos frecuentemente, las de subtipo escamocelular. En la actualidad, existen alrededor de 80 reportes de casos citados en la literatura de metástasis cutáneas secundarias a un carcinoma de cuello uterino; sin embargo, ninguno con localización en la piel del cuello que se origine de un subtipo histológico escamocelular. En Colombia, no hay casos reportados hasta la fecha. Se presenta el caso de una paciente de 43 años que consulta por sangrado vaginal, dolor abdominal y una extensa placa tumoral exofítica de aspecto metastásico en la piel del cuello y del hombro izquierdo, encontrando al examen clínico inicial una masa tumoral en el cuello uterino con confirmación histológica de un carcinoma escamocelular como neoplasia primaria. Se hace diagnóstico de Carcinoma de cuello uterino estadio IVB y se inicia un tratamiento con intención paliativa con radioterapia y posterior quimioterapia sistémica. La enfermedad metastásica de origen ginecológico a nivel cutáneo confiere un mal pronóstico, con una supervivencia reportada de 1 a 37 meses después de su diagnóstico, por lo cual se deduce que la prevención y el diagnóstico temprano, particularmente en cáncer de cuello uterino, es de vital importancia en la población general.

Abstract Cervical cancer is the fourth most common cancer among gynecological neoplasms globally, representing 85% of cases in developing countries. Cutaneous metastases of gynecological origin are very rare, observed more frequently in ovarian malignancies, followed by endometrial and cervical adenocarcinoma and less frequently those of the squamous cell subtype. Currently there are about 80 case reports cited in the literature of cutaneous metastases secondary to cervical carcinoma, however, none with localization in the skin of the neck originated from a squamous cell histological subtype. In Colombia, there are no reported cases to date. We present the case of a 43-year-old patient who consulted for abdominal pain, vaginal bleeding and an extensive exophytic tumor plaque of metastatic appearance in the skin of the neck and left shoulder, finding a tumor mass in the cervix with histological confirmation of a squamous cell carcinoma as primary tumor. A diagnosis of stage IVB cervical carcinoma is made, and treatment is initiated with palliative intention with radiotherapy and subsequent systemic chemotherapy. Cutaneous metastatic disease of gynecological origin confers a poor prognosis, with a reported survival of 1 to 37 months after its diagnosis, for which prevention and early diagnosis, particularly in cervical cancer, is of vital importance in the general population.

Profile of women with cervical changes from a city in the Northeast Brazil / Perfil das mulheres com alterações cervicais em uma cidade do nordeste brasileiro

ABSTRACT Introduction: In Brazil, cervical cancer is the fourth leading cause of cancer death. It reached 5,430 deaths in the year 2013, with estimated 16,370 new cases by 2018. Its occurrence has been associated with previous human papillomavirus (HPV) infection for the development of intraepithelial lesions; however, several factors can influence this appearance, including number of sexual partners and infections by other microorganisms. Objective: The profile of women from the city of Caruaru, Pernambuco, Brazil, with atypia, cervical intraepithelial lesions and cancer, was verified. Material and method: Documentary, analytical, retrospective study, carried out through the collection of information in the database of the State Department of Health of Pernambuco, by TabNet, referring to the tests in the laboratory of the municipality of Caruaru, Pernambuco, Brazil. Results: During the study period, 18,466 tests were evaluated. From the samples evaluated, 735 (4.31%) were squamous and glandular atypia, 167 (0.98%) intraepithelial lesions, and one (0.005%) cancer. Coccus, Gardnerella vaginalis and Lactobacilli were the most evident agents in cervical alterations. Discussion: Studies demonstrate the intimate relationship between infectious agents and the development of cervical lesions and cancers. Gardnerella vaginalis was the most frequent agent in the presence of abnormalities was identified as a facilitator of HPV penetration. Conclusion: Women infected by Gardnerella vaginalis and older than 30 years of age are more exposed to the development of alterations. Guidelines on prevention and screening should be continuous strategies in public services. Understanding these risk factors is a paramount concern because they are involved in the prevention and etiology process of cervical lesions and cancer.

