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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 119-121

Jejunal metastases from squamous cell carcinoma of the cervix presenting as an abdominal wall abscess


Department of Pathology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India

Date of Web Publication2-Jun-2016

Correspondence Address:
Kavita Mardi
12-A, Type V Quarters, GAD Colony, Kasumpti, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.183360

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  Abstract 

Metastatic tumors of the intestinal tract from extra-abdominal sites are rare. In cervical cancer, the liver, lung, and the bones are the most common distant sites of metastases. Metastasis to the small intestine is very rare. We report a rare case of metastasis of cervical squamous cell carcinoma to jejunum after a few months of chemoradiotherapy.

Keywords: cervix, jejunum, small intestine, squamous cell carcinoma


How to cite this article:
Mardi K, Sharma R. Jejunal metastases from squamous cell carcinoma of the cervix presenting as an abdominal wall abscess. Arch Med Health Sci 2016;4:119-21

How to cite this URL:
Mardi K, Sharma R. Jejunal metastases from squamous cell carcinoma of the cervix presenting as an abdominal wall abscess. Arch Med Health Sci [serial online] 2016 [cited 2019 Jun 25];4:119-21. Available from: http://www.amhsjournal.org/text.asp?2016/4/1/119/183360


  Introduction Top


Small bowel lesions are infrequently encountered in surgical pathology. Diagnosis of malignancy in such lesions accounts for only 0.4% of all cancers.[1] Metastatic lesions are more common in the duodenum, jejunum, and ileum than primary lesions. Though malignant melanoma is the most common extra-gastrointestinal primary to metastasize to the small bowel,[2] intestinal metastases are common in end-stage adenocarcinomas of the pancreas, colon or stomach by intraperitoneal seeding. Majority of patients of squamous cell carcinoma (SCC) of cervix usually die from local extension rather than distant metastases. It is exceedingly rare for SCC of the cervix to clinically present with symptoms related to small bowel metastases. We herein report a case of jejunal metastases from SCC of the cervix and review pertinent literature.


  Case Report Top


A 51-year-old female patient presented with pain abdomen in the periumbilical area since 1-month. Pain increased in severity over the last 10 days. There was redness in the periumbilical area along with high-grade continuous fever associated with chills and rigors. Patient also gave a history of being diagnosed with carcinoma cervix and had undergone transabdominal hysterectomy 9 months back and was receiving chemoradiation for 6 months. Local examination revealed a tender hard lump with redness over the swelling. Clinical diagnosis of abdominal wall abscess along with secondaries in the abdominal wall was made. Pus sent for culture studies revealed  Escherichia More Details coli.

Ultrasonography revealed isoechoic round mass with central degenerating area in right periumbilical region. Computed tomography scan revealed collection of fluid in periumbilical region herniating into the anterior abdominal wall with multiple satellite lesions. The mass was excised along with a segment of jejunum and the attached omentum.

Gross examination of specimen sent revealed jumbled up mass of part of jejunum measuring 20 cm, with attached mesentery. There was an irregular mass involving both jejunal wall and mesentery. Cut surface of mass was gray-white in color with focal hemorrhagic and necrotic areas [Figure 1]. Microscopic examination revealed poorly differentiated SCC diffusely infiltrating fibro-fatty tissue of mesentery as well as invading wall of small intestine up to submucosa [Figure 2] and [Figure 3]. Large areas of tumor necrosis and dense acute inflammatory cells were also present. There was evidence of lymphovascular invasion by tumor cells. Immunohistochemically, the tumor cells showed positivity for CK5 and p63. These findings suggested metastatic deposits of SCC in the jejunum and attached mesentery.
Figure 1: Jumbled up specimen of resected segment of jejunum along with mesentery revealing a gray-white solid tumor involving both

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Figure 2: Photomicrograph showing tumor invading jejunum up to submucosa (H and E, ×10)

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Figure 3: Higher magnification of the tumor, revealing features of poorly differentiated squamous cell carcinoma (H and E, ×40)

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  Discussion Top


Extra-pelvic spread of SCC of the cervix to the small bowel is rare with only seven reported cases in the English literature since 1981.[3]

