A case report of perirenal metastases from cervical squamous cell carcinoma on 18F FDG PET-CT

2039 Introduction: Squamous cell carcinoma is the most common malignant neoplasm of the uterine cervix. It accounts for more than 70% of cervical neoplasms. The primary routes of spread include direct local extension and lymphatic spread. Hematogenous dissemination occurs with advanced disease. Distant metastasis involving lung, liver, bone, breast, paraspinal muscles, duodenum and kidney have been reported. We report a case of perirenal metastasis from squamous cell carcinoma of the cervix. Keywords: Squamous cell carcinoma of cervix, perirenal metastasis Introduction: Metastatic disease generally develops in 15% to 61 % of women with cervical cancer and occurs within the first two years of completing treatment (2). The primary routes of spread include direct local extension and lymphatic spread. Hematogenous dissemination occurs only with advanced disease. Distant metastasis involving lung, liver, bone, breast, paraspinal muscles, duodenum and kidney have been reported (1). We report a rare case of perirenal metastasis from squamous cell carcinoma of the cervix, occurring during chemotherapy and radiation therapy. Case Report: 47-year-old female presented with heavy vaginal bleeding and lower abdominal pain for 2 months. Diagnostic computed tomography of abdomen and pelvis showed a large cervical mass with enlarged pelvic and retroperitoneal lymph nodes. There was moderate bilateral hydroureteronephrosis down to the level of the cervical mass. Cervical biopsy revealed well-differentiated non-keratinizing squamous cell carcinoma. Bilateral percutaneous nephrostomy tubes were placed to relieve the renal obstruction. Staging 18F FDG PET-CT scan demonstrated FDG-avid cervical cancer and FDG avid pelvic and retroperitoneal nodal metastases. MR of the pelvis showed extensive local infiltration by the cervical tumor with parametrial and bladder invasion. The patient was treated with combined chemotherapy and radiation therapy. Treatment response assessment 18F-FDG PET-CT scan demonstrated decrease in size and FDG uptake of the cervical mass and pelvic lymph nodes. There was however increase in size of retroperitoneal lymph nodes and new FDG avid irregular soft tissue deposits in the perirenal fascia which were highly suspicious for metastases. CT-guided core biopsy of a left perirenal deposit revealed metastatic squamous cell carcinoma of cervix. Follow up CT abdomen and pelvis after 3 cycles of carboplatin-Taxol-bevacizumab showed decrease in size of left perirenal tumor implants. Discussion: Perirenal space communicates with the infrarenal space and extraperitoneal spaces in the pelvis (4). Renal cell carcinoma, lymphoma, retroperitoneal sarcoma and metastatic disease are the most common tumors involving the perirenal space. There have been isolated reports of perirenal space metastases from lung cancer, malignant melanoma, breast carcinoma, esophageal adenocarcinoma, gastrointestinal adenocarcinoma, prostate cancer and malignant peripheral nerve sheath tumor (8). Two cases of gynecological tumors with perirenal metastases have been reported and the primary tumors were endometrial adenocarcinoma and epithelial ovarian carcinoma (7). Soft tissue deposits in the left perirenal fascia with increased metabolic activity on 18F FDG PET-CT raised the suspicion of metastatic disease, and was confirmed with CT-guided biopsy. Distant metastasis to the perirenal space from cervical cancer confers a substantially poorer prognosis and has important management implications. Conclusions: To the best of our knowledge, this is the first case report of perirenal metastases from squamous cell carcinoma of the cervix. Although an uncommon site of distant metastases from cervical cancer, FDG avid soft tissue deposits in the perirenal space should raise suspicion of metastasis, and early biopsy should be done to confirm the diagnosis. Patients with metastatic cervical cancer, including those with perirenal metastasis, have poor outcomes.