Gastric type mucinous endocervical adenocarcinoma of the uterine cervix: very rare and interesting case

HPV-Negative Adenocarcinomas of the Uterine Cervix: From Molecular Characterization to Clinical Implications

Cervical cancer is the fourth most common cancer in women. It is the leading cause of female deaths in developing countries. Most of these cervical neoplasms are represented by squamous lesions. Cervical adenocarcinoma causes about a quarter of cervical cancers. In contrast to squamous lesions, cervical glandular disease is HPV-negative in about 15-20% of cases. HPV-negative cervical adenocarcinomas typically present in advanced stages at clinical evaluation, resulting in a poorer prognosis. The overall and disease-free survival of glandular lesions is lower than that of squamous lesions. Treatment options require definitive treatments, as fertility-sparing is not recommended. Moreover, the impact of HPV vaccination and primary HPV screening is likely to affect these lesions less; hence, the interest in this challenging topic for clinical practice. An updated review focusing on clinical and molecular characterization, prognostic factors, and therapeutic options may be helpful for properly managing such cervical lesions.

Small Cell and Other Rare Histologic Types of Cervical Cancer

PURPOSE OF REVIEW

The goal of this paper was to summarize the recent evidence on rare subtypes of cervical cancer including small-cell carcinoma of the cervix (SCCC), gastric-type adenocarcinoma, and carcinosarcoma.

RECENT FINDINGS

All three cervical cancer subtypes are aggressive with poor treatment response and high recurrence rates. Molecular studies have identified various actionable mutations in both SCCC (PIK3CA, MYC, TP53, PTEN, ARID1A, KRAS, BRCA2) and gastric-type adenocarcinoma (KRAS, ARID1A, PTEN). While there are a limited number of case reports demonstrating a favorable response for recurrent SCCC to immune checkpoint inhibitors, a larger case series failed to show benefit. The checkpoint inhibitors role in gastric-type adenocarcinoma and carcinosarcoma is yet to be determined. Ninety-one percent of SCCC cases show PARP expression, suggesting a possible role for PARP inhibitors; however, this has yet to be examined in future clinical trials. More studies are needed, with a focus on targeted therapies. The role of PARP inhibitors in SCCC is potentially promising, but significant collaboration between centers/groups will be required to achieve this.

An Unusual Presentation of a Huge Nabothian Cyst of Cervix With Manifestation of Uterine Prolapse: A Case Report

Background

Nabothian cysts are common benign cervical lesions in women of reproductive age. They usually occur due to childbirth or minor trauma; mostly are small and asymptomatic. However, huge nabothian cysts may have variable presentation and can even mimic malignancy thus, biopsy is recommended to rule out malignancy. The unusual presentation of nabothian cyst as uterine prolapse makes it a diagnostic challenge for management of the patient similar to the present case.

Case report

We report a case of a huge nabothian cyst in a perimenopausal, multiparous woman who presented with complaints of something coming out of vagina suddenly after mild heavyweight lifting and pain abdomen. Pelvic examination revealed a second degree uterine prolapse with a large lump protruding outside the vagina. Transvaginal ultrasonography demonstrated a multicystic cervical mass of size 9.5 cm × 8.0 cm arising from the posterior lip of cervix that was protruding through the vaginal canal. After excision of mass, prolapse became first degree. Histopathologic diagnosis was a cervical nabothian cyst. Patient had persisting first degree uterine prolapse along with posterior vaginal wall prolapse on subsequent postoperative follow ups. Hence, vaginal hysterectomy with repair to the vaginal wall was performed later.

Conclusion

The present case of nabothian cyst is reported for its unusual presentation as uterine prolapse. The risk factors for pelvic organ prolapse (POP) in the present case are advancing age, multiparity and perimenopausal status. The connective tissue and levator ani muscle became weak and the nabothian cyst unmasked the POP that was latent and asymptomatic by increasing the prolapse from first degree to second degree.

A rare case of gastric-type mucinous endocervical adenocarcinoma in a 59-year-old woman

INTRODUCTION

Endocervical adenocarcinoma represents 20-25% of the histological types of cervical carcinoma. Gastric-type mucinous adenocarcinoma of the cervix is a rare type of cancer with aggressive behavior. This type of malignancy is not related to high-risk human papillomavirus (HPV).

CASE REPORT

We report a 59-year-old postmenopausal woman complaining of vaginal bleeding and pelvic pain. Histological analysis of punch biopsy and endocervical curettage revealed possible endocervical mucinous adenocarcinoma, while magnetic resonance imaging (MRI) revealed a 10 × 8 cm sized cervical mass. According to oncologists, the tumor was inoperable, so the patient received 6 cycles of chemotherapeutic agents with carboplatin, paclitaxel and bevacizumab from December 2019 to March 2020. However, chemotherapy had very poor results in this patient, because the mass was increased to 24 cm in a new MRI performed after the end of chemotherapy. Finally, the patient underwent radical surgery. On histopathological examination, the surgical margin was all free from everywhere and the mass was confirmed as a gastric-type mucinous adenocarcinoma of the cervix with low differentiation.

CONCLUSION

It is very important to have an early diagnosis of gastric-type mucinous adenocarcinoma of the cervix, as this tumor is poorly symptomatic and very aggressive. When chemotherapy is not effective, radical surgery may be a solution for better survival.

Adenocarcinoma of the uterine cervix: Pathologic features, treatment options, clinical outcome and prognostic variables

Adenocarcinoma accounts for 10-25% of all cervical cancers, and its relative and absolute rate has raised over the past decades. Most, but not all the authors, reported that adenocarcinoma has a greater propensity to lymph node, ovarian and distant metastases and a worse prognosis compared with squamous cell carcinoma. However, whether histologic type is an independent prognostic factor is still a debated issue. Moreover, adenocarcinoma is a very heterogenous disease, including different histological subtypes. Whereas radical hysterectomy and definitive radiotherapy achieve the same clinical outcome in early stage squamous cell carcinoma, surgery seems to obtain better survival compared with definitive radiotherapy in early stage adenocarcinoma. Chemoradiation is the standard treatment for locally advanced cervical cancer regardless of histologic type, although several retrospective studies showed that patients with adenocarcinoma were more likely to die than those with squamous cell carcinoma both before and after concurrent chemoradiation era. The prognostic relevance of biological variables, such as cyclin-dependent kinase inhibitors, p53, cyclooxygenase-2 [COX-2], cell surface tyrosine-kinases and programmed death-ligand [PD-L1], is still under investigation. Palliative chemotherapy is the only treatment option for persistent or recurrent cervical adenocarcinoma not amenable with surgery and radiotherapy. The use of immune checkpoint inhibitors as well as a therapeutic strategy targeting cell surface tyrosine kinases should be adequately explored in this clinical setting.