A Case Report of Advanced Cervical Cancer in a Patient Non-compliant With Age-Appropriate Screening (2024)

Monitoring Editor: Alexander Muacevic and John R Adler

Abstract

Cervical carcinoma is one of the preventable malignancies in the United States. Age-appropriate screening has decreased the incidence of cervical cancer.A multitude of age-appropriate screening methods is available including Papanicolaou (Pap) smear cytology, human papillomavirus (HPV) DNA testing, and visual inspection tests.Patients who are not up to date with the screening can remain asymptomatic until the advanced stage like in the case of our patient. We present a59-year-old female, who came in with progressively worsening shortness of breath on exertion, chest tightness, significant weight loss, and vagin*l bleeding for the past six months. On investigations, she was found to have cannonball metastases in the lung. The patient remained critically ill during her course of hospital stay and eventually passed away.

Keywords: screening, pap smear, cannonball mass, lung metastasis, cervical carcinoma

Introduction

Cervical cancer isone of themajor causesof cancer-related death in women worldwide [1]. It is the fourth mostprevalentcause of malignancy in womenafter breast, colorectal, and lung cancer [2].The incidence ofcervical cancer and mortalityrate has declined by 70% in the United States since the 1950s because of age-appropriate screening[3]. Among the several risk factors, human papillomavirus (HPV) types 16, 18, 31, 33, and 45 are the leading cause of cervical neoplasia [4]. Other risk factorsare smoking, low socioeconomic status, early ageat the first coitus, multiple sexual partners, and multiparity[5].

Case presentation

A 59-year-old female with no significant past medical history, non-compliant with anyage-appropriatecancerscreening, presented to the Emergency Departmentwith progressively worsening shortness of breath on exertionwith productive cough andchest tightness for the past six weeks. She alsoendorsedmalaise, progressive fatigue,anorexia,chronic pelvicdiscomfort,and weight loss of70lbsin the last year. She denied any vagin*l bleeding ordischarge. She had not seen a physician inthe last eight yearsand never hada Papanicolaou (Pap) smear,mammogram,or colonoscopy done.

On arrival, the patient was in respiratory distress, requiring 6-8 L oxygen through nasal canula but otherwise, hemodynamically stable. On systemic examination,sheappeared cachectic, with bilateral coarse breath sounds on lung exam andrightlower quadrant tenderness on abdominal examination. Blood work showed leukocytosis(WBC count: 20K cell/Liter), lactic acidosis (4.6 mmol/L), hypercalcemia(serumtotal calcium12.6 mg/dl), elevated d-dimer(1.6mcg/mL). Urinalysis was significant for hematuria but negative for pyuria. Serum lipase and amylase levels were unremarkable.Acid-base gasshowed pH7.43/PCO2 40/ PO2 59. Computed Tomography (CT) abdomen pelvis with intravenous contrast showed cervical soft tissue mass measuring up to 7x7 cm with an ill-defined feature, suggestive of neoplasm (Figure ​(Figure11).

CT ofthechestwas obtained, which showed multifocal mediastinal masses measuring approximately 3 cm in the pre-tracheal and 35 x 37 mm in the SUV carinal region, bilateral hilar adenopathy,numerousnodular masses throughout the lung, and 50%predominance of focal lung consolidation (Figure ​(Figure22).

Coronavirus disease 2019 (COVID-19) test was done, which was negative. Infectious workup, including blood culture, sputum culture and gram stain, legionella, and pneumococcal antigen tests were obtained, and the patient was started on empiric broad-spectrum antibiotics. As there was concern about cervical cancer with metastasis to the lungs, she was seen bya gynecologist and was planned forabiopsyof the cervical mass. Hematology/oncology was on board as well andrecommended a biopsy of the cervical mass with cytology, and HPV testing. If the biopsy comes positive for cervical cancer, she was planned to be started on a cisplatin-based chemotherapeutic regimen with the addition of checkpoint inhibitor therapy if the programmed death-ligand 1 (PD-L 1) biomarker was positive.

