Synchronous Carcinoma Cecum and Cervical SQ.Ca

Summary:

55/F lady presented to us as cervical cancer. PET picked up lesion in Cecum, Scopy and biopsy proven from both sites.

Synchronous Carcinoma Cecum and Cervical SQ.Ca

Nikhilesh Patil 14 Dec 2010 02:59

55/F presented to gyn clinic with post menopausal bleeding PV. Clinically has FIGO stage IIb cervical cancer. Invasive squamous cell. D& C did not show any endometrial pathology. Non-smoker, medical secretary, irregular pap smears in past. No H/o STD's or OC pills.
Investigations: Was worked up with PET/CT under a study. PET showed uptake in cecum and CT showed a mass(4.5cms). Colonoscopy proved ileo-cecal valve tumor. Pathology from the Cecal mass is awaited, however the surgeons say it looked very much like a cancer.
P/H of bleeding per rectum, patient was advised colonoscopy a year back which she refused to undergo.
Metastatic work up - negative.

Now the dilemma is which primary needs to be addressed first and how? What should be the sequence of the treatments?

Last edited on 14 Dec 2010 03:08 by Nikhilesh Patil Show more

Re: Synchronous Carcinoma Cecum and Cervical SQ.Ca

drbalunair 14 Dec 2010 16:50

Dear Nikhilesh

Just to point out, a few years back we had a lady with squamous cell carcinoma cervix with bleeding PR, evaluation revealed a jejunal growth, later proven to be mets. I think you should wait for the biopsy.

regards

balu

Re: Synchronous Carcinoma Cecum and Cervical SQ.Ca

Santam Chakraborty 15 Dec 2010 02:46

Hi Nikhilesh,
Rather interesting case. Indeed the possibility of metastasis is there but its rare - a cursory literature search brings up few case reports of cervical cancer with caecal metastasis. While as Dr Balu says waiting for the biopsy is the best course as an exercise lets discuss the options assuming this is a synchronous cervical squamous cell carcinoma and a adenocarcinoma of caecum.
In that situation I feel the malignancy that needs to be addressed is the one causing the most symptoms to the patient without compromising the treatment for either site. You have not mentioned the duration of bleeding P/V and what is the status of the Bleeding P/R. Also it would be interesting to know the CT status of the caecal mass (I assume of course that the CT was of diagnostic quality) in terms of presence thickness of tumor and presence of any extramural spread. Also we will need to know weather there is any possibility of obstruction from the ileocecal mass.
Assuming that there is minimal risk of obstruction or perforation from the caecal mass then a reasonable treatment option would be whole pelvic radiation encompassing the cecal mass as for cervix. Post external radiation a surgery can be done in form of radical hysterectomy and hemicolectomy. The objective of the surgery here is to get rid of both tumors in a oncologically sound manner - assuming that we will not be able to get radial margins in view of IIB disease.
An argument might be to go for primary surgery and add adjuvant radiation later on - my reservation against that would be the very high risk of bowel toxicity post a hemicolectomy and extended radical hysterectomy and pelvic nodal dissection that would be mandated by the extent of the disease.
A 3rd course might be to do a hemicolectomy and simultaneously use a mesh to "tie up" the bowel above the pelvis and give local radiation to the cervical tumor - the problem with this approach is that the cervical tumor can progress between the time the surgery gets done and the radiation is started. In essence I am putting my money on cervical cancer as the more lethal of the two diseases.
What does the house think?

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Re: Synchronous Carcinoma Cecum and Cervical SQ.Ca

Nikhilesh Patil 15 Dec 2010 04:40

Hi Balu/Santam,
There is not much bleeding from either site. She is symptomatic for Cervical Ca. Infact the cecal lesion was picked up incidentally. CT showed (4.0 cm cecal lesion) NO SPREAD.
Why do you think cervical primary is more serious. My impression is that her GI primary can be more dangerous than cervix ca.
Encompassing her Cecal mass in RT portal for Cervix cancer will not be a good idea, also the risk of obstruction/complication is high.
This case is being booked for tumor board review while we are awaiting the GI pathology.

Re: Synchronous Carcinoma Cecum and Cervical SQ.Ca

drbalunair 15 Dec 2010 08:32

Dear Nikhilesh /Santam,

There could be two scenarios possible.
The caecal lesion being adenocarcinoma then you consider it a second primary, in that case i second Nikhilesh in saying the GI adenos are more dangerous than cervical cancer in the short term. Considering it a T2 lesion… a surgery would just take care of it.
Radiating the bowel with the cervical cancer in a radical intent.. i'm not sure…there is a danger of perforation.

Lets look at the other scenario in which the caecal lesion is squamous cell carcinoma, then definitely we would switch over to palliative mode. There is possibility of numerous other deposits else where in GIT, which PET may not have picked up, as you know the PET is not that great in picking up peritoneal and bowel lesions.

