A Rare Case of Aggressive Atypical Cervical Cancer With Multi-Organ Involvement

Abstract

Squamous cell carcinoma (SCC) of cervical origin with metastasis to the brain is rare. Our patient was a 30-year-old Caucasian female with squamous cell carcinoma, initially with unknown primary, with metastases to the brain, kidney, cervix, lung, adrenal glands, vulva, pelvic wall, and scalp. She initially presented to her outpatient gynecologist for a vulvar mass. A biopsy of the vulvar mass was consistent with SCC. The patient continued to have fatigue along with thoracic rib pain. An initial work-up was performed, including imaging which showed diffuse metastatic disease involving the lungs, kidneys and adrenal glands, as well as a pathological compression fracture of the seventh thoracic vertebra with cord compression. Brain magnetic resonance imaging (MRI) showed multiple metastatic lesions and she underwent craniotomy for brain lesion resection. Given the aggressive nature of the patient's disease and her symptomatic burden, she was started on chemotherapy in the hospital with Carboplatin, Paclitaxel, and Pembrolizumab.

Keywords: brain metastasis; cervical cancer; hpv; multi-organ; squamous cell carcinoma.

Figure 1. Pre-operative MRI axial image weighted in T1 showing lesions.

There were multiple variable-sized enhancing lesions in the supratentorial (A and B) and infratentorial brain parenchyma with surrounding vasogenic edema likely representing metastasis. (A) There was a 2.7 x 2.6 cm lesion in the right anterior frontal lobe with moderate surrounding vasogenic edema with mass effect upon the underlying cerebellar hemisphere and effacement of the right lateral ventricle and also causing mild subfalcine herniation. (B) A 1.9 cm lesion was seen in the right inferior temporal lobe.

Figure 2. Pre-operative MRI of the head sagittal T1 image showing metastatic lesions.

There were enhancing dural-based extra-axial lesions in the parafalcine location with involvement of the calvarium (A) and enhancing adjacent soft tissue component and causing encasement of the superior sagittal sinus representing metastasis. (B) There was a 2.7 x 2.6 cm lesion in the right anterior frontal lobe with moderate surrounding vasogenic edema with mass effect.

Figure 3. Squamous cells from spinal tumor biopsy.

(A) Low power view showing multiple fragments of poorly differentiated squamous cells and prominent necrosis. (B) High power view showing features of the squamous cells which are pleomorphic, has prominent nucleoli, eosinophilic cytoplasm and frequent mitosis; similar features seen on the vulvar lesion.

Figure 4. Immunohistochemical analysis of spinal tumors specimen.

Immunohistochemistry of the resected tissue specimen was positive for cytokeratin 5/6 or CK5/6 (A), caudal-type homeobox protein 2 or CDX2 (B), and variable positivity for p16 (C).

Figure 5. Surgical pathology for anterior cervical biopsy.

The image shows that the tumor involves stroma and does not connect to overlying histologically unremarkable squamous mucosa. The tumor may represent metastasis or direct extension of the tumor from the adjacent site. Tumor necrosis is seen. (A) Low power view: Right tumor involving the stroma, Left, unremarkable ectocervix. (B) High power view showing cells reminiscent of squamous cells.

Figure 6. Anterior cervix and endocervical canal.

Cytology cell block shows predominantly necrotic debris and cells with prominent nucleoli and high nuclear-to-cytoplasmic ratio.

Figure 7. Surgical pathology of intracranial lesion.

The left area shows what resembles a normal brain. The right shows prominent poorly differentiated squamous cells.

Figure 8. Surgical pathology of extracranial lesion.

(A) This low-power image shows poorly differentiated squamous carcinoma with prominent “comedo-like” necrosis. (B) High power view showing abundant necrosis, pleomorphism, prominent nucleoli, and eosinophil cytoplasm.

Figure 9. Post-operative MRI of the patient’s brain axial image weighted in T1 showing metastatic lesions.

There was a moderate amount of right frontal vasogenic edema and an adjacent enhancing (A) lesion at the superior medial aspect of the surgical bed that increased in size compared to the prior study consistent with neoplasm. (B) There are multiple bilateral enhancing cerebral and cerebellar lesions.