GYNECOLOCIC
ONCOLOGY
44,
284-287 (1992)
CASE REPORT Hepatic Resection for Metastatic Squamous Cell Carcinoma from the Uterine Cervix HIROSHI KASEKI,
M.D.,*
KENZO YASUI, M.D. ,t KUNIAKI NIWA, M.D. ,* KAZUO MIZUNO, TAKEO INOUE, M.D.,* AND MASAHIRO OTA, M.D.*
*Department of Gynecology and TDepartment of Gas&o-Enterological
M.D. ,*
Surgery, Aichi Cancer Center Hospital, Nagoya 464, Japan
Received May 20, 1991
A solitary hepatic tumor was diagnosed3.5 years after a 67year-old woman had undergoneradical hysterectomyand postoperative irradiation for stageIb squamouscell carcinomaof the cervix. Hepatic resectionconfirmedsquamouscell carcinomathat had metastasizedfrom the uterinecervix. Oneyear and 10months following hepatic resection, this patient is doing well with no evidenceof any recurrence.This is a report of successfulhepatic resectionfor metastaticcarcinomafrom the uterine cervix. D1~2 Academic Prss, Inc.
INTRODUCTION Advances in surgical treatment for metastatic liver carcinoma have led to better prognoses for patients with rectal carcinoma [l-3]. To date, however, there have been no attempts at hepatic resection in cases with metastatic carcinoma from the uterine cervix, since liver metastases are almost invariably accompanied by metastatic diseases to other organs [4,5]. This is a report of successful hepatic resection conducted in a case with solitary hepatic metastasis from cervical carcinoma. CASE REPORT
A 67-year-old woman (gravida 5, para 4) underwent a radical hysterectomy and pelvic lymphadenectomy for stage Ib squamous cell carcinoma of the cervix at the Aichi Cancer Center in Nagoya, Japan, on February 21, 1986. Although microscopic metastases were noted in the left parametrium, no metastasis could be found in any of the 35 resected pelvic lymph nodes. Whole pelvic irradiation was subsequently conducted externally using a 6MeV linear accelerator at a total dose of 5080 rads. The patient did well for 3.5 years with no evidence of local or distant recurrence. In March 1989, however, the car0090~82W92 $1.50 Copyright 0 1992 by Academic Press, Inc. AH rights of reproduction
in any form reserved.
284
cinoembryonic antigen (CEA) and squamous cell carcinoma-related antigen (SCC) rose to 15.3 and 1.6 rig/ml, respectively. Chest X ray, pelvic and retroperitoneal computed tomography (CT), and bone scintigram taken at that time showed no signs of any recurrent disease. However, abdominal CT and ultrasonography (USG) conducted in October 1989 revealed a solitary circular tumor 4 cm in diameter in the right lobe of the liver (Fig. 1). Hepatic angiography confirmed a solitary tumor in the S8 portion of the liver. Positive indications were also confirmed by observing levels of CEA (41.2 ng/mg) and SCC (18.6 ng/mg). All other routine chemical analyses of the blood were within normal limits. Laparotomy was performed on November 20, 1989. Macroscopically, no peritoneal dissemination, ascites, or retroperitoneal tumor was noted at the time of surgery. The tumor was confined to the S8 portion of the liver below the diaphragm dome. Right hepatic lobectomy was performed along with regional lymph node dissection and cholecystomy. The resected section of the liver weighed 435 g and contained a circumscribed tumor measuring 4 x 4 x 3 cm in diameter. Microscopically, this metastatic squamous cell carcinoma was found to be similar to the primary cervical carcinoma (Fig. 2). Recovery was good, and the patient was discharged on December 19, 1989. She has been healthy now for 1 year and 10 months since the surgery. Serum levels for CEA and SCC returned to normal at 1 month after the surgery with no chemotherapy treatment prescribed. She has thus survived well for 5.5 years since the radical hysterectomy. DISCUSSION
Liver metastases from carcinoma of the uterine cervix are not necessarily rare findings at autopsy. Badib et al.