During the hospital stay, the patient continued to have worsening hypoxemia, with alteration in her mental status, and eventually developed multiple organ failure with renal dysfunction, transaminitis, and lactic acidosis.She was placed on bilevel positive airway pressure (BiPAP),but her oxygen requirements continued to worsen.The patient was Do-Not-Intubate (DNI)/Do-Not-Resuscitate (DNR).Palliative medicinewas on board forgoals of care discussion due to the patient’s declining clinical condition. The familydecided toproceedwith comfort care measures and the patient passed away. We were not able to obtain the biopsy of the cervical mass as we wanted the patient condition to be more stable.

Discussion

The cervix is the lower part of the uterine cavity and iscovered with twotypes of cells: the glandular and the squamous cells. The junction of these two types ofcellsis known as the transformation zone.Mostcervical cancer originates from the transformation zone.Squamous cell carcinoma (95%) and adenocarcinoma (5%) are the two major histological types ofan epithelial tumor of the cervix, but in rare cases, the tumor can also be of a non-squamousvariant including adenosquamous carcinoma, neuroendocrine carcinoma, glassy cell carcinoma [6].

Metastasis in cervical cancer occursbyhematogenous and lymphatic spread. Lung, bone, liver, and brain are the most common organs of cervical cancer metastasis [7].The lung is the most common metastasis site of the cervix and metastasis to the lung occurs because of the hematogenousspread [8]. The incidence of lung involvement increasesstage-wise; 3.2% in stage I, 5.0% in stage II, 9.4% in stage III, and 20.9% in stage IV disease [9]. In the Surveillance, Epidemiology, and End Results (SEER) database study from 2020, it was found that patients with age greater than 65, non-squamous histology type cervical cancer, pelvic lymph nodes metastases, poor differentiation, other organ metastasiswere at higher riskfor lung metastasis [ 10].

Patients with early-stage cervical cancer are mostly asymptomatic but few of those who are symptomatic, present with lower abdominal pain, postcoital vagin*l bleeding,abnormal menstrual bleeding, post-menopausal bleeding,offensive vagin*l discharge, and dyspareunia [11]. vagin*l discharge may be watery,mucoid,or purulent. Patients in the advanced stage of cancer present with symptoms of urinary symptoms, lower abdominal pressure, hematuria, and hematochezia depending on the site of metastasis.

Screening strategies for cervical cancer include Pap smear testing alone, primary HPV testing alone,or co-testing (with Pap and HPV testing). For patients under 21, screening is notrequiredregardless of the ageof initiation of sexual activity.In patients between 21-29,screening isinitiatedat age 21 with cervical cytology every three years.Forpatients aged 30 to 65, either Pap testing aloneeverythree yearsor co-testing(PAPand HPV testing combined) every five years is recommended. For patients who are above 65,the decision tocontinue screeningdependsonwhether the patient has hadan adequateprior screening, life expectancy,and preferences in a shareddecision-makingdiscussion.Symptomatic patients should have Pap smear testing as part of a diagnostic workup, regardless of prior screeningresults [12].

It has been noted that more than half of patients who develop cervical cancer have not been screened adequately. Inmost ofthe patients with invasive cervical cancer, there was no Pap smear obtained in the past five years [13].Strategiesthat can be used to increase screening rates include actively inviting patients to scheduletimelyappointments for cervical cancer screening. Urgent care clinical visits can be used as an opportunity to screen patients who are unlikely to otherwisecomply withcervical cancer screening recommendations [14,15].

Cervical cancer can be diagnosed by colposcopy, fluorescence spectroscopy, molecular diagnostic methods like HPV DNA test, nuclear aneuploidy detection. Further testing with pelvicMRI and positron emission tomography-computed tomography (PET-CT)should be performed for locally advanced diseases. In patients with advanced cervical carcinoma, chest x-ray and brain CT can be done to rule out metastasis tothelung or brain [16].Early-stage cervical cancer has a good prognosis because of the advancement in the treatment includingsurgery, chemotherapy, or radiotherapy,but advanced cancer with metastasis has a poor prognosis with a median survival of 8-13 months [17].

Conclusions

In conclusion, most patients with advanced cervical cancer with lung metastasisare asymptomatic and are found to have incidental mass on routine chest x-rays or CT.As patients with advanced cancerhave a poor prognosis,age-appropriatescreening, early identification of patients athigh riskfor lung metastases, and early intervention can be lifesaving.

Notes

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Human Ethics

References