RESUMEN Introducción: En Brasil, el cáncer de cuello de útero es la cuarta causa de muertepor cáncer, con 5.430 muertes en 2013 y previsión de 16.370 nuevos casos para 2018. Su aparición se asocia a la infección previa por el virus delpapiloma humano (VPH) para el desarrollo de lesiones intraepiteliales; no obstante, diversos factores pueden influenciarle, por ejemplo, número de companeros sexuales e infeccionespor otros microrganismos. Objetivo: Se ha comprobado el perfil de mujeres del municipio de Caruaru, Pernambuco, Brasil, que tenían atipias, lesiones intraepiteliales cervicales y cáncer. Material y método: Investigación documental, analítica, retrospectiva, realizada mediante una encuesta en la base de datos del departamento de salud de Pernambuco, a través de TabNet, relativas a los exámenes en el laboratorio del municipio de Caruaru, Pernambuco, Brasil. Resultados: En el período del análisis, 18.466 exámenes han sido evaluados. De las muestras analizadas, 735 (4,31%) han sido de atipias escamosas y glandulares; 167 (0,98%) de lesiones intraepiteliales; y una (0,005%) de cáncer. Cocos, Gardnerella vaginalis y lactobacilos han sido los agentes más evidentes en las alteraciones cervicales. Discusión: Investigaciones comprueban una relación directa entre agentes infecciosos y el desarrollo de lesiones y cáncer cervical. Gardnerella vaginalis ha sido aquel más frecuente en presencia de anormalidades, pues facilita la invasión por el VPH. Conclusión: Mujeres mayores de 30 anos infectadas por Gardnerella vaginalis representan una exposición importante al desarrollo de alteraciones. Recomendaciones de prevención y tamizaje deben ser estrategias constantes en el serviciopúblico. Conocer estos factores de riesgo es crucial, porque ellos envuelven el proceso de prevención y etiología de las lesiones y del cáncer de cérvix.

RESUMO Introdução: No Brasil, o câncer do colo do útero é a quarta causa de morte por câncer. Atingiu 5.430 mortes no ano de 2013, com estimativa de 16.370 novos casos para 2018. Sua ocorrência tem sido associada à infecção prévia pelo papilomavírus humano (HPV) para o desenvolvimento de lesões intraepiteliais, no entanto, vários fatores podem influenciar esse aparecimento, por exemplo, número de parceiros sexuais e infecções por outros microrganismos. Objetivo: Verificou-se o perfil das mulheres do município de Caruaru, Pernambuco, Brasil, com atipias, lesões intraepiteliais cervicais e câncer. Material e método: Estudo documental, analítico, retrospectivo, realizado por meio do levantamento de informações no banco de dados da Secretaria Estadual de Saúde de Pernambuco, pelo TabNet, referentes aos exames no laboratório do município de Caruaru, Pernambuco, Brasil. Resultados: No período do estudo foram avaliados 18.466exames. Das amostras avaliadas, 735 (4,31%) foram atipias escamosas e glandulares; 167 (0,98%), lesões intraepiteliais; e uma (0,005%), câncer. Cocos, Gardnerella vaginalis e lactobacilos foram os agentes mais evidentes nas alterações cervicais. Discussão: Estudos comprovam relação íntima dos agentes infecciosos com o desenvolvimento de lesões e cânceres cervicais. Gardnerella vaginalisfoi o agente mais frequente na presença de anormalidades, sendo identificada como facilitadora da penetração do HPV. Conclusão: Mulheres infectadas por Gardnerella vaginalis com idade acima de 30 anos representam maior exposição ao desenvolvimento de alterações. Orientações quanto à prevenção e ao rastreamento devem ser estratégias constantes nos serviços públicos. Entender esses fatores de risco é primordial, porque eles envolvem o processo de prevenção e etiologia das lesões e do câncer cervical.

