PMC4727413_01
Pathology of the primary cecal carcinoma. a Gross appearance of the ulcerous tumor in the cecum (yellow arrowheads). Note that a normal appendix is apparent. b Hematoxylin-and-eosin-stained section of the primary cecal cancer specimen demonstrates that the adenocarcinoma has slightly invaded the muscle layer to reach the subserosa (red arrows) (original magnification x100)
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Fig1
Histopathological examination of the neoplasm revealed adenocarcinoma of the cecum, classified as tub1, pSS, ly2, v1, N0, and stage II (Fig. 1a, b).
Timeline of clinical events and changes in CEA and CA19-9 levels
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Fig2
Ten months later, the levels of tumor markers were increased (CA19-9, 179.7 IU/mL; CEA, 26.9 ng/mL; Fig. 2). Although the levels of CA19-9 and CEA were within normal ranges at the time our patient underwent right hemicolectomy (Fig. 2((1))), both tumor markers became gradually elevated (Fig. 2((2))) and rapidly increased just before the second PET-CT revealed tumor in her uterine cervix (Fig. 2((3))). Furthermore, both CA19-9 and CEA rapidly returned to levels within normal limits after the patient underwent radical hysterectomy (Fig. 2((4))).
Imaging and physical examinations. a Positron emission tomography-computed tomography shows high 18F-fluorodeoxyglucose uptake consistent with a uterine tumor (red arrow). b Colposcopic view shows a solid white tumor on the posterior fornix (yellow arrowheads). c Pelvic magnetic resonance image of a T2-enhanced sagittal section showing an irregularly enlarged uterine cervical tumor (red arrow)
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Fig3
A repeat PET-CT showed a focus of high 18F-fluorodeoxyglucose uptake (standardized uptake valuemax = 7.83) in her uterus (Fig. 3a), and she was referred to our gynecology department. Colposcopy revealed a tumorous lesion on the posterior fornix (Fig. 3b). Pelvic magnetic resonance imaging confirmed the presence of a 22-mm mass showing heterogeneous enhancement (Fig. 3c).
Gross appearance of resected uterus, histopathology, and immunohistochemistry of sections of uterine cervical tumor and cecal tumor specimens. a Gross appearance of the resected uterus. Note that the mucosal surface of the endocervical canal is clear (red arrow). b Hematoxylin and eosin staining of the cervical tumor specimen demonstrates invasive growth of irregular and atypical ductal hyperplasia with moderate differentiation (original magnification x200). c Cervical carcinoma shows diffuse and strongly positive CK7 staining (original magnification x100). d Cervical carcinoma is negative for CK20 staining (original magnification x100). e Cervical carcinoma cells show diffuse and strongly positive CDX2 nuclear staining (original magnification x200). f Hematoxylin-and-eosin-stained section of the cecal adenocarcinoma demonstrates well-differentiated adenocarcinoma (yellow arrowheads). Note that normal crypt architecture is seen on the left side of the picture (red arrows) (original magnification x100). g Cecal carcinoma shows diffuse and strongly positive CK7 staining (original magnification x100). h Cecal carcinoma is negative for CK20 staining. Note that normal crypt architecture is positive for CK20 staining (original magnification x100). i Cecal carcinoma shows diffuse and strongly positive CDX2 nuclear staining (original magnification x200)
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Fig4
Gross examination of the resected uterus found mild swelling and sclerosis of the posterior cervix, but there was no apparent tumor on the mucosal surface of the endocervical canal (Fig. 4a). Histopathological examination found irregular, invasive growth of atypical ductal hyperplasia (Fig. 4b). Immunohistochemical staining of the tumor was positive for CK7 (Fig. 4c), CDX2 (Fig. 4e), and CEA expression and negative for CK20 (Fig. 4d), p16, estrogen receptor, progesterone receptor, vimentin, calretinin, and cluster of differentiation-10 expression. The previous specimens of cecal tumor were also examined after immunohistochemical staining, and the malignant cells manifested the same staining patterns seen for the uterine tumor (Fig. 4g-i). In our case, the immunohistochemistry of our patient's cervical biopsy and surgical specimen showed a CK7-positive/CK20-negative expression pattern (Fig. 4c, d). Therefore, we initially speculated that the possibility of metastatic carcinoma from the cecum was low, although CDX2 was positive in both samples (Fig. 4e).