Radiation Oncology Case Report Journal of Medical Imaging and Radiation Oncology (2008) 52, 91–94 Bulky scalp metastasis and superior sagittal sinus thrombosis from a cervical adenocarcinoma: An unusual case A Abhishek,1 MM Ouseph,1 P Sharma,2 V Kamal2 and M Sharma1 1 Departments of Radiotherapy and Oncology and 2Pathology, Maulana Azad Medical College (MAMC) and Lok Nayak Hospital, New Delhi, India SUMMARY Distant cutaneous metastases from cervical malignancies are uncommon, with scalp metastases being exceptional events. We present the case of a 53-year-old postmenopausal lady with adenocarcinoma of the uterine cervix that metastasized to the scalp with superior sagittal sinus thrombosis 8 months after diagnosis. In contrast to the seven prior cases of scalp metastases of cervical squamous cell carcinoma reported in published reports, ours is the first documentation of such an occurrence in cervical adenocarcinoma. Superior sagittal sinus thrombosis has not been reported with this tumour in the past. Key words: adenocarcinoma; cervical cancer; scalp metastasis; superior sagittal sinus thrombosis. INTRODUCTION CASE REPORT Cervical cancer is the commonest malignancy in women in the A 53-year-old postmenopausal lady presented in August 2005 developing world.1 It spreads locally by direct extension and with vaginal bleeding and discharge since 8 months. Clinical distantly by invading lymphatics. Haematogenous metastases examination showed a 3 · 3 cm friable growth in cervix extend- are uncommon, although such spread may occur to abdominal ing into the left fornix. Bilateral parametria and lower vagina and thoracic viscera or to bone, in decreasing order of fre- were normal on examination under anaesthesia. quency.2 The skin is an infrequent site of metastasis for this A CT scan showed a bulky cervix with a hypodense mass cancer, the reported incidence being 0.7–1.3%.2,3 Common skin lesion extending into the upper third of vagina and stretching the sites involved include the abdominal wall and the lower extrem- vaginal fornix. Superiorly, the growth invaded the endometrium ity.4 Scalp metastases are extremely rare, with only seven and extended till inner half of myometrium. Bilateral parametria, indexed cases in published reports. kidneys, bladder and rectum were uninvolved. Clinicoradiolog- Superior sagittal sinus thrombosis is common in haemato- ical diagnosis was cervical carcinoma International Federation logical malignancies but occurs only rarely with solid tumours, of Gynaecology and Obstetrics stage IIA. Cervical biopsy usually secondary to calvarial involvement. It has, however, not showed poorly differentiated adenocarcinoma. been previously reported in association with a uterine cervical adenocarcinoma.5–12 The patient underwent Wertheim’s hysterectomy. At gross, the tumour measured 3.0 · 2.5 · 1.0 cm and extended into the We report a case of adenocarcinoma of uterine cervix in left fornix. Microscopically, the moderately differentiated (Grade a patient who presented with scalp metastasis and superior II) endocervical-type adenocarcinoma showed intracytoplasmic sagittal sinus thrombosis 8 months after diagnosis and treat- mucin and numerous mitoses (Fig. 1). A prominent lymphocyte- ment of primary disease. rich inflammatory infiltrate was seen in the adjacent stroma. A Abhishek MB BS; MM Ouseph MD; P Sharma MD DNB; V Kamal MD; M Sharma MD, FICR. Correspondence: Dr Ashu Abhishek, O.P.D. Room No. 124, Department of Radiotherapy, Lok Nayak Hospital, Delhi Gate, Bahadur Shah Zafar Road, New Delhi 110002, India. Email: ashuabhishek@yahoo.com; ashuabhishek@gmail.com Conflict of interest: None. Submitted 2 August 2006; accepted 22 August 2006. doi: 10.1111/j.1440-1673.2007.01918.x ª 2008 The Authors Journal compilation ª 2008 The Royal Australian and New Zealand College of Radiologists 92 A ABHISHEK ET AL. Fig. 1. Histological section from the cervical primary tumour shows closely packed papillae lined by large cells with abundant clear cytoplasm and hyperchromatic nuclei (haematoxylin–eosin, ·250). Inset: fine needle aspiration cytology scalp lump displays malignant epithelial cells with prominent mitoses forming acini in a necrotic background (Giemsa, ·400). No