Lower extremity pain as initial presentation of cervical cancer
The patient was a previously healthy 36-year-old nulligravida woman who presented with isolated back and right leg pain (RLE) for two weeks. Imaging workup included X-ray and magnetic resonance imaging (MRI) of the spine, which demonstrated multiple vertebral body lesions with spinal canal extension at the T6 level (A); Tc99m bone scan redemonstrated the multiple spine and RLE lesions, including a large, distal right femoral lesion (B). Distal right extremity X-rays and MRI were obtained to exclude pathologic fracture at this site (C). An anterior cortex, lytic lesion with associated soft tissue component was seen, without associated fracture. A subsequent FDG-PET/CT (D) of the abdomen and pelvis demonstrated multiple organ lesions and lymphadenopathy. Because the etiology of the presumed diffuse metastatic disease was unclear, the patient subsequently underwent a CT-guided, core biopsy of the femur. Pathology revealed sheets of undifferentiated pleomorphic neoplastic cells with high nuclear/cytoplasmic (N:C) ratio, prominent nucleoli and numerous mitotic figures (A–C). The tumor cells stained strongly for cytokeratin (AE1/3) (D) and negative for CK7/CK20, S100, HMB45, synaptophysin, chromogranin, estrogen receptor (ER), progesterone receptor (PR), thyroid transcription factor-1 TTF1, CA125, renal cell marker, and calretinin. Because the primary site was still unidentifiable, excisional biopsy of the femur lesion was performed. Pathology showed rare areas of squamous differentiation among nests of tumor cells immunoreactive for p63 (E) and CK5/6 ( F), consistent with a poorly-differentiated squamous cell carcinoma from either the lung, head and neck or uterine cervix. A pelvic examination revealed a single 2-cm erosive lesion on her anterior cervix, and a cervical biopsy demonstrated a moderately-to-poorly differentiated squamous cell carcinoma.\nZoledronic acid was administered to slow the progression of the bone metastases, and surgical excision and internal fixation were performed to the femur. She also received palliative radiation therapy (20 Gy over 5 fractions to T4–T7 and 8 Gy in a single fraction to L5-sacrum). The patient received one cycle of systemic gemcitabine (1600 mg/m2) with cisplatin (100 mg/m2). Although the thoracic spine showed partial response to the palliative radiation on follow-up imaging (E), multiple, new diffuse bone and soft tissue metastases were found. The patient rapidly deteriorated and passed away before any further chemotherapy could be offered.