A 47 y.o. woman with a hx of dm, ht, and cervical cancer sp chemo and RT presents with diplopia

The patient has been seen in the ED 6 times in two months with R facial pain and has had multiple dental extractions.

what do you notice on her MRI?

Our patient had metastatic cervical cancer which invaded the bone of the sphenoid wing causing a fifth and sixth nerve palsy.  Cervical cancers only rarely metastasize outside the pelvis but have been shown to metastasize to lymph nodes, lung, liver and bone when they do.  Nearly 70% of cervical cancers that metastasize have only one site of metastasis and the majority(37.9%) occur in the lungs.

Cervical cancer is the fourth most common cancer in women globally with 242,000 deaths in 2020.  It is most common in developing countries. In developing countries, the public health  goal is to screen women in their 30s and 40s for precancerous lesions. The current recommendation is to screen every 3 years  in women ages 30-65. 

World map

The Pap smear (Papanicolaou)  was invented in the 1920s by Georgios Papanikolaou a Greek physician and consists of removing a sample of cells from the transformation zone of the outer opening of the cervix and examining the cells for malignant transformation.  It is still recommended for women who have received the HPV vaccine.

Almost all cervical cancers are caused by human papillomavirus  (HPV) which is sexually transmitted . Since  HPV vaccination was first recommended in 2006, infections in the US h dropped 88% among teen girls and  81% among young adult women. In developing countries less than 25%  of low income countries have done so.

Treatment of cervical cancer consists of surgery, radiation and chemotherapy.

Our patient had a frontal temporal craniotomy with biopsy and partial resection of a mass that extended into the cavernous sinus on the R. The bone biopsy showed tumor, squamous cell type, consistent with the previous cervical cancer. She has persistent double vision and facial pain and will be followed by oncology for further treatment.

TAKE HOME POINT

This patient was seen multiple times over several months with each provider assuming she had a dental infection and tooth pain. Beware of a previous diagnosis causing anchoring bias.

Zhou S, Peng F. Patterns of metastases in cervical cancer: a population-based study.  Int J Clin Exp Pathol 2020;13(7):1615-1623.

Quinn MA, Benedet JL, Odicino F, Maisonneuve P, Beller U, Creasman WT, Heintz AP, Ngan HY, Pecorelli S. Carcinoma of the cervix uteri. FIGO 26th annual peport on the results of treatment in gynecological cancer. Int J Gynaecol Obstet. 2006;95(Suppl 1):S43–S103. 

Sherris J, Herdman C, Elias C.  Cervical cancer in the developing world. West J Med 2001 Oct;175(4):231-233. 

Singh D, Vignat J, Lorenzoni V, et al. Global estimates of incidence and mortality of cervical cancer in 2020: a baseline analysis of the WHO