angiolymphatic emboli or any associated in situ component were noted. The parametrial and paracervical soft tissues, uter- Fig. 2. Clinical photograph showing midline frontal scalp swelling without skin involvement. ine corpus, fallopian tubes, ovaries and all the resection margins (including the vaginal cuff) were histologically uninvolved. Two of the 13 lymph nodes dissected harboured tumour metastases. The pathological stage was (pT2, pN1, pMX). The patient was offered concomitant postoperative adjuvant chemoradiotherapy, considering the risk factors identified in the specimen. She, however, declined chemotherapy and was therefore started on external beam radiotherapy in November 2005. But after receiving 28 G in 14 fractions, she discontinued treatment because of personal reasons and was lost to further treatment and follow up. The patient returned 4 months later in March 2006 with a rapidly progressing painful swelling over the anterior scalp present for 20 days and repeated episodes of generalized tonic clonic seizures. There was no history of vomiting or symptoms suggestive of raised intracranial pressure. Patient did not have any clinically identifiable neurological deficits or papilloedema. Examination showed a midline 8 · 8 cm firm, nontender, noncompressible, nonpulsatile swelling over the midline frontal scalp fixed to the underlying skull (Figs 2,3). The overlying stretched skin of the swelling was, however, uninvolved without any evidence of fixity, dilated veins or ulceration. Pelvic examination did not show any residual disease. Plain radiogram of skull was suggestive of a soft tissue swelling, with pressure effects over the outer table of skull. A MRI of her cranium confirmed presence of the scalp mass with involvement of both tables of frontal skull with thickening of adjacent dura. There was no evidence of direct invasion into brain parenchyma or superior sagittal sinus (Fig. 4). Magnetic resonance venogram showed complete thrombosis of superior sagittal sinus (Fig. 5). Systemic evaluation did not show any other foci of metastases. Fig. 3. Clinical photograph showing a distinct scalp swelling with no dilated veins or ulceration. ª 2008 The Authors Journal compilation ª 2008 The Royal Australian and New Zealand College of Radiologists UNUSUAL METASTASIS FROM CERVICAL CANCER 93 Fig. 4. T1-weighted post-gadolinium magnetic resonance coronal image showing midline scalp swelling with direct invasion to both tables of skull and thickening of adjacent dura matter. The figure in the inset shows thrombosis of superior sagittal sinus. Fig. 5. Magnetic resonance venogram image showing nonvisualization of superior sagittal sinus, suggestive of complete thrombosis of superior sagittal sinus. Fine-needle aspiration cytology carried out from the scalp because of lymphatic invasion. Haematogenous spread in car- swelling showed metastatic adenocarcinoma with extensive cinoma cervix is a late process and usually is seen to spread to necrosis (Fig. 1, inset). The cytological features of sheet-like liver, lungs and bones, especially in poorly differentiated sub- as well as acinar arrangements of cells with focal mucin content types. Few of the uncommon sites of metastases that have and brisk mitotic activity were similar to the cervical primary been reported include the skin and s.c. tissues, brain, menin- mass. ges, heart and breast.2–5,13 Metastatectomy was unfeasible despite the solitary site of A review through the reported cases suggests that occur- spread (without local failure) as a result of the superior sagittal rence of scalp metastases does not appear to be related to the sinus thrombosis. After stabilization of symptoms with antico- initial stage of presentation. It has been reported in patients agulant therapy and anti-epileptic drugs, she was initiated on treated for early as well as advanced stages of disease.14–17 In multiagent chemotherapy (cisplatin 30 mg Day1 (D1)–D4, the available reports, interval from initial diagnosis to develop- 5-fluorouracil 500 mg D1– D5 and bleomycin 15 IU D1 and D5, ment of scalp metastases varied from 8 months to 4 years and in 3-weekly schedules). With two chemotherapy cycles, the the location of scalp involved and number of