PMC5021815_01
(A) Magnetic resonance imaging (MRI) shows a normal endometrium and myometrium with a mass originating in the cervix. (B) MRI shows a cervical tumor without parametrial compromise. (C) A radical hysterectomy specimen. (D) Cervical tumor (7 cm) with a clear origin in the cervix.
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T2 signal intensity with hyperintense signal predominance originating in the left side of the cervix. The lesion measured 59 x 64 x 60 mm (width x depth x length) and extended into and occupied the vaginal cavity (Fig. 1A and B). Abdominal radical hysterectomy was performed along with resection of the left external iliac lymph nodes that were suspected for metastatic involvement during surgical exploration of the pelvic and para-aortic regions (Fig. 1C and D).
(A) Cervical stroma highly infiltrated by the sarcoma. The exocervical (arrow) and endocervical (head of arrow) epithelia are histologically normal (20x magnification, hematoxylin & eosin). (B) Close-up of the areas of mesenchymal overgrowth (arrow) associated with the areas of cartilage in the heterologous component (head of arrow) and benign glands (asterisk) (20x magnification, hematoxylin & eosin). (C) The proliferation index as determined via Ki67 staining was 60%, with normal reactivity in the basal layer of the exocervix (arrow) (20x magnification, Ki67 immunostaining). (D) Lymph node metastasis at 4x (arrow) and 20x (arrowhead) magnification.
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Microscopically, the lesion was a Mullerian adenosarcoma of the cervix with stromal overgrowth greater than 25% and a heterologous component (cartilage and rhabdomyoblasts); the maximal tumor size was 7.5 cm in diameter (Fig. 2A and B). The proliferation index as determined via Ki67 staining was 60% (Fig. 2C). Lymphovascular invasion was present; 1 left iliac lymph node displayed tumoral compromise (Fig. 2D), whereas parametrium and proliferative endometrium did not.
(A) Speculoscopy shows local tumor regrowth in the vaginal vault. (B) Positron emission tomography-computed tomography (PET-CT) shows intense capture of 18-fluorodeoxyglucose in the right iliac nodal conglomeration, which measured 44 x 53 x 57 mm. (C) PET-CT shows hypermetabolic vaginal vault regrowth and a tumor measuring 76 x 39 mm. (D) PET-CT shows bony recurrence in the right pubic ramus.
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We observed local and regional tumor regrowth in the form of an exophytic mass 6 cm in diameter originating in the vaginal vault (Fig. 3A). These lesions were visualized clearly via PET-CT, as was a metastatic lesion in the right pubic ramus (Fig. 3B, C and D).
(A) Posterior speculoscopy at the start of external pelvic radiotherapy shows a clear reduction in tumor volume. (B) Magnetic resonance imaging (MRI) in the sagittal plane of the dorsal spine shows vertebral body metastasis with pathological fracture of the T12 vertebra. (C) MRI at the T12 level shows infiltrative metastatic compromise of the medullary canal.
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After receiving 2.3 Gy of external pelvic radiation, the patient was once again asymptomatic, with a significantly improved clinical status and a 95% reduction in vaginal tumor volume (Fig. 4A). MRI revealed osteolytic lesions with diffuse infiltration of the T11, T12, L1, and L2 vertebral bodies with a compression fracture of T12, left spinal infiltration, and medullary canal compromise (Fig. 4B and C).