Case report. In this paper we report the case of a year-old woman, gesta 2, para 2, presenting with a cervical well vascularized mass causing vaginal bleeding two years after the delivery of her second baby at term by caesarean section.
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The cervical CCA suspicion diagnosis was established based on imaging aspect - transvaginal ultrasound showing a parenchymatous area that protrudes into the cervical canal with intense peripheral vascular network and contrast-enhanced MRI describing an expansive bulky, round-oval, well defined mass with a long necrotic pedicle and extensive central area of necrosis.
The histopathological results correlated with the increased levels of βHCG suggested choriocarcinoma with large necrotic and hemorrhagic areas. Usually, the diagnosis of cervical cancer mri primary extrauterine CCA is difficult because of the non-specific clinical presentation that can mimic other conditions.
Primary cervical choriocarcinoma is an extremely rare condition that should be considered in the differential diagnosis of a cervical mass with profuse bleeding particularly due to intense vascularity, especially in young women. Trachelectomy represents a therapeutic measure able to stop the bleeding in patients who wish to maintain future fertility.
Keywords cancer metastaze osoase cervical choriocarcinoma, gestational trophoblastic neoplasia, cervical mass, vaginal bleeding Rezumat Introducere. Prezentare de caz. În această lucrare am raportat cervical cancer mri unei paciente, în vârstă de 40 de ani, secundigestă, secundipară, care prezintă o formaţiune tumorală bine vascularizată la nivelul colui uterin, cauzatoare de sângerari vaginale debutate la doi ani de la naşterea celui de-al doilea copil, prin operaţie cezariană.
Diagnosticul de suspiciune de CCA cervicală a fost stabilit pe baza aspectului imagistic - cervical cancer mri transvaginală arată o masă parenchimatoasă care protruzionează în canalul cervical cu reţea vasculară cervical cancer mri intensă, iar IRM cu substanţă de contrast descrie un proces expansiv voluminos, rotund-ovalar, bine helminthic therapy personal stories, cu pedicul lung necrotic şi zonă centrală extinsă de necroză.
Rezultatele histopatologice corelate cu nivelurile crescute de βHCG au sugerat diagnosticul de coriocarcinom cu zone necrotice şi hemoragice extinse. A fost efectuată trachelectomie urmată de cerclaj uterin abdominal, în scopul de a păstra capacitatea ulterioară a pacientei de a obţine şi păstra o viitoare sarcină până la termen.
De obicei, diagnosticul unui CCA extrauterin primar este dificil, din cauza tabloului clinic nespecific care poate imita alte patologii. Coriocarcinomul primar al colului uterin este o condiţie extrem de rară, care ar trebui luată în considerare în diagnosticul diferenţial al unei formaţiuni de col uterin cu cervical cancer mri abundentă, în special din cauza vascularizaţiei intense, mai ales la femeile tinere.
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Trachelectomia reprezintă o atitudine terapeutică în măsură să oprească sângerarea la pacientele care doresc să îşi menţină fertilitatea ulterioară. Cuvinte cheie coriocarcinom primar al colului uterin neoplazie trofoblastică gestaţională tumoră col uterin sângerări vaginale Introduction Gestational trophoblastic neoplasia GTN represents a generic term that includes a variety of malignant pathologies, the common link between them being the uniqueness of their physiopathology, as the maternal characteristic lesions arise only from fetal tissues 1.
On the other hand, the term gestational trophoblastic disease GTD describes a set of benign proliferation of the trophoblast of the placenta, including placental site nodule, exaggerated placental site, and hydatidiform mole 2.
Gestational trophoblastic disease GTN has cervical cancer mri incidence of 0. Half of the GTN appear after molar pregnancies, a quarter after ectopic pregnancies or abortions and another quarter after normal term pregnancies 4.
The period of time between the last pregnancy of any type and the appearance of CCA is described in very wide range, from a few months up to 15 years 5. Choriocarcinoma is the most aggressive, malignant form of gestational trophoblastic disease and has varying incidence, increasing in patients older than 40 years 6. Cervical cancer mri are associated with high levels of the beta subunit of the human chorionic gonadotropin bHCGand frequently need monochemotherapy, usually using methotrexate or actinomycin D.
On the other hand, the more rare cases of PSTT and ETT express low levels of bHCG and are relatively resistant to chemotherapy, multiagent treatment which combines etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine being necessary, but in these cases the first line of treatment is surgery, especially in non-metastatic cases 8.
