although ascites has been reported in cases with cervical cancer , it is due to other causes such as ovarian metastasis .
a 78-year - old diabetic woman who presented with ascites and abdominopelvic mass was misdiagnosed with ovarian cancer and treated with neoadjuvant chemotherapy followed by radical hysterectomy and adjuvant radiotherapy . however , pathology confirmed locally advanced cervical cancer stage iv in this patient .
considering all signs and symptoms to reach a verdict would reduce such malpractices and consequently lead to select the best management and treatment .
the initiating event in cervical cancer is hpv infection and immunosuppression is a risk factor ( 2 ) .
several studies proposed that diabetes mellitus ( dm ) could increase the risk of developing cervical cancer ( 35 ) .
the most common symptoms are abnormal vaginal bleeding and discharge ; patients with advanced disease may present with pelvic pain and bowel or urinary symptoms ( 6 ) . although ascites has been reported in the cases with cervical cancer , it is due to other causes such as ovarian metastasis ( 7 , 8) .
many studies were done to compare different treatments of locally advanced cervical cancer . finally , primary cisplatin - based chemoradiotherapy was recommended as the best current treatment of it ( 9 , 10 ) .
recently , a new study has reported that neoadjuvant chemotherapy followed by radical hysterectomy ( nac+rh ) improves survival of patients with locally advanced cervical cancer in comparison to concurrent chemoradiotherapy ( ccrt ) ( 11 ) . in this study , a case was reported who was consulted by gynecologic oncology service because of pelvic mass and ascites .
our case was a menopausal woman who had diabetes mellitus and was a new case of cirrhosis .
neoadjuvant chemotherapy was suggested for her because she had comorbidity and suffered from cirrhosis and it was presumed that she had ovarian cancer . during laparotomy after chemotherapy , our misdiagnosis was discovered because she had a pelvic mass in upper part of cervix that was fixed to bladder .
therefore , radical hysterectomy was done and she received several courses of radiotherapy after surgery .
our case was a 78-year - old diabetic woman who presented with ascites and abdominopelvic mass and was admitted into firoozgar hospital in tehran , iran on june 2010 .
she also complained of weight loss about 8 kg in the last 3 months , nausea , vomiting , anorexia , dysuria , and fever .
she had diabetes mellitus since ten years ago and took metformin , glibenclamide , losartan , and atorvastatin . on physical examination ,
her abdomen was distended with fluid wave and there was a palpable 25 cm  20 cm mass in hypogartric part . during bimanual pelvic examination , a large , solid , irregular , fixed pelvic mass was found which occupied the whole pelvis .
laboratory data revealed a normocytic anemia , pyuria , hematuria , mild hyponatremia , hypoalbu - minemia , increased prothrombin time , and elevated serum level of cancer antigen 125 ( ca125 ) .
abdominal ultrasound ( us ) reported a small - sized liver ( 4 cm ) with increased paranchymal echogenicity , bilateral hydronephrosis , huge amount of free fluid in abdominopelvic area , and a large pelvic mass with irregular border which us was not able to identify its origin .
abdominopelvic computed tomography ( ct ) scan showed ascites and frozen pelvis with no evidence of metastasis and lymphadenopathy ( figures 12 ) .
large mass was shown in pelvic ct scan cirrhosis was revealed by abdominal ct scan our first diagnosis was ovarian cancer ; therefore , three cycles of neoadjuvant chemotherapy with taxol 175 mg / m and carboplatin 300 mg / m were performed .
laparotomy was performed 3 weeks after the last chemotherapy cycle . during exploration of pelvis ,
the disease was at stage 4 and therefore radical hysterectomy was prepared for the patient and performed removing parameters and 1/3 of proximal vagina .
she was in menopause and bilateral salpingo - oophorectomy was done and the tissue samples were sent for pathologic evaluations .
the histopathology of removed cervix showed localized advanced squamous cell carcinoma , stage iv ( figures 34 ) .
pathology : invasion to myometrium pathology : invasion to the bladder staging of ovarian cancer was surgicopathological but staging cervical cancer is clinical .
there was a misdiagnosis about our case and after pelvic exploration during laparotomy , correct diagnosis was reached and radical hysterectomy was performed . the patient was discharged three weeks later with no complication .