CASE REPORT
FIG. 1. Abdominal
CT showing a solitary circular tumor in the right lobe of the liver.
demonstrated that the common sites for cervical carcinoma metastases were the lungs and the liver, and that liver metastases accounted for 27.4% of all autopsied cases [4]. Liver metastases from carcinoma of the cervix discovered at autopsy were reported with a frequency of 18.7% by Plentl and Friedman and 15.8% by Lifshitz and Buchsbaum [5,6]. In contrast, liver metastasis from cervical carcinoma in the absence of any other organ involvement is extremely rare. Carlson et al. reported a 2.2% incidence of liver metastases from a series of 2220 patients with cervical carcinoma, and only 0.3% were cases involving only the liver [7]. In virtually almost all of these instances, hepatic involvement was accompanied by widespread metastasis, and conservative treatment was given. Abu-Ghazaleh and Creasman presented a patient with metastatic carcinoma of the liver and enlarged para-aortic lymph nodes and reported that they were unable to offer this patient any aggressive therapy [8]. Raggio and Kaplan reported on a patient with cervical carcinoma involving metastases to the liver and retroperitoneal nodes who did well with administrations of CDDP [9]. Liver metastasis from carcinoma of the cervix was suspected in the case in our report on the basis of elevations
in CEA and SCC. There were no signs of metastatic carcinoma in the pelvis, lung, or retroperitoneal lymph nodes at the time of hepatic resection. The patient did well for 1 year and 10 months after hepatic surgery, and pelvic CT, retroperitoneal CT, and chest X-ray were all negative for the entire 5.5 years after the first operation for radical hysterectomy. Therefore, we believe that it is unlikely that metastasis could have developed in any other site. This may be the first report in which hepatic resection conducted in a case of liver metastases from cervical cancer resulted in complete remission. Surgical treatment for liver metastatic carcinoma has been increasing as a result of recent developments in surgical methods and modalities. In particular, hepatic resection of metastatic carcinoma from rectal cancer has been reported in a number of publications, with good prognoses shown for some of these cases [l-3]. Schwartz [lo] maintains that the indication for surgery for hepatic metastases should include: (1) control of the primary tumor, (2) no evidence of other organ involvement, (3) patient’s toleration for surgery, and (4) total resection of the metastatic tumor. With recent improvement in the local management of cervical carcinoma, it is suspected that unusual distant metastases will become
286
KASEKI
ET AL.
2. (A) Squamous cell carcinoma of the uterine cervix (H.E., (B) Metastatic squamous cell carcinoma in the liver (H.E., x 150).
FIG.
and improved medical instrumentation and tumor markers will make it easier to detect small nests of metastases in the earlier stages. This means that hepatic resection for liver metastasis from carcinoma of the uterine cervix may be clinically relevant and become a more common form of treatment. more
tutional study of long-term survivors, Dis. Colon
apparent,
REFERENCES 1. Hughes, K. S., Simon, R., Songhorabodi, S., et al. Resection of the liver for colorectal carcinoma metastases: A multiinstitutional study of patterns of recurrence, Surgery 100, 278-284 (1986). 2. Hughes, K. S., Rosenstein, R. B., Songhorabodi, S., et al. Resection of the liver for colorectal carcinoma metastases: A multiinsti-
X 150).
Rectum
31, 1-4
(1988). 3. 4.
5. 6. 7.
Steele, G., and Ravikumar, T. S. Resection of hepatic metastases from colorectal cancer, Ann. Surg. 210, 127-138 (1989). Badib, A. O., Kurohara, S. S., Webster, J. H., and Pickren, J. W. Metastasis to organs in carcinoma of the uterine cervix. Influence of treatment on incidence and distribution, Cancer 21, 434-439 (1968). Pientl, A., and Friedman, E. Lymphatic system of the female genitaria, Saunders, Philadelphia (1971). Lifshitz, S., and Buchsbaum, H. Spread of cervical carcinoma, Obstet. Gynecol. Ann. 6, 341-354 (1977). Carlson, V., Delclos, L., and Fletcher, G. Distant metastasis in squamous cell carcinoma of the uterine cervix, Radiology 6, 961966 (1967).
287
CASE REPORT
FIG. 2 -Continued 8. Abu-Ghaza deh, S. Z., and Creasman, W. T. Unusual metastasis in carcinoma Nof the cervix uteri, Surg. Gynecol. Obstet. 148, 728-730 (1979). 9. Raggio, M. , and Kaplan, A. Case report: Carcinoma of the cervix
metastatic to the liver presenting with obstructive jaundice, GYnecol.
Oncol.