In this paper we report the case of a year-old woman, gesta 2, para 2, presenting with a cervical well vascularized cervical cancer mri causing vaginal bleeding two years after the delivery of her second baby at term by cesarean section.
Case report The year-old Caucasian patient had an obstetrical history of two hpv inflamacao utero deliveries by caesarean section inrespectively She presented in June at the gynecologist cervical cancer mri irregular vaginal bleeding with reduced to moderate flow, after her last normal cervical cancer mri in 20 May.
The local exam showed normal external genital organs and reduced metrorhagia with a normal cervical aspect at the speculum exam. The vaginal tact revealed though an enlarged cervix, with a diameter of 6 centimeters, regulated surface and reduced consistency with a normal uterine dimension and mobility cervical cancer mri normal adnexal areas. A transvaginal ultrasound was then performed, which described normal ovaries and at the level of the uterine isthmus in the cervical cancer mri uterine wall a parenchymatous area with a diameter of 5 centimeters, which protrudes into the inferior third of the uterine cavity and the superior cervical cavity with peripheral vascular network in direct cervical cancer mri with the urinary bladder.
Primary choriocarcinoma of the cervix mimicking a cervical pregnancy
According to the clinical examination findings and the ultrasound aspect, the diagnostic suspicion of uterine leiomyoma cervical cancer mri raised. Magnetic resonance imaging with contrast substance is recommended in order to establish the extent and particularities of the cervical tumor.
The expansive mass pedicle shows peripheral gadolinophily, with extensive central area of necrosis and necrotic pedicle.
It does not invade the cervical wall or the vagina, which show normal appearance.
Uterine junctional zone appears continuous with normal thickness and normal hyposignal. The ovaries and the rest of abdominal pelvic organs appeared normal, with no lymph nodes involvement, ascites, abdominopelvic collections or bone lesions with secondary character in the examined segments. The conclusion of the contrast Papiloma humano fisiopatologia exam was the presence of a bulky pediculate mass developed within the uterine cavity, cervical cancer mri noninvasive junctional zone, cervixwhich obstructs and protrudes in the cervical cavity - MRI appearance suggests a cervical pregnancy, an endometrial polyp or a submucosal pediculate leiomyoma Figures 1, 2, 3.
Cervical cancer mri 1. MRI aspect of cervical expansive mass - transversal section Figure 2. MRI aspect of cervical expansive mass - axial section Figure 3.
Local experience in cervical cancer imaging: Comparison in tumour assessment between TRUS and MRI
This paraclinical finding brings into attention the diagnosis of primary cervical choriocarcinoma, according to its location. The surgical excision of the tumor is decided, given the fact that no secondary lesions have been found. Distance dissemination, which occurs on hematogeous way most frequently in cases of choriocarcinoma as it is a highly vascularized tumor, has been investigated in our case with chest X-ray and contrast enhanced abdomen and cervical cancer mri MRI.
Pulmonary X-ray showed no sign of metastasis, while abdomen Cervical cancer mri described normal ovaries, urinary bladder, rectum, sigmoid, liver, spleen, pancreas and kidneys with no abdominal lymph node involvement and no sign of ascites, collections or secondary bone lesions. Given the fact that no sign of metastasis was found, on 16 June an exploratory laparotomy is performed, with the finding of a slightly enlarged uterus with a much increased cervix, with a diameter of centimeters and macroscopically normal adnexa.
The histopathological extemporaneous exam had an uncertain result, showing fragments of wide necrotic tratamiento de oxiuros en pediatria area with chronic inflammation and the presence of pleomorphic cells, hyperchrome atypical cervical wall with fibro-conjunctive structure showing tumor infiltrates with high malignancy suspicion and haemorrhagic areas.
Thus, the high suspicion of malignancy called for the certainty paraffin exam.
After that, an abdominal uterine cerclage was performed and the bHCG repeated. The paraffin exam described malignant proliferation of trophoblastic cell made up of pleomorphic confounding cyto and syncytiotrophoblast cells and intermediate trophoblast cells, with hyperchromic nuclei that separate vascular spaces and have trabecular disposition infiltrating the cervical wall until near the endocervical lining.
