A 56 year-old post-menopausal previously healthy woman was admitted with one week epigastric pain. Physical examination revealed an adequate general physical status and painful abdomen at deep epigastric palpation. Serum lipase was 3231 UI/L.
Abdominal ultrasound (US) revealed two solid hypoecogenic hepatic nodules, in the V and VI segments, with well defined limits and “target” sign, suggestive of metastasis; in the pancreatic head, a nodular hypoechogenic 26x28mm lesion with poorly defined boundaries and several other hypoechogenic centimetric nodules dispersed in the pancreatic body and tail (Figure 1). The CT Scan confirmed the hepatic and pancreatic US findings and revealed a heterogeneous uterine cervix and isthmus with increased dimensions, with a 43x46x53mm lesion in the left side.
Figure 1. A- Hepatic metastasis; B- Pancreatic head with a nodular hypoechogenic 26x28mm lesion;
C- Hypoechogenic centimetric nodules dispersed in the pancreatic body; Wirsung not dilated.
Endoscopic ultrasound (EUS) identified multiple hypoechogenic well defined nodules throughout the pancreas, the largest with 19mm in the cephalic region, without dilatation of the Wirsung or common bile duct and without vascular invasion (Figure 2).
Figure 2. A- Hypoechogenic 19mm lesion in the pancreatic head. B- Smaller (9 mm) nodule in the pancreatic tail.
Citology analysis from EUS-FNA of the cephalic and tail pancreatic nodules (25G needle, three passages), identified small cells, with scarce cytoplasm, nucleus with granular chromatin, without nucleoli. Endovaginal US and Pelvic Magnetic Resonance Imaging (MRI) identified a solid cervix lesion with invasion of the uterine body (Figure 3).
Figure 3. A- Endovaginal US showed a solid 49x51x54mm uterine cervix lesion, with irregular contour, which involves the isthmus and lower part of the uterine body. B- MRI revealed a uterine cervix lesion with 70x55x52mm, with intermediate signal on T1WI and T2WI, with restriction on diffusion weighted imaging.
The biopsy of the uterine cervix identified a neuroendocrine carcinoma, small cell type, Grade 3, high degree, with high proliferation index and necrotic areas; Immunohistochemistry profile CD 56 +, p63- and Ki-67 positivity for 80% of the neoplastic cells (Figure 4).
Figura 4. Histology of uterine neuroendocrine carcinoma. A- Hematoxylin-eosin staining, 40x magnification; B- CD56 positive immunohistochemistry staining, 10x magnification C- Ki-67 positive immunohistochemistry staining, 40x magnification.
This is an atypical case of a neuroendocrine carcinoma of the uterine cervix, with an unusual primary manifestation associated to pancreatic metastasis. The pancreas is an uncommon site for metastatic disease, with only 2-4% of pancreatic malignancies being metastasis and more than 50% of which being asymptomatic (1,2). The most common primary cancer site responsible for pancreatic metastasis is the kidney, followed by colorectal cancer, melanoma, breast cancer, lung carcinoma and sarcoma. (1,2) To our knowledge, in the literature, there are only five cases describing pancreatic metastasis from uterine cervix tumours (3).
1- Sperti C, Molleta L, Patané G, Metastatic tumors to the pancreas: The role of surgery. World J Gastrointest Oncol 2014; 6(10):381-392
2- Zerbi A, Pecorelli N, Pancreatic metastases: An increasing clinical entity; World J of Gastrointest Surg 2010; 2(8):255-259
3- Nishimura C, Naoe H., Hashigo S, Tsutsumi H,Ishii S, Konoe T, et al. Pancreatic Metastais from mixed adenoneuroendocrine carcinoma of the uterine cervix: a case report.Case Rep Oncol 2013;6:256-262.
Maria Ana Túlio1, Miguel Bispo1, Tiago Bana-Costa1, Lucília Monteiro2, Pedro Pinto-Marques3, Cristina Chagas1
1- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Lisbon
2- Department of Pathology, Centro Hospitalar Lisboa Ocidental, Lisbon
3- Department of Gastroenterology, Hospital Garcia de Orta, Almada