Carcinoma linfoepitelial del cuello uterino / Linfoepitelial cancer of the cervix

El cáncer linfoepitelial del cuello uterino es excepcional en nuestro continente, el propósito de la presente publicación es evaluar la etiología, diagnóstico y tratamiento de un caso clínico. El estudio anátomo-patológico ofreció ciertas dificultades, por lo que se recurrió a la inmunohistoquímica para hacer el diagnóstico diferencial con el carcinoma epidermoide, el carcinoide de células grandes y el linfoma anaplásico. El compromiso del virus de Epstein-Barr y el virus del Papiloma Humano, con el cáncer linfoepitelial, no fueron con-cluyentes. Se encontró tinción positiva granular en el citoplasma de células epiteliodeas aisladas en relación al primero, e indicios de daño coilocitico en el epitelio pavimentoso en relación al segundo. La enfermedad se presentó como lesión única sangrante en el labio anterior del cuello uterino. El tratamiento fue quirúrgico con erradicación completa, lo que favorece el pronóstico.

Linfoepitelial cancer of the cervix is exceptional in our continent. The purpose of this publication is to evaluate the etiology, diagnosis and treatment. Anatomical and pathological study offered certain difficulties; immunohistochemistry was used to make the differential diagnosis with squamous carcinoma, large cell carcinoid and anaplastic lymphoma. Compromise of Epstein - Barr virus and virus of Human Papilloma, with linfoepitelial cancer, were not conclusive. We found positive granular staining in the cytoplasm of isolated epithelioid cells in relation to the first virus and koilocytic damage of the squamous epithelium in regard to the second. The disease was presented as unique, bloody injury, in the anterior lip of the cervix. The treatment was surgical with complete eradication, which favors the prognosis.

Cáncer cérvico uterino, un simulador letal / Cervical cancer, a lethal simulator

Se presentó una paciente de 65 años, fumadora, con antecedentes patológicos personales de litiasis vesicular hace 4ños y NIC II en el año 1997. Acudió a la consulta por cuadro de dolor en columna lumbar, pérdida de peso y del apetito de 2 meses de evolución, durante su ingreso ocurre un deterioro significativo de su estado general. Se describió la evolución clínica y los estudios realizados mediante los cuales se le diagnosticó un carcinoma indiferenciado de células pequeñas de cuello uterino e infiltrante

A 65-year-old female patient, smoker, with a medical history of gallstones 4 years ago and CIN II in the year 1997, presented with lumbar pain and loss of weight and appetite of 2 months of evolution. During her stay in hospital there was significant deterioration of her general state. A description is provided of her clinical evolution and of the tests performed, through which she was diagnosed with infiltrating small-cell undifferentiated carcinoma of the uterine cervix

Use of the Rectal Retractor to Reduce the Rectal Dose in High Dose Rate Intracavitary Brachytherapy for a Carcinoma of the Uterine Cervix

Commercially available rectal retractors can be used in high dose rate intracavitary brachytherapy (HDR ICR) as one of the methods for reducing the rectal dose in radiotherapy for a uterine cervical cancer. However, the extent of the rectal protection achieved using these rectal retractors has not been reported. The aim of the study was to examine the effect of a rectal retractor on reducing the rectal dose in HDR ICR. Thirty patients were treated with HDR ICR using rectal retractors. Tandem and ovoids were applied in 15 patients and ovoids only were used in the other 15 patients. During the simulation, the rectum was filled with barium, and anteroposterior and lateral radiographs were then taken with and without the rectal retractor. Along the anterior rectal wall outlined, 4 to 8 points (median 6) were chosen to calculate the dose for each patient including the rectal point (RP), which is an author-defined rectal point modified from the definition of the rectal reference point in the ICRU report 38. The length of the measured rectum was 3-7 cm (median 5 cm). The bladder point (BP) dose was measured as recommended by the ICRU. The prescription doses to point A varied from 3.5 to 5 Gy (median 4 Gy). Paired comparisons were made on the individual patients by calculating the normalized mean doses of the RP, the maximal point (MP), and the longitudinal average (LA) with and without the rectal retractor. The doses to the bladder points (BP) were also calculated in parallel to the rectal points. The anterior rectal walls were displaced posteriorly after inserting the rectal retractor. In the tandem and ovoids group, the number of patients with a reduced dose in the RP, MP and LA were 14 (93.3%), 12 (80.0%) and 13 (86.7%), respectively. In the ovoids only group, the corresponding figures were 14 (93.3%), 14 (93.3%) and 14 (93.3%). In the tandem and ovoids group, the reduced dose in the RP, MP, and LA dose were 0.52 Gy (13.0%), 0.50 Gy (12.5%), and 0.39 Gy (9.8%), respectively (p 0.05). The mean RP, MP, and LA dose reduction rates of the patient subgroup where the RP dose was 70%. The effect of the rectal dose reduction was significant only in the subgroup of patients who received > 70% of the prescription dose (p < 0.05). The use of the rectal retractor was a simple and an effective method for reducing the rectal dose. It was also considered to be a highly reproducible method, which can replace the time-consuming vaginal gauze packing in HDR-ICR.