13, 269-270
10. Schwartz, S. I. Surgical York (1964).
(1982). disease
of rhe liver,
McGraw-Hill,
New
ONCOLOGY
44,
284-287 (1992)
CASE REPORT Hepatic Resection for Metastatic Squamous Cell Carcinoma from the Uterine Cervix HIROSHI KASEKI,
M.D.,*
KENZO YASUI, M.D. ,t KUNIAKI NIWA, M.D. ,* KAZUO MIZUNO, TAKEO INOUE, M.D.,* AND MASAHIRO OTA, M.D.*
*Department of Gynecology and TDepartment of Gas&o-Enterological
M.D. ,*
Surgery, Aichi Cancer Center Hospital, Nagoya 464, Japan
Received May 20, 1991
A solitary hepatic tumor was diagnosed3.5 years after a 67year-old woman had undergoneradical hysterectomyand postoperative irradiation for stageIb squamouscell carcinomaof the cervix. Hepatic resectionconfirmedsquamouscell carcinomathat had metastasizedfrom the uterinecervix. Oneyear and 10months following hepatic resection, this patient is doing well with no evidenceof any recurrence.This is a report of successfulhepatic resectionfor metastaticcarcinomafrom the uterine cervix. D1~2 Academic Prss, Inc.
INTRODUCTION Advances in surgical treatment for metastatic liver carcinoma have led to better prognoses for patients with rectal carcinoma [l-3]. To date, however, there have been no attempts at hepatic resection in cases with metastatic carcinoma from the uterine cervix, since liver metastases are almost invariably accompanied by metastatic diseases to other organs [4,5]. This is a report of successful hepatic resection conducted in a case with solitary hepatic metastasis from cervical carcinoma. CASE REPORT
A 67-year-old woman (gravida 5, para 4) underwent a radical hysterectomy and pelvic lymphadenectomy for stage Ib squamous cell carcinoma of the cervix at the Aichi Cancer Center in Nagoya, Japan, on February 21, 1986. Although microscopic metastases were noted in the left parametrium, no metastasis could be found in any of the 35 resected pelvic lymph nodes. Whole pelvic irradiation was subsequently conducted externally using a 6MeV linear accelerator at a total dose of 5080 rads. The patient did well for 3.5 years with no evidence of local or distant recurrence. In March 1989, however, the car0090~82W92 $1.50 Copyright 0 1992 by Academic Press, Inc. AH rights of reproduction
in any form reserved.
284
cinoembryonic antigen (CEA) and squamous cell carcinoma-related antigen (SCC) rose to 15.3 and 1.6 rig/ml, respectively. Chest X ray, pelvic and retroperitoneal computed tomography (CT), and bone scintigram taken at that time showed no signs of any recurrent disease. However, abdominal CT and ultrasonography (USG) conducted in October 1989 revealed a solitary circular tumor 4 cm in diameter in the right lobe of the liver (Fig. 1). Hepatic angiography confirmed a solitary tumor in the S8 portion of the liver. Positive indications were also confirmed by observing levels of CEA (41.2 ng/mg) and SCC (18.6 ng/mg). All other routine chemical analyses of the blood were within normal limits. Laparotomy was performed on November 20, 1989. Macroscopically, no peritoneal dissemination, ascites, or retroperitoneal tumor was noted at the time of surgery. The tumor was confined to the S8 portion of the liver below the diaphragm dome. Right hepatic lobectomy was performed along with regional lymph node dissection and cholecystomy. The resected section of the liver weighed 435 g and contained a circumscribed tumor measuring 4 x 4 x 3 cm in diameter. Microscopically, this metastatic squamous cell carcinoma was found to be similar to the primary cervical carcinoma (Fig. 2). Recovery was good, and the patient was discharged on December 19, 1989. She has been healthy now for 1 year and 10 months since the surgery. Serum levels for CEA and SCC returned to normal at 1 month after the surgery with no chemotherapy treatment prescribed. She has thus survived well for 5.5 years since the radical hysterectomy. DISCUSSION
Liver metastases from carcinoma of the uterine cervix are not necessarily rare findings at autopsy. Badib et al.
