Solitary cerebel­lar metastasis of uterine cervical carcinoma

Summary

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manu script met the ICMJE “uniform requirements” for biomedical papers.

Dear Editor,

Uterine cervical cancer is one of the lead­­ing cancers in women as it is the second most com­mon cancer worldwide. It causes approximately 275,000 female deaths yearly [1]. Nevertheles­s, CNS metastasis of uterine cervical carcinoma are uncom­mon [2,3]. Cervical cancer metastasis potential is very low (< 10%), and there is a tendency to enter retroperitoneal lymph nodes, lungs and bone [4]. Cerebral metastasis occurs as part of a dis­seminated dis­ease with systemic involvement, which has an incidence of 0.5% to 1.2% [5]. The cerebel­lum is a very unusual site for metastasis. The most com­mon histopathology is shown to be a squamous cell tumor [2].

A 65-year-old woman suf­fer­­ing from vaginal bleed­­ing was refer­red to a gynecology clinic. Pelvic examination resulted in abdominal ultrasonography which reveal­­ed a 35 × 33 × 48 mm tumor of the cervix with parametrial invasion. Thorax and upper abdominal tomography were normal. Cervical bio­psy was performed. Pathology show­ed a moderately dif­ferentiated invasive squamous cell carcinoma. The dis­ease was staged 2b accord­­ing to The International Federation of Gynecology and Obstetrics (FIGO) staging, so the patient underwent adjuvant radiation ther­apy and concur­rent cis­platin contain­­ing chemother­apy. The patient was symp­tom free for 6 months. Then, she started to complain of nausea and dizzines­s. PET did not reveal any metastasis but the symp­toms remained, so head tomography was performed, which revealed an occupy­­ing lesion in the left cerebel­lum with a mass ef­fect on the fourth ventricle caus­­ing hydrocephalus and increas­­ing intracranial pres­sure. The patient underwent a midline occipital craniotomy and total excision of the mass (Fig. 1), which histological­ly proved to be squamous cell carcinoma metastasis (Fig. 2). Intraoperatively, the tumor had a medium hardnes­s. It was encapsu­lated with wel­l-defined planes and soon after the capsule was opened, a grayish yel­low mucoid fluid was seen.

She received radiother­apy to the brain 1 month post-surgery. At the end of the 10^th radiation ther­apy, she started vomit­­ing and displayed cerebel­lar syndrome. Medical treatment showed no recovery. She was sleepy and unconscious. Brain MRI revealed total excision of the left cerebel­lar metastasis but also tetraventricular hydrocephalus with transependymal cerebrospinal fluid pas­s. After pres­sure measurement by lumbar puncture, she underwent surgery for ventriculoperitoneal shunting. She recovered after the procedure. Eight months after cerebel­lar resection, the patient was dead. Before her death, she had multiple metastases to the lungs and bones.

Henriksen first reported cerebral metastasis of cervical carcinoma in 1949 in an autopsy study [6]. Cervical carcinomas similar to other gynecologic malignancies have a lower tendency to metastasize to the brain, with a rate of 0.4– 1.2%. General­­ly, head­ache and hemiplegia are the most significant symp­toms of brain metastasis; how­ever, dizziness and nausea were the most com­mon complaints of our patient. In the literature, the time from initial diagnosis to metastasis has been reported in a various range of 5 weeks to 8 years [7]. In our patient, metastasis was discovered 6 months after dia­gnosis. In the literature, brain involve­ment without systemic involvement of the cervical carcinoma is very rare [8].

The treatment of brain metastasis includes radiation or surgery combined with postoperative radiation ther­apy. Solitary metastasis and life-threaten­­ing mas­ses are some of the surgical indications. The median survival is longer with surgery combined with radiother­apy, which is more ef­fective than radiother­apy treatment alone. Pal­liative ther­apy is recom­mended in multiple intracranial lesions with systemic dis­semination [8]. It is reported that surgical resection fol­lowed by whole brain radiother­apy is the best choice in solitary brain metastasis cases [5].

Similar case reports in the literature have shown that comorbidities such as lung metastasis, are generally determined at the time of diagnosis. In our opinion, surgical resection should be performed in solitary cerebel­lum metastasis of cervical cancer, in the absence of another organ metastasis. Otherwise, pal­liative management should be chosen. Although there are several treatment modalities are available, the prognosis of cerebral metastasis from cervical cancer is still very poor.

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Accepted for review: 15. 6. 2018

Accepted for print: 30. 10. 2018

Atilla Kırcelli, MD.

Department of Neurosurgery

Istanbul Research Hospital

Baskent University

Altunizade Mahallesi

7, Kısıklı Caddesi, Oymacı Sk.

34662 Üsküdar/İstanbul

Turkey

e-mail: atillakircelli@gmail.com