Endometrial and Corporal Extension in Carcinoma of Uterine Cervix / 대한부인종양콜포스코피학회잡지

OBJECTIVE: The objective of this study was to evaluate clinical significance of endometrial and corporal extensions of Carcinoma of the uterine cervix. METHODS: The 273 patients with locally advanced cervical cancer who underwent radical hysterectomy after neoadjuvant chemotherapy between Jan 1983 to May 1998 were included in this study and endometrial and corporal extension was examined by pathologic report. Then, clinical characteristics such as age, stage, tumor size, geographic contour, the lymph node and parametrial invasions, recurrence rate, and 5 year-survival rate were compared between extension(n=30) and non-extension(n=243) group. Pearson chi-square test, Fisher's exact test, and Kaplan-mayer survival analysis were used for calculation of statistical significance between two group. p-value less than 0.05 was considered to be clinically significant. RESULTS: The incidence of endometrial and corporal extension in this locally advanced cervical cancer group was 11% (30/273). The endometrial and corporal extension were closely related with advanced stage, larger cervical tumor mass, endophytic type, and pelvic lymph node metastasis. However, 5-year disease free survival rates or 5-year actuarial survival rates did not show statistically significant differences between extension and non-extension group (7S% vs 83% and 81% vs 84%, respectively) CONCLUSION: The endometrial and corporal extension were closely associated to high risk factors of advanced cervical cancer. Though its clinical significance for poor outcome were not proved in this study, prospective study with more patients is needed to clarify its clinical significance.

Result of Radiation Therapy and Extrafascial Hysterectomy in Bulky Stage lB, llA-B Carcinoma of the Uterine Cervix / 대한방사선종양학회지

PURPOSE: To evaluate the efficacy of tadiation therapy and eatrafascial hysterectomy in bulky stage lB,lla-B uterine cervix cancers. MATERIALS AND METHODS: Twenty four patients with bulky stage lB and llA-B carcinoma of the uterine cervix were treated with extrafascial hysterectomy following radiation therapy due to doubts of residual disease at Department of therapeutic radiology, Keimyung University, Dongsan Hospital , From April 1986 to December 1997. According to FIGO staging system, there were 7 Patients with stage lB, 9 patients with llA and 8 patients with llB stage whose median age was 45. Pathologic distribution showed 16 patients with squamous cell carcinoma and 8 with adenocarcinoma. Seven patients had tumors that are less than 5Cm in size 17 patients had tumors with larger than 5Cm.The mean interval between radiation therapy and extrafascial hysterectomy was 57 days. The radiation therapy consisted of irradition to the whole pelvis (180 cGy/fraction, Mean 4100 cGy)and parametrial boost ( for a mean total dose of 5000cGy) with midline shield (4x10Cm), followed by intracavitary irradiation up to 7500 cGy to point A (maximum 8500cGy). The maximum follow up duration was 107 months and mean follow up duration was 42 months. RESULTS: Ten out 24 patients (41.7%)had residual disease found at the time of eatrafascial hysterectomies. Five year Overall survival rate (5Y OSR) and five year disease free survival rate (5Y DFSR) were 63.6% and 62.5% respectively . Five year overall survial rate for stage lB and llA was 71.4% and 50% for stage llB. There was a significant difference in 5Y OSR and 5Y DFSR between patients with and those without residual disease (negative vs Positive, 83.3% vs. 40% (p=0.01), 83.3% vs36% (p=0.01) respectively). There was a notable tendency of better survival with adenocarcinoma than with squamous cell carcinoma (adenocarcinoma vs squamous cell carcinoma, 85.7% vs. 53.3% (p=0.1), 85.7% vs. 50.9% (p=0.1) of 5Y OSR and 5T DFS respectivey). Total dose to A point did not make a significant difference in survival rate or the existence of residual lesion ( or =7500 cGy). It was also noted that significantly more frequent local have occurred in patients with positive residual residual disease compared with negative residual disease (5/10 vs. 0/14, p=0.003). There was no death related to treatment. CONCLUSION:T here was no improvement of residual and to the overall survial rate in sqite of increased total dose to point A. We conclude that there is a possible beneficial of radiation therapy follow by extrafascial hysterectomy in survival for adenocarcinoma of bulky stage lB and llA-B uterine cervix. We need to this with follow up and large number of patients.

