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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 4  |  Page : 77-79

Supraclavicular lymphadenopathy as the initial manifestation in carcinoma of cervix


1 Department of Obstetrics and Gynaecology, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India
2 Department of Radiotherapy, Acharya Harihara Regional Cancer Centre, Cuttack, Odisha, India

Date of Submission11-Jul-2019
Date of Acceptance07-Nov-2019
Date of Web Publication26-Dec-2019

Correspondence Address:
Dr. Tapan Kumar Sahoo
Department of Radiotherapy, Acharya Harihara Regional Cancer Centre, Cuttack - 753 007, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ctm.ctm_23_19

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  Abstract 


Carcinoma of the cervix has been considered as a preventable disease. However, it continues to be a significant health problem worldwide and is the second most frequent cause of cancer death among women in developing countries. It rarely metastasizes to the supraclavicular group of lymph nodes during the initial presentation, and few cases have been reported in the literature. Here, we report a case of cervical carcinoma in a 40-year-female with unusual manifestation at the time of initial presentation. The patient was diagnosed with squamous cell carcinoma of the cervix with supraclavicular lymph node metastatic FIGO Clinical Stage IVB and treated in the line of concurrent chemoradiotherapy followed by adjuvant chemotherapy. The patient is reported to be disease-free after 1 year of completion of therapy.

Keywords: Cervix, response, supraclavicular lymphadenopathy


How to cite this article:
Priyaarshini P, Sahoo TK. Supraclavicular lymphadenopathy as the initial manifestation in carcinoma of cervix. Cancer Transl Med 2019;5:77-9

How to cite this URL:
Priyaarshini P, Sahoo TK. Supraclavicular lymphadenopathy as the initial manifestation in carcinoma of cervix. Cancer Transl Med [serial online] 2019 [cited 2020 Jul 3];5:77-9. Available from: http://www.cancertm.com/text.asp?2019/5/4/77/274028




  Introduction Top


Supraclavicular lymph node (SCLN) metastasis at the time of initial diagnosis of cervical carcinoma is rare, with a reported incidence of 0.1%–1.5%.[1],[2] The involvement of SCLN in cervical carcinoma indicates a high tumor burden and considers under FIGO Clinical Stage IVB. SCLN involvement in cervical cancer follows in stepwise pattern from pelvic lymph nodes to para-aortic lymph nodes, cisterna chyli, and thoracic duct and finally opens into the junction of the left subclavian and internal jugular vein with drop metastasis to SCLN. Cervical cancer patients with SCLN involvement at the time of the primary diagnosis have poor outcomes. Here, we reported a case of squamous cell carcinoma of the cervix with left SCLN metastasis as initial presentation in a 40-year-old female.


  Case Report Top


A 40-year-old female, P3L3, menstruating and sexually active, presented with a chief complaint of irregular menstruation for 1 year, whitish discharge per vaginam for 8 months, intermittent pain abdomen for 6 months, and swelling in the left supraclavicular region for 2 months. On examination, vitals were stable with the presence of moderate pallor. A fixed hard mass of 5 cm × 4 cm was palpable in the left supraclavicular region [Figure 1]. On abdominal examination, the uterus was 16-week size with restricted mobility. Per speculum examination revealed a huge cauliflower growth measuring 5 cm × 8 cm on the anterior lip of cervix [Figure 2]. Per vaginal and per rectal examination showed that bilateral parametrium is involved up to the lateral pelvic wall. Rectal mucosa was free. Other systemic examinations were found to be normal. Cervical biopsy revealed features of squamous cell carcinoma [Figure 3]. Fine-needle aspiration cytology of the left SCLN showed metastatic deposits of squamous cell carcinoma and tadpole cells specific for squamous cell carcinoma. Total abdominal ultrasound showed bulky heterogeneous uterus with thickened endometrium, bulky hypoechoic cervix with adjacent upper vaginal wall and urinary bladder wall thickened, and left-sided moderate hydronephrosis. Contrast-enhanced computed tomography (CECT) scan of the abdomen and pelvis showed a heterogeneous enhancing mass measuring 6.0 cm × 5.0 cm × 6.5 cm located in the uterine cervix with involvement of both the parametrium extending up to the pelvic wall without involvement of the urinary bladder and rectum and multiple pelvic and para-aortic lymphadenopathy. CECT scan of the thorax showed normal findings. CECT scan of the neck showed a solid left SCLN measuring 3.6 cm × 4.2 cm.
Figure 1: Left supraclavicular lymph node enlargement

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Figure 2: A cauliflower-like growth of size approximately 5 cm × 8 cm on the anterior lip of the cervix on per speculum examination

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Figure 3: Microsection (H and E, ×100) showing malignant squamous epithelial cells present in sheets with many squamous pearls

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A diagnosis of squamous cell carcinoma of the cervix with metastases to SCLN was confirmed and considered under FIGO Stage IVB. She received external beam radiotherapy to the pelvis, para-aortic lymph node, and left SCLN region with a dose of 50 Gy in 25 fractions along with five cycles of weekly cisplatin 40 mg/m 2 and high dose rate (HDR) brachytherapy (7 Gy per fraction on a weekly basis for 3 fractions), followed by 6 cycles of chemotherapy with paclitaxel (1.75 mg/m 2) and carboplatin (area under the curve 6) with the resolution of all lesions. The patient was on regular follow-up and was found disease-free after 1 year completion of treatment.


