Metastatic Cervical Cancer With Ureter Obstruction Case File

Metastatic Cervical Cancer With Ureter Obstruction Case File

Eugene C. Toy, MD, Lawrence M. Ross, MD, PhD, Han Zhang, MD, Cristo Papasakelariou, MD, FACOG

CASE 29

A 50-year-old female who has borne five children complains that she has noticed vaginal spotting of blood after intercourse for approximately the past 6 months. More recently, she has had a foul-smelling vaginal discharge and indicates that her left leg seems larger than her right one. She previously had syphilis. She has smoked one pack of cigarettes per day for 20 years. Examination of her back shows left flank tenderness. The circumferences of her left thigh and calf are larger than those of the right. Pelvic examination shows normal female external genitalia and a 3-cm growth on the surface on the left lip of the uterine cervix.

⯈ What is the most likely diagnosis?

⯈ What is the applied clinical anatomy for this condition?

ANSWER TO CASE 29:

Metastatic Cervical Cancer with Ureter Obstruction

Summary: A 50-year-old female who has borne five children complains of a 6-month history of spotting after intercourse and foul-smelling vaginal discharge. She has had syphilis and is a smoker. Left costovertebral tenderness is present, and the left lower limb is swollen. Speculum examination of the uterine cervix shows a 3-cm growth of the left lip of the cervix.

• Most likely diagnosis: Metastatic cervical cancer

• Applied anatomy for this condition: Extension of the tumor to obstruct the left ureter and metastasis to iliac lymph nodes

CLINICAL CORRELATION

This patient’s age, multiple pregnancies, and histories of smoking and a sexually transmitted disease are risk factors for cervical cancer. Vaginal spotting after intercourse is a common presenting sign for cervical cancer in a sexually active woman. Cervical cancer typically arises at the squamocolumnar epithelial junction, and the foul-smelling discharge suggests necrosis of a portion of this large tumor. Such a tumor can spread inferiorly to involve the vagina or laterally into the region of the transverse cervical (cardinal) ligament and can obstruct the ureter, which passes through the ligament. Further growth may reach the lateral pelvic wall. Involvement of iliac lymph nodes, in particular the external iliac nodes, may inhibit lymphatic drainage of the lower limb with resultant edema. Bilateral ureteral obstruction can lead to uremia, the most common cause of death in this disease. Radiotherapy is the primary treatment for advanced cervical cancer.

APPROACH TO:

The Internal Female Genital System I

OBJECTIVES

1. Be able to describe the anatomy of the ovaries, uterine tubes, uterus, and upper vagina, including changes in their epithelial lining

2. Be able to describe the anatomy of the lateral uterine support structures and

related organs 3. Be able to draw the lymphatic drainage of the uterus and upper vagina

DEFINITIONS

POSTCOITAL SPOTTING: Vaginal bleeding after sexual intercourse, usually due to friable cervical tissue, that may be a sign of cervical inflammation or cancer

CERVICAL DYSPLASIA: Premalignant condition of the cervical epithelium usually induced by human papilloma virus, which over time may evolve into cervical cancer

CERVICAL CYTOLOGY: Method of studying cells obtained by scrapings from the cervix

COLPOSCOPIC EXAMINATION: Method of visually examining the cervix with a binocular magnifying device, usually with the addition of acetic acid to locate areas of cervical dysplasia

DISCUSSION

The uterus or womb is a thick-walled, hollow, pear-shaped, pelvic organ. Its main parts are the body and cervix. The fundus is the superior portion of the body between the openings of the uterine tubes, and the isthmus is the narrowed inferior portion of the body at its junction with the cervix. The narrow uterine cervix protrudes into the anterior wall of the upper vagina. The lumen of the cervix is the cervical canal; its superior part opens into the uterine cavity as the internal os, and its inferior part opens into the vagina as the external os. The uterus is usually angled anteriorly in relation to the vagina, or anteverted, and the body and cervix of the uterus are flexed anteriorly with respect to each other, or anteflexed. This places the body of the uterus superior to the urinary bladder, often deforming it on cystograms. Posterior to the cervix is the rectum. The vagina, a tubular structure that is closed anteroposteriorly, begins at the vestibule and is directed posterosuperiorly to the level of the cervix. The protrusion of the cervix into the anterior wall of the vagina creates a circumferential gutter around the cervix, which, although a continuous space, is typically referred to as the anterior, posterior, or lateral fornix. The urethra is embedded in the anterior wall of the vagina. The columnar epithelium, which lines the uterine cavity and cervical canal, changes to a nonkeratinized stratified squamous epithelium at the margins of the external os. This type of epithelium covers the external surface of the cervix and lines the vagina (Figure 29-1).

The uterine (fallopian) tubes extend posterolaterally from the superolateral region of the uterus, the uterine horns. The uterine tubes are divided, from medial to lateral, into four regions: a uterine or intramural portion within the wall of the uterus, the narrowest portion or isthmus, the widest portion or ampulla, and the funnel-shaped infundibulum. The lumen of the infundibulum opens into the abdominal cavity, and its margin is arranged in a series of finger-like structures called fimbriae, one of which is usually attached to the ovary. The female gonads, the ovaries, lie close to the lateral pelvic wall, just inferior to the pelvic brim. Each almond-shaped ovary is supported by a suspensory (infundibulopelvic) ligament, which consists of the peritoneally covered ovarian vessels, an ovarian ligament, a derivative of the proximal portion of the embryonic gubernaculum, and the mesovarium portion of the broad ligament.

