Case No. :	54
Month :	June
Year :	2003
Contributor :	Dr. Ankit Tandon.

Other Cases

A 35yr-old-housewife (G3P3L3A0) presented with the chief complaints of pain in the left hip with difficulty in walking following a fall from a bicycle four months back. Her routine blood investigations were unremarkable.

RADIOLOGICAL FINDINGS:

A radiograph of the pelvis & left hip joint (Fig 1, 2) showed supero-medial displacement of the head of left femur. There was extensive destruction of the ilium; where as the femoral head was intact. Considering the history and the degree of destruction, a diagnosis of pathological protrusio acetabuli was made.

Fig.1	Fig.2

Ultrasound followed by a guided biopsy of the lesion had been performed at another institution. This was reported as squamous cell carcinoma from an unknown primary.

At our institution, an ultrasound examination of the abdomen & pelvis was performed. This showed a bulky uterus especially in its lower part. This lesion in the lower segment of the uterus was of mixed echogenicity and measured 4.7 by 4.7 by 4.5 cm. There was a thin rim of fluid seen in the endometrial cavity. The right ovary was normal; the left ovary could not be visualized. There was mild bilateral hydronephrosis.

Plain & contrast enhanced CT scan of abdomen & pelvis (Figs. 3,4,5) revealed extensive destruction of the left ilium with involvement of the ischium, hip joint, head of femur, ilio psoas muscle & the gluteal group of muscles by a heterogeneously enhancing soft tissue mass. There was another mass in the region of the lower uterine segment & cervix with no visible fat plane demonstrated between the mass, the urinary bladder & rectum. The ischio-rectal fossa was also invaded by the mass. This
mass was involving both the ureters resulting in bilateral hydronephrosis.

Fig.3	Fig.4
Fig.5

The left kidney appeared to be non-functioning . Multiple heterogeneously enhancing lymph node masses were noted in right adnexe & iliac regions. The rest of the organs appeared normal. There was no ascites or pleural effusion.

Ultrasound guided biopsy of the cervical mass demonstrated islands of malignant squamous cells with abundant eosinophilic cytoplasm & keratin pearls.

MRI of the pelvis & hip was performed for surgical management of the left protrusio acetabuli .The mass lesion of the hip ( Figs.6,7,8,9) appeared heterogeneously hyperintense on T2W images & hypointense on T1W images. The left psoas, gluteal & muscles of the medial compartment appeared hyperintense on STIR images suggestive of either involvement or edema.

Fig.6	Fig.7
Fig.8	Fig.9

DISCUSSION:

Cervical carcinoma develops in the setting of gradual changes of the epithelium from progressively severe dysplasia to carcinoma in situ (CIN) to invasive carcinoma. The incidence of CIN outnumbers that of invasive carcinoma by 4:1.Its peak incidence occurs at the age of 30, 10-15 yrs earlier than that of invasive carcinoma. The most important risk factors for carcinoma are age at first sexual intercourse, multiple sexual partners & high-risk sexual partners.

About 99.7% carcinomas are associated with HPV infection. The strains most commonly involved are type 16& 18.The virus is sexually transmitted (approx 75% women are sexually active).

Invasive cervical carcinoma manifests clinically in various forms. In 25-30% of cases, the lesion begins in the endocervical canal, leaving the cervical lips covered by normal mucosa, i.e. clinically normal. Fungating or exophytic growths are most common and ulcerating & infiltrative forms less common. The tumour grows by direct extension to adjacent organs like the vagina, pelvic wall, bladder & rectum. Lymphatic spread of metastasis occur to periaortic chains in 17-29% of cases. Peritoneal seeding is not uncommon with locally advanced disease.

About 10-25% of cervical carcinoma is non-squamous, mostly adenocarcinoma & undifferentiated carcinoma. Adenocarcinoma show a higher frequency of lymphatic and hematogenous metastasis.

PAP Smear has a sensitivity of 51% & specificity of 98% as a screening modality. Newer upcoming screening modalities such as visual inspection with acetic acid (VIA) has proven to be more sensitive.

Clinical staging of cervical cancer as defined by FIGO ,consists of bimanual pelvic examination,chest radiography,excretory urography,barium enema,cystoscopy & sigmoidoscopy.The most important limitation of CT is a low accuracy rate of 30-58% in assessing parametrial tumour invasion. The CT criteria for parametrial tumour invasion (Stage 2 B) are irregularity or poor definition of lateral cervical margins,prominent parametrial soft tissue strands, increased density & or mass around the pelvic ureter & the presence of eccentric soft tissue mass.Pelvic sidewall tumour extension is characterized by confluent,irregular,linear parametrial soft tissue tumour infiltration extending to the obturator internus muscle laterally & or piriformis muscle posterolaterally.

Cervical carcinoma possesses a typical & fairly invariable appearance on MR images.T1W images usually fail to depict smaller lesions because of a lack of contrast between cervix, vagina, paracervical venous plexus & tumour.T2W images will clearly show the high signal intensity lesion contrasted with the very low signal cervical stroma. MR imaging especially with endorectal surface coils, may become the procedure of choice in differentiating stage 1b from stage 2b cervical cancer because of its improved soft tissue contrast between tumour, normal cervical stroma & ligaments & parametrial vessels.

Bone metastasis in cervical malignancy is a rare phenomenon & heralds poor prognosis. The most frequent site of metastasis was the vertebral column, particularly the lumbar spine followed by the pelvic bones. Pulmonary metastasis also occur frequently. The most common mechanism of bone involvement from carcinoma of the cervix is extension of the neoplasm from para-aortic nodes, with involvement of the adjacent vertebral bodies.

Bone metastasis in cervical malignancy is a rare phenomenon & heralds poor prognosis. The most frequent site of metastasis was the vertebral column, particularly the lumbar spine followed by the pelvic bones. Pulmonary metastasis also occur frequently. The most common mechanism of bone involvement from carcinoma of the cervix is extension of the neoplasm from para-aortic nodes, with involvement of the adjacent vertebral bodies.

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