| Japanese Journal of Clinical Oncology | Pages |
Uterine Cervix Metastasis from Rectal Carcinoma: a Case Report and a Review of the Literature
Introduction
Case Report
Discussion
References
Uterine Cervix Metastasis from Rectal Carcinoma: a Case Report and a Review of the Literature
A 59-year-old woman underwent a radical hysterectomy for a metastatic uterine cervix tumor caused by rectal carcinoma, which had been previously resected. Metastatic carcinoma from the large bowel to the uterus is rare. A total of 48 patients (including nine Japanese patients) with metastasis from the large bowel to the uterus were reviewed. The metastatic site of the uterus was the cervix in 27 cases and the corpus in 18. The interval between primary carcinoma and the secondary diagnosis was 17 months. The mean survival after the diagnosis of the secondary deposit was 11 months. Our patient died of lymph node, lung, local and bone metastases 7 months after the diagnosis of the secondary deposit.
Key words: metastasis - uterine cervix - uterine corpus - rectal carcinoma
INTRODUCTION
Common metastatic sites of colorectal cancer are the liver, lung, lymph nodes and peritoneum. Metastatic carcinoma from colorectal cancer to the uterus is rare. We present here a case of metastatic carcinoma from the rectum to the uterine cervix and review the literature on metastases from colorectal cancer to the uterus.
CASE REPORT
A 59-year-old Japanese woman was diagnosed as having rectal carcinoma in April 1996. Carbohydrate antigen 19-9 (CA 19-9) was 51.9 U/ml (normal range <37 U/ml) and carcinoembryonic antigen (CEA) was 1.0 ng/ml (normal range <2.5 ng/ml). Other laboratory data were within normal values. The patient had neither other organ metastases nor peritoneal dissemination. A low anterior resection was performed curatively. The tumor located at the left wall in the rectum below the peritoneal reflection, 4 × 3 cm in size, was an elevated and ulcerated type and the histological diagnosis was well differentiated adenocarcinoma with invasion of the muscularis propria (Fig. 1). Both lymphatic and vascular permeation were present with nine regional lymph node metastases. The tumor was stage C according to the Dukes classification. The patient received adjuvant chemotherapy of intravenous mitomicin C (total 36 mg) and perioral carmofur (total 27,000 mg) without significant adverse drug effects.
Figure 1. Photomicrograph showing a well-differentiated adenocarcinoma in the primary site. Hematoxylin-eosin stain, 10 × 3.3 mm.
Six months later, intestinal obstruction occurred with CA 19-9 of 18.9 U/ml and CEA of <0.9 ng/ml. The patient had a very dull appetite and nausea without vomiting. The patient was treated conservatively with intravenous hydration and without a nasogastric tube in hospital. The intestinal obstruction was not improved completely. Neither liver nor lung metastasis was documented and peritoneal or local recurrence was suspected. One course of combination chemotherapy with 5-fluorouracil (5-Fu) (500 mg/body, days 1-5 c.i.v.), leucovorin (21 mg/body, days 1-5 d.i.v.), mitomicin C (2 mg/body, day 5 i.v.) and cisplatin (CDDP) (60 mg/body, day 5 d.i.v.) was applied without significant adverse drug effects. In screening, cervical smear examination showed adenocarcinoma in spite of the absence of gynecological symptoms. A radical hysterectomy was performed based on the diagnosis of primary carcinoma in the cervix. No other organ metastases including the liver, lung, bone, peritoneal dissemination or lymph node were documented by either imaging study or laparotory exploration. The resected specimen was 15 × 14 mm in size and an elastically firm tumor located in the uterine cervix. Microscopically, the tumor was a well-differentiated adenocarcinoma of the uterine cervix, indicating metastasis from rectal cancer (Fig. 2). Neither uterus nor ovary metastasis was detected.
Figure 2. Photomicrograph showing adenocarcinoma of the metastatic site similar to the primary site. Hematoxylin-eosin stain, 10 × 3.3 mm.