The Results of Curative Radiation Therapy for 49 Patients of the Uterine Cervical Carcinomas / 대한치료방사선과학회지

Fifty patients with carcinoma of the uterine cervix received curative radiotherapy by external irradiation of the whole pelvis and intracavitary radiation at the Department of Therapeutic Radiology, Kangnam St. Mary's Hospital from September,1983 to October, 1986. External beam whole pelvic irradiation was done first up to 4500-5940 cGy in 5 weeks to 6.5 weeks, followed by an intracavitary radiation. Total dose of radiation to point A varied from 6500 cGy to l1344 cGy (average 6764 cGy). Of the 50 patients, one patient was lost to follow up and follow up period of the remaining 49 patients ranged from 3 months to 93 months (median 32 months). According to FIGO classification, 6 (12.2%) were in stage Ib, 6(12.2%) in stage Ia, 25 (51%) in stage IIb, 7 (14%,) in stage III, and 5 (10.2%) in stage IV. Age of the patients ranged from 33 to 76 years (Median 60 years). Pathologically, fourty six(94%) patients had squamous cell carcinoma, 2 (4% had adenocarcinoma, and 1 (2%) had adenosquamous cell carcinoma. Overall response rate was 84%. 5-year survival rate was 49% for entire group (75% for stage Ib, 83% for Stage IIa, 42.5% for stage IIb, 25% for stage III, 40% for stage IV). Complications were observed in 11(22.4%) patients, who revealed rectal complications with most common frequency. Others were self limiting trifle ones such as wet desquamation, fatigue, mild leukopenia, etc. The correlation of the survival rate with various factors (age, dose, Hb level, pelvic Iymph node status, performance status, local recurrence) was evaluated but showed no statistical significance except the age and local recurrence in this series; survival of patients less than 50 years of age was worse than that of the older, and the presence of local recurrence had worse prognosis(p< 0.05).

Treatment of Carcino ma of the Uterine Cervix with High-Dose-Rate Intracavitary Irradiation using Ralstron / 대한치료방사선과학회지

From May 1979 through December 1981 a total of 524 patients with carcinoma of the uterine cervix were treated by radiation therapy with curative intent. Among the 524 patients, 356 were treated with a high-dose-rate (HDR), remote-controlled, afterloading intracavitary irradiation (ICR) system using a cobalt source (Ralstron), and 168 patients received a low-dose-rate (LER) ICR using a radium source. External beam irradiation with a total dose of 40-50 gy to the whole pelvis followed by intracavitary irradiation with a total dose or 30-39 gy in 10-13 fractions to point A was the treatment protocol ICR was given three times a week with a dose of 3 gy per fraction. Five-year actuarial survival rates in the HER-ICR group were 77.6% in stage IB (N=20), 68.2% in stage II (N=182), and 50.9% in stage III (N=148). In LDR-ICR group, 5-year survival rates were 87.5% in stage IB (N=22), 66.3% in stage II (N=91), and 55.4% in stage III (N-52). Survival rates showed a statistically significant difference by stage, but there was no significant difference between the two ICR groups. Late bowel complications after radiotherapy were noted in 3.7% of the HDR-ICR group and 8.4% of the LDR-ICR group. There was no severe complication requiring surgical management. The incidence of bladder complications was 1.4% in the HDR-ICR group and 2.4% in the LDR-ICR group. The application of HDR-ICR was technically simple and easily performed on an outpatient basis without anesthesia, and the patients tolerated it very well. Radiation exposure to personnel was virtually nil in contrast to that of LDR-ICR. Within a given period of time, more patients can be treated with HDR-ICR because of the short treatment time. Therefore, the HDR-ICR system is highly recommended for a cancer center, particularly one with a large number of patients to be treated. In order to tachieve an improved outcome, however, the optimum dose-fractionation schedule of HDR-ICRand optimum combination of intracavitary irradiation with external beam irradiation should be determined through an extensive protocol study with different treatment regimens.