Coriocarcinom primar al colului uterin mimând o sarcină cervicală
Bizarre intermediate trophoblast cells, some multinucleated, were present, as well as large areas of intratumoral and peritumoral hemorrhage and necrosis and chronic inflammation and bleeding at the level of cervical cancer mri endocervical mucosa.
The cervix presented acanthosis, parakeratosis and subepithelial chronic inflammation, the tumor proliferation interesting the smooth muscle, while chorionic villi were absent.
The histopathological results correlated cervical cancer mri the increased levels of bHCG suggest choriocarcinoma with large necrotic and hemorrhagic areas that interested the endocervical wall until near the endocervical mucosa and adjacent smooth muscle fibers Figure 4.
Figure 4. Trophoblast proliferation of malignant cells, including cytosyncytiotrophoblast type with wide areas of intra- and peritumoral hemorrhage and necrosis - HE staining x40 Immunohistochemistry testing was recommended for certainty diagnosis.
The positive was established as trophoblastic tumor proliferation in the type of choriocarcinoma. It was recommended the interpretation of the result in anatomical, clinical and cervical cancer mri context, correlated with the dynamic bHCG dosing Figure 5.
Diffusely positive in the syncytiotrophoblast renal cancer with vena cava thrombus immunohistochemistry x40 βHCG Postoperative evolution of the patient was good, being discharged from the hospital three days later.
The last 3 rounds were recommended for stabilization. The follow-up of the patient cervical cancer mri normal clinical and ultrasound exams, until 3 months postoperative.
Discussions Choriocarcinoma is a highly aggressive tumor, which depending on the association with pregnancy has two different forms. Cervical cancer mri usually appears after a malignant alteration in a molar gestation, only rarely after an abortion or normal or ectopic pregnancy 9.
If associated with gestation, it is the most aggressive, malignant form of GTN and bears the name of gestational choriocarcinoma. If it appears in the absence or preceding pregnancy, the term used is non gestational choriocarcinoma, appearing most frequently in the ovary in women or testes in men.
CCA usually arises in association with genital organs such as: the uterus, which is the most common site, the cervix, the fallopian tubes, the ovary, the vagina, the vulva or the vulvar region. It can also occur extremely rare outside the reproductive system, the sites of appearance where it has been described including: the brain, the lungs, the pulmonary arteries, the stomach, the small intestine or the pancreas. Even more rare cases of intrauterine pregnancy associated with placental CCA have been reported Trophoblastic tumor cells have great affinity for blood vessels, which is why the tumors frequently metastasize by hematogenous route Saito et al.
Although an extremely rare pathology with only 87 cases reported in literature until present Table 1from all types of extrauterine CCA, the cervical one is the most common, and several hypotheses have been developed in order to explain cervical cancer mri physiopathology Some authors say it could be a metastasis of a vanishing uterine choriocarcinoma, others a malignant transformation of a cervical pregnancy, others describe it as the result of the implantation of trophoblasts in the cervix after an abortion with malignant change after a dormant period 14, Tabelul 1.
Primary cervical choriocarcinoma - cases published in the specialty literature The risk of fetal teratogenicity from cervical cancer mri is present only if conception occurs during or immediately following the treatment cycles. Fertility is not impaired following chemotherapy. Successful pregnancies have occurred in women who have had widespread GTN, including cerebral metastases The prevalence of CCA has decreased in the recent years according to the improvement of the social and economic conditions, remaining higher in Africa, Asia and South America compared to the United States and Europe 17, The diagnosis of cervical CCA is a difficult one considering its rare incidence, the differential diagnosis including isthmus or cervical leiomyomas, cervical cancer, endocervical polyp, abortion and cervical pregnancy In our case, the cervical CCA was first suspicioned cervical cancer mri be a uterine leiomyoma protruding into the cervical cavity.
The suggestive ultrasound aspect showing intense vascularization was the diagnosis element that determined us to measure the bHCG serum level, knowing that trophoblastic malignant cells produce up to times more hormone than normal cells That is why its measurement has a great diagnostic value and is a useful tool in the follow-up of the patient, as it is the most important recurrence predictor factor of the disease Although in very rare cases its value is not very elevated, in our patient the extreme level of serum bHCG correlated with the rich vascularization was the decisive factor that inclined the balance cancer sigmoidian simptome considering cervical CCA as the positive diagnosis.
Usually the diagnosis of a cervical cancer mri extrauterine CCA is difficult because of the non-specific clinical presentation that can mimic other conditions