CASE REPORT
FIG. 1. Abdominal
CT showing a solitary circular tumor in the right lobe of the liver.
demonstrated that the common sites for cervical carcinoma metastases were the lungs and the liver, and that liver metastases accounted for 27.4% of all autopsied cases [4]. Liver metastases from carcinoma of the cervix discovered at autopsy were reported with a frequency of 18.7% by Plentl and Friedman and 15.8% by Lifshitz and Buchsbaum [5,6]. In contrast, liver metastasis from cervical carcinoma in the absence of any other organ involvement is extremely rare. Carlson et al. reported a 2.2% incidence of liver metastases from a series of 2220 patients with cervical carcinoma, and only 0.3% were cases involving only the liver [7]. In virtually almost all of these instances, hepatic involvement was accompanied by widespread metastasis, and conservative treatment was given. Abu-Ghazaleh and Creasman presented a patient with metastatic carcinoma of the liver and enlarged para-aortic lymph nodes and reported that they were unable to offer this patient any aggressive therapy [8]. Raggio and Kaplan reported on a patient with cervical carcinoma involving metastases to the liver and retroperitoneal nodes who did well with administrations of CDDP [9]. Liver metastasis from carcinoma of the cervix was suspected in the case in our report on the basis of elevations
in CEA and SCC. There were no signs of metastatic carcinoma in the pelvis, lung, or retroperitoneal lymph nodes at the time of hepatic resection. The patient did well for 1 year and 10 months after hepatic surgery, and pelvic CT, retroperitoneal CT, and chest X-ray were all negative for the entire 5.5 years after the first operation for radical hysterectomy. Therefore, we believe that it is unlikely that metastasis could have developed in any other site. This may be the first report in which hepatic resection conducted in a case of liver metastases from cervical cancer resulted in complete remission. Surgical treatment for liver metastatic carcinoma has been increasing as a result of recent developments in surgical methods and modalities. In particular, hepatic resection of metastatic carcinoma from rectal cancer has been reported in a number of publications, with good prognoses shown for some of these cases [l-3]. Schwartz [lo] maintains that the indication for surgery for hepatic metastases should include: (1) control of the primary tumor, (2) no evidence of other organ involvement, (3) patient’s toleration for surgery, and (4) total resection of the metastatic tumor. With recent improvement in the local management of cervical carcinoma, it is suspected that unusual distant metastases will become
286
KASEKI
ET AL.
2. (A) Squamous cell carcinoma of the uterine cervix (H.E., (B) Metastatic squamous cell carcinoma in the liver (H.E., x 150).
FIG.
and improved medical instrumentation and tumor markers will make it easier to detect small nests of metastases in the earlier stages. This means that hepatic resection for liver metastasis from carcinoma of the uterine cervix may be clinically relevant and become a more common form of treatment. more
tutional study of long-term survivors, Dis. Colon
apparent,
REFERENCES 1. Hughes, K. S., Simon, R., Songhorabodi, S., et al. Resection of the liver for colorectal carcinoma metastases: A multiinstitutional study of patterns of recurrence, Surgery 100, 278-284 (1986). 2. Hughes, K. S., Rosenstein, R. B., Songhorabodi, S., et al. Resection of the liver for colorectal carcinoma metastases: A multiinsti-
X 150).
Rectum
31, 1-4
(1988). 3. 4.
5. 6. 7.
Steele, G., and Ravikumar, T. S. Resection of hepatic metastases from colorectal cancer, Ann. Surg. 210, 127-138 (1989). Badib, A. O., Kurohara, S. S., Webster, J. H., and Pickren, J. W. Metastasis to organs in carcinoma of the uterine cervix. Influence of treatment on incidence and distribution, Cancer 21, 434-439 (1968). Pientl, A., and Friedman, E. Lymphatic system of the female genitaria, Saunders, Philadelphia (1971). Lifshitz, S., and Buchsbaum, H. Spread of cervical carcinoma, Obstet. Gynecol. Ann. 6, 341-354 (1977). Carlson, V., Delclos, L., and Fletcher, G. Distant metastasis in squamous cell carcinoma of the uterine cervix, Radiology 6, 961966 (1967).
287
CASE REPORT
FIG. 2 -Continued 8. Abu-Ghaza deh, S. Z., and Creasman, W. T. Unusual metastasis in carcinoma Nof the cervix uteri, Surg. Gynecol. Obstet. 148, 728-730 (1979). 9. Raggio, M. , and Kaplan, A. Case report: Carcinoma of the cervix
metastatic to the liver presenting with obstructive jaundice, GYnecol.
Oncol.
13, 269-270
10. Schwartz, S. I. Surgical York (1964).
(1982). disease
of rhe liver,
McGraw-Hill,
New
