Intramural Metastases of Rectum from Carcinosarcoma (Malignant
Müllerian Mixed Tumor) of Uterine Cervix
Yu-Chin Wu, M.D.,†‡ Chun-Fan Yang, M.D.,§ Cheng-Nan Hsu, M.D.,¶
and Te-Chun Hsieh, M.D.‡*
From the †Department of Nuclear Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu City, Taiwan; ‡Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan; §Department of Pathology, China Medical University Hospital, Taichung, Taiwan; ¶Department of Radiology, China Medical University Hospital, Taichung, Taiwan; and *Department of Biomedical Imaging and Radiological Science, China Medical University,
Taichung, Taiwan.
Reprints and corresponding author: Te-Chun Hsieh, M.D., Department of Nuclear Medicine and PET Center, China Medical University Hospital, No. 2, Yuh-Der Road, Taichung 404, Taiwan. E-mail: [email protected]
Abstract: A 25-year-old woman had carcinosarcoma of uterine cervix after definitive
treatment. One year later, local recurrent disease was found in the right posterior pelvis on FDG PET/CT. FDG PET/CT also disclosed an incidental intramural hypermetabolic lesion in the rectum, which seemed separate from the right pelvic lesion on contrast-enhanced CT. The rectal lesion was confirmed as metastatic carcinosarcoma from uterine cervix after endoscopic biopsy.
Key Words: carcinosarcoma; uterine cervix; rectum; metastasis; intramural; FDG
TEXT:
Figure 1. A 25-year-old woman had carcinosarcoma (malignant müllerian mixed
tumor) of uterine cervix after radical hysterectomy and adjuvant chemoradiotherapy. One year later, she had gradually deteriorated right buttock pain that was suspected to be relevant to recurrent malignancy. FDG PET/CT disclosed a focal hypermetabolic soft tissue lesion (SUVmax= 9.6) in the right rectovesical recess (arrowheads), which was thought to be a local recurrent malignancy. Physiological radioactivity was also present as concentric luminal uptake in the most of rectum. However, it seemed that there was a tiny focus with persistent eccentric intense FDG radioactivity (SUVmax= 8.0) in the right lateral wall of rectum (arrows), which was not explainable as part of physiological rectal radioactivity.
Figure 2. Contrast-enhanced CT of the pelvis showed an enhancing mass in the right
rectovesical recess (arrowhead) as the local recurrent malignancy demonstrated on FDG PET/CT. In addition, there was a well-demarcated intramural enhancing tumor within the right lateral wall of rectum (arrow), which was corresponding to the persistent hypermetabolic focus on FDG PET/CT.
mucosal erythematous change and central ulceration in the rectum (arrow).
Figure 4. Biopsy of the rectal mass revealed anaplastic tumor cells infiltrating the
submucosal layer of rectum (A). The immunohistochemical stains showed positive for cytokeratin, vimentin and p16INK4A (B-D). The pathological findings confirmed the
diagnosis of rectal intramural metastasis from carcinosarcoma of uterine cervix. Cervical carcinosarcoma is an uncommon malignancy and mostly occurs in older age and advanced stage.1 In a retrospective cohort study consisting of 33074 women
with invasive cervical neoplasms, there are only 1% of women with cervical
sarcomas, and the most common subtype (accounting for 40%) of cervical sarcoma is carcinosarcoma.2 It has been suggested that prior radiation to pelvis, chemotherapy
and human papillomavirus infection are associated with the development of cervical carcinosarcoma. Cervical carcinosarcoma usually has a poor prognosis because of the common resistance to various treatments.3
The mechanisms of gastrointestinal metastases include hematogenous (embolic) metastases, peritoneal carcinomatosis (serosal implants) and direct invasion by extracolonic malignancy.4,5 Hematogenous metastases to the intestine typically appear
as well-defined submucosal nodules or masses with or without central ulceration.4,5
Because of the relative abundance of blood supply, the small intestine tends to develop metastasis more frequently than the colon and rectum.4,6 Rectal metastasis
from hematogenous spread is rare and has been reported from prostate cancer,7 breast
cancer,8,9 gastric cancer,10 malignant fibrous histiocytoma,11 ovarian cancer,12
melanoma13 and lung cancer.14 In our current case, the rectal intramural mass appears
as a well-defined submucosal lesion with central ulceration, and separates from the adjacent right pelvic mass. Therefore, we consider that the rectal mass is more likely to be a hematogenous metastasis rather than direct invasion or serosal implant. Nevertheless, the current case also reminds clinicians that an eccentric intestinal uptake on FDG PET should be checked carefully and not simply considered as part of physiological radioactivity in case certain malignant lesion should be missed.
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