Carcinoma of the cervix usually spreads in an orderly and predictable fashion. The earliest and most common metastases are by direct extension to the contiguous structures including the vagina, peritoneum, urinary bladder, ureters, rectum, and paracervical tissue; however, distant metastatic spread with unusual patterns such as pulmonary lymphangitic carcinomatosis have also been reported.[4] Up to 50% of stage IV patients can present with distant metastases.[4] Common sites of such occurrences are the liver, lungs, and bone marrow. The gastrointestinal tract is involved in approximately 8% of patients with carcinoma of the cervix and such metastatic deposits are commonly found in the rectosigmoid region as a result of local extension.[5] Gastric lesions are identified in <2% of patients with carcinoma of the cervix, and are usually asymptomatic.[5] Isolated metastases to the small bowel are exceedingly rare. Such spread is believed to occur commonly through the lymphatics, usually the para-aortic or mesenteric nodes to the bowel's serosa and less often via the blood stream or by peritoneal seedlings.[5],[6],[7]

Metastatic lesions in the small bowel are more common than primary lesions, and commonly arise from malignant melanoma, carcinoma of the lung, genitourinary cancers, breast cancer, Kaposi's sarcoma, colonic and renal cell carcinomas.[4],[8] The most common presenting symptom of small bowel lesions is a partial or complete bowel obstruction and less commonly, bowel perforation, persistent abdominal pain or hemorrhage.[5],[7] In the present case, patient presented with unusual signs and symptoms related to abdominal wall abscess.

Metastatic tumors in the small intestine predominantly involve the bowel wall, the subserosa, the serosa or the mesentery. However, submucosal involvement is rare. According to Farmer and Hawk,[9] metastatic masses to small bowel are divided into three types:

  1. Spherical mesenteric masses encroaching on or extending into intestine,
  2. Intramural masses, often with ulceration; and
  3. Bulky polypoidal masses extending into bowel lumen.


Varied times between the primary and the manifestation of metastatic lesions is reported in the literature ranging from being synchronous [5],[7] to metachronous with a delayed time interval ranging from 2 to 13 years.[6] Clinical presentations reported are varied. The overall long-term prognosis of cases with jejunal metastases is extremely poor as it probably indicates disseminated disease. This is further compounded by delayed diagnosis of these unusual lesions


  Conclusion Top


Jejunal metastasis from SCC of the cervix is an extremely rare “malignant” cause of abdominal wall abscess. Yet, accurate recognition of such unusual patterns of metastases in cervical cancer by histopathology is vital for best practice therapeutic decisions in these patients.

 
  References Top

1.
Schottenfeld D, Beebe-Dimmer JL, Vigneau FD. The epidemiology and pathogenesis of neoplasia in the small intestine. Ann Epidemiol 2009;19:58-69.  Back to cited text no. 1
    
2.
Kanthan R, Gomez D, Senger JL, Kanthan SC. Endoscopic biopsies of duodenal polyp/mass lesions: A surgical pathology review. J Clin Pathol 2010;63:921-5.  Back to cited text no. 2
    
3.
Kanthan R, Senger JL, Diudea D, Kanthan S. A review of duodenal metastases from squamous cell carcinoma of the cervix presenting as an upper gastrointestinal bleed. World J Surg Oncol 2011;9:113.  Back to cited text no. 3
    
4.
Kanthan R, Senger JL, Diudea D. Pulmonary lymphangitic carcinomatosis from squamous cell carcinoma of the cervix. World J Surg Oncol 2010;8:107.  Back to cited text no. 4
    
5.
Gurian L, Ireland K, Petty W, Katon R. Carcinoma of the cervix involving the duodenum: Case report and review of the literature. J Clin Gastroenterol 1981;3:291-4.  Back to cited text no. 5
    
6.
Misonou J, Natori T, Aizawa M, Jou B, Tamaki A, Ogasawara M. Stage (Ia) cervical cancer recurring 13 years after hysterectomy and causing small intestinal perforation. A case report with a review of the literature. Acta Pathol Jpn 1988;38:225-34.  Back to cited text no. 6
    
7.
Mathur SK, Pandya GP. Solitary metastatic malignant stricture of the ileum: A rare cause of small bowel obstruction (a case report). J Postgrad Med 1984;30:186-8.  Back to cited text no. 7
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8.
Loualidi A, Spooren PF, Grubben MJ, Blomjous CE, Goey SH. Duodenal metastasis: An uncommon cause of occult small intestinal bleeding. Neth J Med 2004;62: 201-5.  Back to cited text no. 8
    
9.
Farmer RG, Hawk WA. Metastatic tumors of the small bowel. Gastroenterology 1964;47:496-504.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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