Thats why i feel the biopsy report will tell us which way to go

thanks

balu

Re: Synchronous Carcinoma Cecum and Cervical SQ.Ca

Indranil Mallick 15 Dec 2010 18:52

Assuming that these are synchronous primaries (on the path report), I would approach the caecal lesion first. I would speak to the surgeon and see if an atypical incision that is clear of the traditional radiation portals could be performed. I would follow the surgery with standard treatment for the cervix after explaining the risks to the patient. If possible I would do an IMRT with small bowel dose constraints for the XRT.
If we approach it the other way round, I feel it would delay surgery for the caecal lesion by a minimum of 2 months. If the lesion becomes T3 there would arise an additional question of chemo and that would complicate matters considerably.

Re: Synchronous Carcinoma Cecum and Cervical SQ.Ca

Santam Chakraborty 15 Dec 2010 20:19

Hi Nikhilesh,
My persumption about the cervical primary being more serious is based on the MD teaching we had where we were always taught that a sq cell ca of cervix is likely to be more dangerous stage for stage as compared to an adenoca of the ovary/ uterus for example. now I acknowledge that colonic adenoca never came up but the kind of localized colonic ca you are mentioning makes it well "less" malignant than the cervical leison to my eyes. An interesting series from the early days of oncology does say the same thing http://onlinelibrary.wiley.com/doi/10.1002/1097-0142%28195101%294:1%3C1::AID-CNCR2820040103%3E3.0.CO;2-R/abstract

That said where did you get the data regarding risk of perforation / obstruction during radiation in cecal cancer? I tried to find hard data on that but could not though I will keep searching. Most of old articles where they have given preoperative radiation to rectosigmoid donot show a very high incidence of perforation or obstruction during radiation though I acknowledge following the Laplace law the cecum will be at higher risk of perforation than sigmoid.

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Last edited on 15 Dec 2010 20:34 by Santam Chakraborty Show more

Re: Synchronous Carcinoma Cecum and Cervical SQ.Ca

Nikhilesh Patil 15 Dec 2010 22:56

Hi,
The only evidence I have for bowel perf after pelvic RT is http://www.ncbi.nlm.nih.gov/pubmed/11426977 and http://www.ncbi.nlm.nih.gov/pubmed/17449197. I would have loved to have more data from developing nation since we treat huge number of cervix cancer patients but we just have one reported series http://www.ncbi.nlm.nih.gov/pubmed/16477917.
My GI team told me Ileocecal lesions tend to obstruct. So the plan is exactly what Indranil has mentioned.

I will update you on the pathology when ready.

This case has certainly raised a very pertinent issue of utility of PET scans in Locally Advanced Cervical Cancer. Since PET is not funded in Ontario we do see patients who cross the border and pay for there PET scans.

Last edited on 15 Dec 2010 22:57 by Nikhilesh Patil Show more

Re: Synchronous Carcinoma Cecum and Cervical SQ.Ca

Nikhilesh Patil 16 Dec 2010 20:01

Hello guys,
The pathology is "Invasive colonic Adenocarcinoma". As of now patient is book for surgery for her GI primary first followed by CT/RT to the Cervix cancer. If the final path from the GI primary shows something bad then we may have to rediscuss.

Re: Synchronous Carcinoma Cecum and Cervical SQ.Ca

drbalunair 17 Dec 2010 03:04

Hi nikhilesh,

I think thats the best news for the patient. A good surgery followed by RT to pelvis should give her the best chance of survival. Thanks for the discussion

balu

Re: Synchronous Carcinoma Cecum and Cervical SQ.Ca

Nikhilesh Patil 13 Jan 2011 21:10

Final Pathology from the cecal tumor:
Cecum tumour Greatest Dimension: 4.0 cm x4.0 x 1.0 cm
Tumour Perforation: not identified, Histologic Type: adenocarcinoma, Histologic Grade: low grade (well to moderately differentiated), Microscopic Tumour Extension: tumour invades muscularis propria.
Lymphovascular Invasion (Small Vessel): indeterminate, Venous Invasion (Large Vessel): present intramural
Perineural Invasion: absent. Tumour Deposits: tumour deposits absent. Features Suggestive of Microsatellite Instability: none identified. All Resection Margins: uninvolved by invasive carcinoma. Distance of invasive carcinoma from closest margin: 30 mm
Nodes: 1/ 36 postive (including macro and micro-metastases, >2.0 mm)
Stage: pT2: Tumour invades muscularis propria Regional Lymph Nodes (pN): pN1a: Metastasis in 1 regional lymph node.
What further treatment does her GI cancer needs , chemo? What regimen and when?
Now her Cervix Cancer needs to be treated first.

Last edited on 13 Jan 2011 21:12 by Nikhilesh Patil Show more