  Discussion Top


The extent of the disease at the time of diagnosis is the greatest prognostic factor for cervical carcinoma, and survival decreases with advanced stages. Disease status during initial diagnosis is important to select appropriate treatment methods for cervical carcinoma to increase efficacy. In FIGO Stage I–IIA cervical cancer, surgery is the primary standard of treatment, and RT or concurrent chemoradiotherapy may be used according to postoperative indications, whereas, for FIGO Stage IB2–IVA cervical carcinomas, concurrent chemoradiotherapy is the optimal treatment.[3] Systemic chemotherapy is known as the only treatment for Stage IVB cervical carcinomas.[4] However, there is a limitation for such systemic chemotherapy in terms of low response rate (20%–30%) and survival.[5]

SCLN metastasis at initial presentation of cervical carcinoma is not incurable. However, RT is not widely performed in such cases due to the relatively rare presentation. Few kinds of literature documented the role of concomitant chemoradiation therapy (CCRT) for cervical cancer with SCLT metastasis. The rationale behind the use of SCLN RT for cervical cancer patients with SCLN involvement at the time of initial diagnosis relies on the following two reasons. First, the pattern of lymphatic spread in cervical cancer is stepwise from the pelvic lymph nodes to the para-arotic lymph nodes (PALNs) and finally to the SCLNs, considering SCLN involvement as a localized disease. Second, few retrospective studies on PALN RT give hints that the effect of CCRT would be better than that with just chemotherapy alone or with observation for cervical cancer patients with SCLN involvement.

According to Kim et al., concurrent chemoradiation has superior results than chemotherapy alone, and the conduct of prospective clinical trials for the efficacy of chemoradiation in Stage IVB cervical carcinoma with distant lymphatic metastasis may be worthwhile.[6] According to Tran et al., the median survival of 7.5 months was reported in 14 cervical cancer patients with SCLN involvement, and according to Chao et al., 2-year overall survival rate of 24.7% was reported in 12 cervical cancer patients with SCLN metastasis.[7] However, according to Hong et al. and Lee et al., favorable outcomes were found in the patient with SCLN involvement.[8] According to Kim et al., cervical cancer patients with SCLN metastasis receiving RT to the pelvis, PALN, and SCLN with simultaneous chemotherapy showed long-term survival.[9]

In a study, a review of 18 cases of cervical cancer with SCLN involvement showed a survival time between 1 and 16 months after the appearance of metastases.[2] A study by Qiu et al. on 33 cases of SCLN metastasis at primary diagnosis of carcinoma of cervix showed the 3-year and 5-year survival rates of 16.5% and 16.5%, respectively. According to Qiu et al., positron emission tomography scan may help in selecting appropriate patients for curative primary and/or salvage treatment.[10]

The present case has received concurrent chemoradiation followed by adjuvant chemotherapy with a complete response.


  Conclusion Top


SCLN involvement at the initial diagnosis of cervical carcinoma is rare with poor prognosis but not incurable. Chemoradiotherapy should be considered as an active therapy in carcinoma of the cervix, with SCLN involvement at the time of initial diagnosis without any other distant metastasis to provide favorable results. Few preliminary results on CCRT treatment in cervical carcinoma with initial involvement of SCLN show long-term survival. However, the well-designed study enrolling more patients will be necessary to draw selective criteria for CCRT.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tunio MA, Asiri MA, Mohamed R, Al-Dandan S. Supraclavicular lymphadenopathy: initial manifestation of metastasis in carcinoma of cervix. Case Rep Obstet Gynecol 2013; 2013: 1–3.  Back to cited text no. 1
    
2.
Henriksen E. The lymphatic spread of carcinoma of the cervix and of the body of the uterus. A study of 420 necropsies. Am J Obstet Gynecol 1949; 58: 924–42.  Back to cited text no. 2
    
3.
Suh DH, Kim K, Kim JW. Major clinical research advances in gynecologic cancer in 2011. J Gynecol Oncol 2012; 23: 53–64.  Back to cited text no. 3
    
4.
National Comprehensive Cancer Network. Cervical Cancer Clinical Practice Guidelines in Oncology (v.I.2010) [Internet] Fort Washington: National Comprehensive Cancer Network. Available from: http://www.nccn.org. [Last accessed on 2012 Nov 01].  Back to cited text no. 4
    
5.
Pectasides D, Kamposioras K, Papaxoinis G, Pectasides E. Chemotherapy for recurrent cervical cancer. Cancer Treat Rev 2008; 34: 603–13.  Back to cited text no. 5
    
6.
Kim HS, Kim T, Lee ES, Kim HJ, Chung HH, Kim JW, Song YS, Park NH. Impact of chemoradiation on prognosis in Stage IVB cervical cancer with distant lymphatic metastasis. Cancer Res Treat 2013; 45: 193–201.  Back to cited text no. 6
    
7.
Chao A, Ho KC, Wang CC, Cheng HH, Lin G, Yen TC, Lai CH. Positron emission tomography in evaluating the feasibility of curative intent in cervical cancer patients with limited distant lymph node metastases. Gynecol Oncol 2008; 110: 172–8.  Back to cited text no. 7
    
8.
Lee SH, Lee SH, Lee KC, Lee KB, Shin JW, Park CY, Sym SJ, Lee JH. Radiation therapy with chemotherapy for patients with cervical cancer and supraclavicular lymph node involvement. J Gynecol Oncol 2012; 23: 159–67.  Back to cited text no. 8
    
9.
Kim K, Cho SY, Kim BJ, Kim MH, Choi SC, Ryu SY. The type of metastasis is a prognostic factor in disseminated cervical cancer. J Gynecol Oncol 2010; 21: 186–90.  Back to cited text no. 9
    
10.
Qiu JT, Ho KC, Lai CH, Yen TC, Huang YT, Chao A, Chang TC. Supraclavicular lymph node metastases in cervical cancer. J Gynaecol Oncol 2007; 28: 33–8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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