A Case of Uterine Cervical Cancer Presenting with Granulocytosis
A 56-year-old woman was admitted to our hospital on December 22, 2002, complaining of vaginal spotting. The symptom developed initially about six months before admission. Colposcopic examination revealed a 5-cm sized cauliflower-like mass in the uterine cervix with upper vaginal invasion. A biopsy specimen was taken from the mass. Microscopically, the biopsy specimen revealed a keratinizing type invasive squamous cell carcinoma (). There was a 5.5×3.5 cm high signal intensity mass in the uterine cervix with invasion of the left parametrium and a 1 cm lymph node in the left external iliac area on MRI scan (). A chest X-ray revealed no abnormality. A blood sample showed the following findings: WBC, 12.7×103/µL (78% neutrophils, 15% lymphocytes, 6% monocytes, 1% eosinophils); RBC, 3.54×106/µL, Hb, 8.7 g/dL, Hct, 34.6%, platelets, 413×103/µL, C-reactive protein, 7.0 mg/dL, blood urea nitrogen, 13 mg/dL, creatinine, 0.6 µg/dL, alkaline phosphatase, 207 IU/mL, AST, 29 IU/mL, ALT, 8 IU/mL, and total protein, 7.4 g/dL. There was no evidence of HIV and hepatitis infection by serological studies. The radiological diagnosis was uterine cervical cancer stage IIB, but physical examination revealed a movable cervix. Consequently, she was assessed as a potential candidate for radical hysterectomy.\nConsidering potential resectability, we treated the patient with neoadjuvant chemotherapy with MVC regimen (mitomycin-C 10 mg/m2, vincristine 1.0 mg/m2 and cisplatin 70 mg/m2) every three weeks, . After two cycles of treatment, the tumor size had increased as detected by a follow-up colposcopic examination. Simultaneously, the WBC count became markedly elevated to 69,000/µL. We performed a comprehensive evaluation of the newly developed severe leukocytosis, including blood culture, bone marrow aspiration and biopsy to rule out infection and hematological malignancy. No abnormalities were found.\nThe hematological diagnosis was a granulocytic reactive marrow. There was no evidence of bone marrow involvement of malignant tumor (). Furthermore, there was no specific infection or drug intake history, including steroid and herb medication. Therefore, we considered the granulocytosis to be associated with the tumor itself. However, we could not determine the levels of G-SCF, GM-CSF, and IL-6 in serum because the patient refused these lab tests. Accordingly, we confirmed immunochemical expression of G-CSF and IL-6 by using paraffin block. Staining for G-CSF and IL-6 was mainly observed in the cytoplasm of cancer cells ().\nAfter the diagnosis of granulocytosis, we changed the treatment plan. We started external radiation for six weeks (4000 cGy), six cycles of chemotherapy with weekly cisplatin administration (40 mg/m2), and two cycles of sequential intra-cavitary radiation (ICR). After these treatments, the cervical mass was no longer seen in the follow up MRI scan (). The WBC count returned to the normal range (4,100/µL) at that time. The follow-up complete blood count profile revealed: WBC, 4,100/µL (65% neutrophils, 15% lymphocytes, 16% monocytes); RBC, 2.77×106/µL; Hb, 10.3 g/dL; and platelets, 366×103/µL.\nOne month later, a cavitary nodule was found in the left upper lobe of the lung in the chest X-ray, and a vulval mass was detected. Both lesions were confirmed pathologically as metastatic squamous cell carcinoma by percutaneous needle aspiration cytology. At that time, the WBC count became elevated again to 29,600/µL. Lastly, we changed the chemotherapy regimen to paclitaxel plus cisplatin. Over three months, four cycles of this combination chemotherapy were carried out. After four cycles of treatment, a marked increase in metastatic lung nodules was found on the follow-up chest X-ray (), with severe granuocytosis (52,700/µL). The patient refused further chemotherapy and symptomatic management. She died three months later.