The uterus, uterine tubes, and ovary are draped by a mesentery, the broad ligament, which passes from the sides of the uterus to the lateral pelvic wall to divide the pelvic cavity into anterior and posterior compartments. The broad ligament has three subdivisions: a shelflike portion derived from the posterior layer of the broad

Figure 29-1. Frontal section of the uterus and vagina. (Reproduced, with permission, from Lindner HH. Clinical Anatomy. East Norwalk, CT: Appleton & Lange, 1989:514.)

ligament that attaches to the ovary, called the mesovarium; the portion of the broad ligament superior to the mesovarium that attaches to the uterine tube, called the mesosalpinx; and the portion from the uterus to the lateral pelvic wall, called the mesometrium. The continuation of peritoneum from the anterior surface of the uterus onto the anterior placed urinary bladder creates the uterovesicular pouch. Similarly, the continuation of peritoneum from the posterior uterine surface onto the anterior surface of the rectum creates the rectouterine pouch (of Douglas), the most inferior recess of the abdominopelvic cavity in the female.

The uterus and uterine tubes are covered with a layer of visceral peritoneum, but the ovary is not; it is covered instead by a cuboidal germinal epithelium. The ovarian ligament is a cordlike structure between the layers of the mesovarium that extends from the uterine pole of the ovary to the uterine horn. Its continuation anteriorly to and through the deep inguinal ring and inguinal canal to the labia majora is the round ligament of the uterus (also derived from the gubernaculum). Beneath the peritoneum of the pelvic floor, paired condensations of connective tissue, the uterosacral ligaments, pass from the uterine cervix to the sacrum. An additional pair of condensation passes from the cervix to the lateral pelvic wall, the transverse cervical (cardinal) ligaments. The transverse cervical ligaments lie in the base of the mesometrium, and the uterine vessels lie within or very close to these ligaments. The ureters coursing anteromedially on their way to the urinary bladder pass inferiorly to the uterine vessels (mnemonic: “water under the bridge”) and continue anteriorly, approximately 2 cm laterally to the uterine cervix.

The blood supply to the uterus consists primarily of the paired uterine arteries and the ovarian arteries. The uterine arteries arise from the internal iliac arteries and traverse through the transverse cervical (cardinal) ligaments. The fundus (top) of the uterus is supplied mainly by the ovarian arteries, which arise from the abdominal aorta. Lymphatic drainage from the fundus and body of the uterus is to the lumbar abdominal nodes and the external iliac nodes. The cervical lymph drainage is primarily to external iliac nodes, but some lymph drains to internal iliac and sacral nodes. Drainage from the upper vagina is similar to that of the cervix, to the external and internal iliac lymph nodes.

COMPREHENSION QUESTIONS

29.1 A 31-year-old woman is in her physician’s office for a fitting for an intrauterine contraceptive device. The physician performs a pelvic examination to ensure that the device is placed in the correct direction. The physical examination shows that the uterine body is tipped toward the rectum and that the uterine fundus is tipped anteriorly. Which of the following describes the position of the uterus?

A. Anteverted, anteflexed

B. Anteverted, retroflexed

C. Retroverted, anteflexed

D. Retroverted, retroflexed

29.2 A 45-year-old woman is having significant uterine bleeding from uterine fibroids. The radiologist performs an embolization procedure of the uterine arteries. Through which of the following structures do the uterine arteries traverse?

A. Transverse cervical (cardinal) ligaments

B. Uterosacral ligaments

C. Vesicouterine fold

D. Anterior vaginal fornix

29.3 A 20-gauge spinal needle is placed through the vagina to assess whether there is blood in the peritoneal cavity. Which of the following describes the most dependent part of the peritoneum or pelvis?

A. Vesicouterine fold

B. Pararectal space

C. Paravesical space

D. Rectouterine pouch (of Douglas)

29.4 A 42-year-old woman is undergoing a total abdominal hysterectomy due to leiomyomata of the uterus that has caused significant abnormal vaginal bleeding. During the surgery, the surgeon locates the left ureter to ensure its safety prior to clamping the uterine artery. The ureter is found at the pelvic brim. In this area, the left ureter is located immediately lateral to the

A. Left ovarian vein

B. Left external iliac artery

C. Abdominal aorta

D. Left internal iliac artery

E. Left uterine artery

F. Left renal artery

ANSWERS

29.1 C. “Version” refers to the relation between the cervix and uterine body, whereas “flexion” denotes the relation between the uterine body and the uterine fundus (top). Thus, this uterus is retroverted and anteflexed.

29.2 A. The uterine arteries travel through the transverse cervical ligaments.

29.3 D. The most dependent region of the pelvis is the rectouterine pouch of Douglas. The procedure described is called a culdocentesis, in which the spinal needle is placed through the posterior vaginal fornix.

29.4 D. One of the key surgical anatomical landmarks for the ureter is at the pelvic brim, in which the ureter crosses medially at the bifurcation of the common iliac artery. At this location, the ureter is medial to the ovarian vessels and lateral to the internal iliac artery and vein. From this location, the ureters travel more medially, under the uterine artery, to the bladder.

ANATOMY PEARL

⯈ The posterior vaginal fornix is in close relation to the rectouterine pouch (of Douglas), the most inferior portion of the abdominopelvic cavity in the female.

⯈ The suspensory ligament of the ovary contains the ovarian vessels.

⯈ After passing inferiorly to the uterine vessels, the ureters course medially and lie approximately 2 cm laterally to the uterine cervix.

⯈ Lymph from the uterine cervix and upper vagina drains primarily to the external iliac node group.

References

Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy, 2nd ed. New York, NY: Thieme Medical Publishers; 2012:237, 240, 243, 245. 

Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy, 7th ed. Baltimore, MD: Lippincott Williams & Wilkins, 2014:385−389, 395. 

Netter FH. Atlas of Human Anatomy, 6th ed. Philadelphia, PA: Saunders; 2014: plates 340−342, 346, 352.

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