Small intestine metastasis from cervical cancer with acute abdomen: A case report

Cervical cancer metastasis to the small intestine is a rare occurrence that is easily misdiagnosed as a small bowel obstruction. The present study reports the case of a 46-year-old cervical cancer patient with metastasis to the small intestine, which presented as an acute abdomen due to intestinal obstruction. Enteroscopy revealed no primary intestinal tumors. The patient underwent exploratory laparotomy and resection of the tumor of the small intestine. Pathology revealed the mass to be squamous cell carcinoma, limited to the outer muscular layer and serosa. This case demonstrates that small intestine seeding must be considered in the differential diagnosis of acute abdomen in patients with cervical cancer.


Introduction
Cervical cancer has been established as the second most common cancer among females worldwide (1,2). Cervical cancer is a serious heath problem and the majority of cases occur in developing countries (3), as no effective screening procedures are available (4). Recently, with the improvement of cervical cancer screening, the worldwide incidence and mortality of cervical cancer has decreased (5). However, the incidence of cervical cancer in young individuals worldwide has markedly increased and exhibits a poor prognosis (6,7). Patients with localized disease may be cured after definitive cancer therapy, and previous studies have indicated that surgery or radiation therapy provide an equivalent outcome (8). Patients that present with regional or distant disease are at a greater risk of mortality (9). Common metastases of cervical cancer include local extension and lymph node and pulmonary metastasis. However, metastasis to the small intestine is rare and, to the best of our knowledge, it has not been reported in the literature in the previous several decades. Small intestine metastasis from primary tumors located elsewhere in the body easily results in a missed or incorrect diagnosis, as the metastasis is frequently regarded as acute abdomen, with the main symptom of abdominal pain (10,11). The present study presents and discusses a case of cervical cancer with symptomatic small intestine metastasis.
The resection of the small intestinal tumors and ileostomy was immediately performed. A pathological diagnosis of squamous carcinoma was determined, and cancer tissue was limited to the outer muscular layer and serosa (Fig. 5). A final diagnosis of cervical cancer with small intestine metastases was determined. Postoperatively, the ileus symptoms improved and the general condition of the patient also improved. The patient was treated with four cycles of a docetaxel-cisplatin combination chemotherapy regimen (day 1, 75 mg/m 2 docetaxel; days 1-3, 25 mg/m 2 cisplatin, every 21 days). One month following chemotherapy, the patient returned to the hospital for regular follow-up appointments, which were subsequently attended every three months for two years.
Written, informed consent was obtained from the patient for the publication of the present study and the related images.

Discussion
Cervical cancer is the second most common cancer in women, being second only to breast cancer (12). The traditional treatment is radical surgery, with radiotherapy and chemotherapy predominantly used for the treatment of advanced or recurrent patients. In 2001, the National Comprehensive Cancer Network recommended cisplatin-based concurrent chemoradiotherapy as the standard treatment for advanced and high-risk early cervical cancer. Over the past decade, treatment with concurrent chemoradiotherapy has evidently prolonged the survival of patients with cervical carcinoma (13)(14)(15). However, with the improvement of survival, the patients are also at increased risk of recurrence and metastases.
When cervical carcinoma metastasizes, it usually does so via local or lymphatic dissemination. Hematogenous dissemination occurs less frequently, can spread to almost all organs and usually affects the lungs initially, followed by the bones and paraaortic, intraperitoneal and supraclavicular lymph nodes (16). Cervical cancer metastasis to the small intestine is rare, and easily misdiagnosed as it is frequently regarded as acute abdomen. According to the main diagnosis standard of metastatic small intestinal tumors (17), it must first be clear where the primary tumors are located. Secondly, the patient presents with serious clinical complications, including perforation, obstruction or hemorrhage. Thirdly, the tumor must be histopathologically confirmed and, finally, it must arise neither from direct infiltration nor abdominal metastasis. In the present case, combined with the histopathological characteristics of the patient and the history of cervical squamous cell carcinoma, the patient was finally diagnosed with squamous cell carcinoma with metastasis to the small intestine.
It is generally considered that small intestine metastasis does not easily occur, due to the intensive lymphoid tissue in intestinal wall, which can produce immunoglobulin to enhance immunity (18). It has been reported that small intestine metastasis occurs in approximately 4-10.6% of cancer cases (19). The stomach, colon and ovary are common primary tumor sites (20). Small intestinal tumors are likely to present with intussusception and intestinal obstruction with bowel stricture or expansion, and thus, surgeons must investigate the possibility of bumps close to the lesions. As metastasis from cervical cancer is considered unlikely, and the lesions are often considered to be advanced symptoms or side-effects of chemotherapy, the metastases are difficult to identify. When patients present with abdominal symptoms, including abdominal pain, nausea, vomiting, anemia and weight loss, or CT scans depict short segmental bowel-wall thickening or a polypoid mass in the small intestine in combination with regional lymphadenopathy, perforation, or intussusception, the gastrointestinal tract of the patient must be meticulously examined to enable early detection and treatment. At the present time, comparison between positron emission tomography-CT, abdominal contrast-enhanced CT and endoscopy is the most effective method for determining digestive tract metastasis (21). In the current study, the patient's condition deteriorated following chemotherapy, and this was hypothesized to be due to small intestine metastasis.
The present case indicates that if cervical cancer patients present with small intestine obstruction, small intestine metastasis must be considered in the differential diagnosis of the condition as acute abdomen.