In March 1997, the patient was readmitted to the hospital because of vaginal bleeding and constipation. The values of a CA 19-9 and CEA were elevated to 24,000 U/ml and 8.6 ng/ml, respectively. Multiple lung, liver and bone metastases were documented by imaging studies. Inguinal lymph node metastases were evident and Douglas tumor with rectal stenosis was palpable by digital examination. Double-barrel colostomy of the transverse colon was constructed, but the patient died of cancer 2 months later.
DISCUSSION
Common metastatic sites of colorectal cancer are the liver, lung, lymph nodes and peritoneum and metastasis from colorectal cancer to the uterus is an uncommon event. Only 48 cases have been reported in the literature (1-14). We recently experienced such a case and report it here with a review of the literature.
The average age of patients reported in the literature was 58 years with a wide range from 27 to 85 years. The metastatic site of the uterus was the cervix in 27 cases and the corpus in 18. Simultaneous metastasis to the ovary was found in three out of 14 cases (3,5,8,9,11-13). The interval between primary carcinoma and the secondary diagnosis was 17 months with a range from 0 to 60 months. Gynecological symptoms were as follows: vaginal bleeding in 18 cases, pelvic pain in four, mass in four, vaginal discharge in two and no gynecological symptoms in four, including our case. The survival period after the diagnosis of the secondary deposit was 11 months, ranging from 1 to 60 months.
In 43 autopsy cases with metastases to the uterine corpus from extragenital cancers, other metastasis sites were the lymph node in 100%, the lung in 81%, the liver in 76%, the bone in 65%, the adrenal gland in 63% and the urinary bladder in 26% (4). Our case ultimately developed lymph node, lung and bone metastases and the survival period after the diagnosis of the secondary deposit was 7 months.
The incidence of adenocarcinoma ranged from 0.42 to 11.7% of all cervix carcinomas (1), and the incidence of metastatic adenocarcinoma of the cervix was reported to be 21.6 or 56.9% of cervical adenocarcinoma (1,2). Judging from a compilation of 173 cases cited in three literature reviews (3-5), extragenital tumors most often metastasizing to the uterine cervix or corpus were generated from the breast (42.2%), colon (18.5%), stomach (18.5%), pancreas (5.2%), lung (4.6%), urinary bladder and kidney (4.6%), gallbladder (2.3%) and cutaneous melanoma (1.7%). One case generated from the liver and one case generated from the thyroid were also documented.
The rarity of cervical metastases has been attributed to the following: (1) the high fibrous tissue content of the cervix and an unfavorable medium for metastatic tumor growth; (2) the smallness of the cervix as a target organ with a relatively limited blood flow; (3) lymphatic vessels of the pelvis all draining away from the cervix; (4) failure to exclude another site as primary in cases diagnosed as adenocarcinoma of the cervix; and (5) failure to screen the cervix routinely in the follow-up of women with adenocarcinoma of the breast or gastrointestinal tract (3,6).
The spread of the tumor to the uterine cervix in our case might have been due to lymphatic and/or hematogenous pathways, because (1) lesions by direct extension from the rectum or by peritoneal implantation had been excluded, (2) both lymphatic and vascular permeation were present in a previously resected specimen, (3) hematogenous metastases to lung, liver, bone and lymphatic metastases to inguinal lymph nodes were observed after the second operation, (4) most uterine metastases are secondary to local lymphatic vessels spread from preceding ovarian metastases while the spread is probably hematogenous when the ovaries are not affected (15) and (5) routine lymphatic channels of the cervix drain centrifugally (3,6,7); however these channels are blocked by surgery or lymph node metastases and retrograde flow occurs.
Metastatic carcinoma from extragenital tumors has a poor prognosis, so multimodality therapy including chemotherapy (16) is required to treat the metastasis.
References
Received July 5, 1999; accepted September 27, 1999
For reprints and all correspondence: Katsunao Nakagami, Department of Surgery, Ogawa Red Cross Hospital, 152 Ogawa-Machi, Hiki-Gun, Saitama 355-0397, Japan
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Copyright© 1999 Foundation for the Promotion of Cancer Research.
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