Recurrent carcinoma cervix presenting as metastatic splenomegaly: ¹⁸F-FDG PET/CT findings in a rare scenario

Sir,

Cervical cancer is the leading gynecological cancer in India.[1] Nodes are the commonest site of metastasis followed by lungs.[2] Splenic metastasis from cervical cancer is very rare.[3] We present such a case where recurrent carcinoma cervix presented as metastatic splenomegaly. A 52-year-old lady diagnosed to have carcinoma cervix stage IIIB had undergone radical hysterectomy followed by pelvic radiotherapy. She was on routine follow up. Three-years later she presented with pain and heaviness in left hypochondrium. Physical examination revealed massive splenomegaly. Pelvic examination was within normal limits. She underwent contrast-enhanced ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) whole body positron emission tomography/computed tomography (PET/CT) because of suspicion of metastasis. PET/CT revealed heterogeneously enhancing ¹⁸F-FDG avid splenomegaly [Figure 1a, e-g]. In addition, metastasis was also noted in the pancreas [Figure 1a, h-j] and left supraclavicular node [Figure 1a, k-m]. No local recurrence or any abdominopelvic nodal metastasis was seen [Figure 1a-d]. Because splenic metastasis from carcinoma cervix is very rare, fine-needle aspiration cytology (FNAC) was performed from the splenic mass. FNAC revealed metastatic squamous cell carcinoma. She was started on chemotherapy (carboplatin and paclitaxel) but died of progressive disease 4-months later.

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Figure 1 Maximum intensity projection PET image (a) showing abnormal ¹⁸F-FDG accumulation in left hypochondrium (arrows), mid abdomen (broken arrow), and left lower neck (arrowhead). No local recurrent disease was seen (b-d). Axial contrast CT (e), PET (f), and PET/CT (g) images reveal massive solid cystic splenomegaly (arrows) with heterogeneous enhancement and irregularly increased ¹⁸F-FDG uptake (SUVmax-7.9). The splenic lesion is also infiltrating the tail of pancreas. Another enhancing ¹⁸F-FDG avid (SUVmax-4.1) mass at junction of head and body of pancreas (h-j, broken arrow) was seen. Also noted was enlarged ¹⁸F-FDG avid (SUVmax-3.1) left supraclavicular lymphadenopathy (k-m, arrowhead) PET = positron emission tomography, ¹⁸F-FDG = ¹⁸F-fluorodeoxyglucose, CT = Computed tomography, SUV = Standardized uptake value.

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Splenic metastasis from carcinoma cervix is extremely rare.[4] Less than 100 cases of solitary splenic metastases have been reported with half of them being metastases from the female genital tract malignancies: 30 ovarian carcinoma, 11 endometrial carcinoma, eight cervical carcinoma, and one tubal carcinoma.[3] Goktolga et al.,[4] reported a case of a 45-year-old lady, postoperative case of carcinoma cervix who presented with splenic metastasis. Pang et al.,[5] reported a case of recurrent carcinoma cervix presenting with splenic metastasis and successfully treated with laparoscopic splenectomy and chemotherapy. Campagnutta et al.,[6] also reported isolated splenic metastasis in a postoperative patient of carcinoma cervix. Splenic metastasis can rarely present as painful splenomegaly[7] as in the present case. To the best of our knowledge, there is no published report showing ¹⁸F-FDG PET/CT findings in metastatic splenomegaly from cervical cancer. In the present case, ¹⁸F-FDG PET/CT confirmed the suspicion of metastasis to spleen, a rare site. In addition, it demonstrated previously unknown metastasis to pancreas and supraclavicular node. The current case further highlights the importance of ¹⁸F-FDG PET/CT in restaging of cervical cancer.