she has received twelve courses of epr ( external pelvic radiotherapy ) after surgery till now .
our patient was successfully treated with nac+rh+epr ( neo adjuvant chemotherapy + radical hysterectomy + external pelvic radiotherapy ) .
she was followed up with serial clinical examination , pap smear , and abdominopelvic ct scan .
in this case presentation , an old diabetic and newly - diagnosed cirrhotic woman was reported who presented with abdominopelvic mass , ascites , and elevated ca125 .
findings during laparotomy and pathologic evaluation of specimens confirmed locally advanced cervical cancer , stage iv in this patient .
the most common symptoms are abnormal vaginal bleeding , postcoital bleeding , and vaginal discharge . in advanced stages of the disease
, it presents with pelvic or lower back pain , and urinary and bowel involvement symptoms ( 6 , 12 ) . while abdulhathi et al .
reported cervical cancer cases presented with ascites , they were due to ovarian metastasis ( 7 , 8) .
no study could be found to report ascites due to cervical cancer alone or with concomitant cirrhosis .
approximately , 5 percent of ascites cases have more than one cause , such as cirrhosis plus peritoneal carcinomatosis ( 13 ) . in ultrasonography
, the presence of solid non hyperechoic ovarian mass and ascites together could be suggestive of ovarian malignancy but metastases to the ovary should be considered as a differential diagnosis .
metastatic disease accounts for 6 to 9 percent of ovarian malignancies and the uterus is also a common primary site for ovarian metastases ( 14 , 15 ) .
therefore , if there is any doubt in diagnosis , image - guided biopsy of the peritoneum or omental cake may help to exclude a non ovarian malignancy ( 16 ) . in literature review ,
zhan et al . , jee et al . , and also kuriki et al . showed that dm increased the risks for developing cervical cancer but there is no evidence to offer , such an association with ovarian cancer ( 35 ) .
similarly , immunosuppression is one of the risk factors of cervical cancer that can be caused by cirrhosis and dm in this case .
human papillomavirus ( hpv ) infection is the most common causal agent of cervical cancer and can be detected in 99.7 percent of cervical cancers ( 17 , 18 ) .
it is also increased in adenocarcinoma of the cervix , liver disease and cirrhosis , ascites , diabetes , and in approximately 1 percent of healthy women ( 19 ) .
if the patient was diagnosed correctly with cervical cancer stage iv , she needed to be treated by ccrt rather than nac+rh , especially in this case ( 9 , 10 ) .
she presented with ascites and had comorbid disease and accordingly was not a good candidate for initial surgery ( 20 ) .
although yin has recently reported that nac+rh improve the long - term disease - free survival ( dfs ) and overall survival ( os ) of patients with locally advanced cervical cancer compared with ccrt , the patients in his sample were all in stage ib2-iib and this case was in stage iv ( 11 ) .
in conclusion , the combination of abdominopelvic mass , ascites , elevated ca125 , and negative human papillomavirus infection in conjunction with lack of attention to epidemiologic hints , dm history , bilateral hydronephrosis , and newly diagnosed cirrhosis misled us to diagnosis of ovarian cancer in this patient .
it seems that considering all signs and symptoms to reach a verdict would reduce such malpractices and consequently lead to selecting the best management and treatment .
it seems necessary to refine our differential diagnosis using complementary workup and confirm our final diagnosis before choosing the appropriate treatment for each patient .
 background : cervical cancer is the second most common malignancy in women worldwide . 
 vaginal bleeding and vaginal discharge are the most common symptoms . 
 although ascites has been reported in cases with cervical cancer , it is due to other causes such as ovarian metastasis.case presentation : a 78-year - old diabetic woman who presented with ascites and abdominopelvic mass was misdiagnosed with ovarian cancer and treated with neoadjuvant chemotherapy followed by radical hysterectomy and adjuvant radiotherapy . 
 however , pathology confirmed locally advanced cervical cancer stage iv in this patient . 
 she was discharged from the hospital three weeks after surgery with no serious complications.discussion:considering all signs and symptoms to reach a verdict would reduce such malpractices and consequently lead to select the best management and treatment . 