The Results of Radiation Treatment in Carcinoma of the Uterine Cervix / 대한치료방사선과학회지

From July 1979 through March 1985, 112 patients with carcinoma of the uterine cervix were treated by whole pelvis irradiation and intracavitary radiation with Cs-37. The treatment consisted of 3600rad-200rad to the whole pelvis by parallel opposing portals, 5 days per week, 180-00rad per day. Parametrial boost with 400-00rad was given in 60 patients. 2 intracavitary Cs-37 radiation using TAO applicator were done with 7-0 days interval. Total treatment times were 40-5 days with average 52 days. Total dose of radiation to point A varied from 6820 to 10500rad with average 8388rad and to point B from 4850 to 6899rad with average 5898rad. All patients had follow up from 6 months to 75 months and median follow up of 31 months. 9(8%) had stage Ib, 14(12.5%) had stage IIa, 50(44.6%) had stage llb, 33(29.5%) had stage III, 6(5.4%) had stage IV. 110 patients had squamous cell carcinoma and 2 patients had adenocarcinoma. 5 year actuarial survival rates were 61.8% for the entire group, 84.6% for stage Ib, 77.8% for stage IIa, 56.7% for stage IIb, 60% for stage III, 33.3% for stage IV. RT dose to medial parametrium (point A) below 8000rad resulted in 7/18(38.9%) failure (=death) in contrast to 25/94 (26.5%) failure with dose over 800rad. RT dose to lateral parametrium (point B) below 6000rad yielded 20/63 (34.9%) failure compared to 10/49 (20.4%) failure with dose over 6000rad. Poor survival group of age were between 40-9 years with failure of 14/41 (34.1%). There was no increased failure rate below age of 40 with failure of 2/11 (13.9%). The results suggest that survival is as good as other published data, and that higher doses over 8000rad to point A and 6000rad to point B should be delivered.

Treatment Result of Postoperative Radiotherapy of Carcinoma of the Uterine Cervix / 대한치료방사선과학회지

The early carcinoma of the uterine cervix may be treated by either radical surgery or radical radiotherapy according to the patient's characteristics, and the survival is high with either treatment. But, because of the size of the lesion, metastasis to lymph nodes, and vascular space invasion by tumor have all been shown to influence recurrence and survival, postoperative radiotherapy may be considered as their histopathologic finding after radical surgery. However, there are still debates on the increasing survival rates with postoperative radiotherapy. Two hundreds and three patients with carcinoma of the uterine cervix who were treated with postoperative radiotherapy from February 1979 to September 1982 in the Department of Therapeutic Radiology, Seoul National University were analyzed and following results were obtained. 3-ear actuarial survival rate and 3-ear disease free survival rate were 83.4% and 73.4% respectively and 3-ear actuarial survival rates by stages were 90.7% for IB, 69.6% for IIA, and 85.2% for IIb. 3-ear actuarial free survival rates by stage IB, IIA, IIB were 79.8%, 67.8%, 68.3% respectively. The overall failure rate was 25.1%(51/203); local recurrence rate was 8.4%, distant metastasis rate was 14.3% and simultaneous local recurrence and distant metastasis was 2.4%. Failure rates by stages were 19.8%(18/19) for IB, 29.1%(16/55) for IIA and 29.8%(17/57) for IIB. The overall acute complication rate was 57.6%; tolerable cases was 50.2% and severe cases was 7.4%, Late complication rate was 7.9% and the major late complication were intestinal obstruction, aggravated urinary symptom, radiation cystitis in order of frequency.