lesions in scalp patient achieved approximately 50% clinical regression. At this were varied and nonuniform.14–19 Except in the report from Park stage, she received palliative whole-brain radiotherapy (30 G in et al., these patients had scalp as the sole site of metastasis.14 10 fractions over 2 weeks, with two parallel opposed fields, the Although our patient had involvement of pelvic lymph nodes upper border of which was left to fall off in air to include the scalp at presentation, the lack of para-aortic, mediastinal or supra- lesion). The patient was last assessed at the end of radiother- clavicular lymph node involvement makes retrograde lymphatic apy when she was clinically stable. Unfortunately, she chose to spread a very unlikely mode of spread. Different hypotheses stop all treatment at this stage and was unavailable for further have been put forward for explaining isolated haematogenous follow up. involvement of scalp from distant malignancies. Fay et al. attributed the presence of rich vascularity, warmth and immo- DISCUSSION bility to explain metastases in scalp region.20 Another hypothe- Carcinoma cervix commonly spreads through direct local sis that has been used for explaining this kind of spread extension, and when distant spread occurs, it is usually involves interaction between tumour cells and endothelial cell ª 2008 The Authors Journal compilation ª 2008 The Royal Australian and New Zealand College of Radiologists 94 A ABHISHEK ET AL. receptors in the target organs. This possibility was first 3. described by Nicolson et al. for explaining the tendency of cancer cells to metastasize to specific organs.21 It is a known fact that systemic malignancies, especially 4. 5. lymphoreticular, with or without scalp or calvarial involvement, can be associated with intracranial venous sinus thrombosis.6–11 Although rare and none reported in carcinoma of uterine cervix, 6. there are reports of skull metastasis from distant primary solid tumours leading to superior sagittal sinus thrombosis.12 Direct 7. invasion into venous sinus or thrombosis extending through venous communications between scalp and intracranial venous sinuses (when there is scalp or skull involvement) and systemic 8. hypercoagulability (when there is no such direct sinus, skull or scalp involvement) have been the proposed explanations. Irrespective of the mode of spread, presence of scalp metastases in patients with carcinoma of uterine cervix indi- 9. 10. cates advanced disease and a very poor prognosis. Two of the reported cases had survival of less than few weeks from the time of diagnosis of the metastatic disease.15 It is not known whether presence of sagittal sinus thrombosis will have an 11. adverse effect on prognosis of these patients. In view of the poor prognosis in these patients, the intent of 12. management should ideally be palliative. Radiation therapy is an accepted method for palliative treatment for these patients. But in patients with good general condition, surgical excision of the metastatic lesion and combination chemotherapy are also 13. 14. options that need to be considered. Our patient has achieved good symptom palliation with use of multiagent chemotherapy 15. and radiation therapy. Although some of the manifestations of metastatic uterine cervical carcinoma such as nodal metastases and involvement 16. of solid organs of abdomen and thorax are well known, cutaneous, especially scalp, involvement is rare and the association with superior sagittal sinus thrombosis makes this an extremely 17. rare presentation. With growing technical advances and knowledge, we can expect more frequent reports and better understanding of mechanisms and natural history of these rare 18. manifestations, thereby leading to clearer management strategies for these patients. 19. 20. REFERENCES 1. 2. Ferlay J, Bray F, Pisani P, Parkin DM. Globocan. 2000: cancer incidence, mortality and prevalence worldwide, version 1.0. IARC CancerBase no. 5. IARC Press, Lyons, France, 2001. Carlson V, Delclos L, Fletcher GH. Distant metastases in squamous-cell carcinoma of the cervix. Radiology 1967; 88: 961–6. 21. Imachi M, Tsukamoto N, Kinoshita S, Nakano H. 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