HPV-Bağımsız Gastrik Tip Endoservikal Adenokarsinomun Multimodal Tedavisi Sonrasında Nüksü Taklit Eden Yanlış Pozitif Vajinal Kaf PET/BT Bulgusu: Bir Olgu Sunumu

Öz

Giriş: Gastrik tip endoservikal adenokarsinom (GEA), servikal adenokarsinomun nadir görülen, insan papilloma virüsünden (HPV) bağımsız bir alt tipidir ve HPV ile ilişkili olağan tip adenokarsinoma kıyasla agresif biyolojik davranışı ve olumsuz prognozu ile karakterizedir. Tümör gelişimi yüksek riskli HPV tarafından yönlendirilmediği için hastalık sitoloji ve HPV temelli taramalarla sıklıkla saptanamamakta ve daha ileri evrede tanı almaktadır. Multimodal tedavi sonrasındaki izlem de en az tanı süreci kadar güçtür; çünkü radikal cerrahi ve radyoterapi, klinik ve radyolojik olarak nükseden hastalığı taklit eden inflamatuvar, ülseratif ve fibrotik değişikliklere yol açabilmektedir. Olgu: Elli beş yaşında kadın hasta, servikal sitolojisinde ASC-H saptanması ve HPV tip 16 ile diğer yüksek riskli HPV tiplerinin pozitif bulunması üzerine değerlendirildi. LEEP ve endoservikal küretaj sonrası histopatolojik incelemede, 2,8 cm boyutunda, lenfovasküler alan invazyonu gösteren ve endoservikal rezeksiyon sınırına komşu yerleşimli, gastrik tip adenokarsinom lehine yorumlanan HPV'den bağımsız endoservikal adenokarsinom saptandı. Hastaya tip III radikal histerektomi, bilateral salpingo-ooforektomi, pelvik ve paraaortik lenf nodu değerlendirmesi, sentinel lenf nodu ultraevrelemesi, omentektomi ve apendektomi uygulandı. Nihai patolojide serviksin tüm kadranlarını tutan 2,3 cm boyutunda grade 2 gastrik tip endoservikal adenokarsinom; 10 mm kalınlığındaki serviks duvarında 9 mm stromal invazyon, lenfovasküler alan invazyonu ve alt uterin segment ile myometriyuma uzanım izlendi. Parametriyumlar, vajen kafı, uterin seroza, cerrahi sınırlar ve tüm lenf nodları negatifti; tümör pT1b2 pN0, FIGO 2018 evre IB2 olarak sınıflandırıldı. Postoperatif dönemde eksternal ışın radyoterapisi, vajinal brakiterapi ve eşzamanlı sisplatin temelli kemoterapi uygulandı. İzlemde üç ayrı seansta alınan vajen kafı biyopsilerinde malignite saptanmaksızın inflamatuvar, ülseratif, rejeneratif ve fibrotik değişiklikler gözlendi. Radikal cerrahiden yaklaşık 15 ay sonra çekilen 18F-FDG PET/BT'de, sağ vajen kafının hemen inferiorunda SUVmaks 5,8 olan yeni gelişmiş fokal hipermetabolik lezyon saptandı ve lokal nüks kaygısı doğdu. Buna karşılık aynı dönemde yapılan pelvik MRG'de vajen kafı normal izlendi. Multidisipliner değerlendirmenin ardından laparoskopik vajinektomi uygulandı; histopatolojide vajinal cerrahi sınırda aktif kronik inflamatuvar infiltrasyon gösteren erode doku ile taze ve eski kanama odakları, vajen kafı üzerinden eksize edilen dokuda ise fibrolipomatöz doku izlendi. Rezidü veya nüks malignite saptanmadı. Sonuç: Bu olgu, HPV'den bağımsız gastrik tip servikal adenokarsinomun izleminde lokal nüks ile tedavi sonrası inflamatuvar ve fibrotik değişikliklerin ayırt edilmesindeki tanısal güçlüğü ortaya koymaktadır. Daha önce radyoterapi almış hastalarda vajen kafındaki fokal FDG tutulumu, agresif alt tiplerde dahi dikkatle yorumlanmalıdır. PET/BT bulguları MRG ve önceki biyopsilerle uyumsuz olduğunda histopatolojik doğrulama özel önem taşır; doğrulanmamış bir görüntüleme temelli nüks tanısı hastayı yüksek morbiditeli kurtarma cerrahisine veya gereksiz sistemik tedaviye maruz bırakabilir.

Anahtar Kelimeler

• gastrik tip
• endoservikal adenokarsinom
• hpv-bağımsız servikal adenokarsinom
• serviks kanseri
• yanlış pozitif PET/BT
• vajinektomi
• nüks

A False-Positive Vaginal Cuff PET/CT Finding Mimicking Recurrence After Multimodal Treatment of HPV-Independent Gastric-Type Endocervical Adenocarcinoma: A Case Report

Öz

Background: Gastric-type endocervical adenocarcinoma (GEA) is a rare human papillomavirus (HPV)-independent subtype of cervical adenocarcinoma and is characterized by aggressive biological behavior and an unfavorable prognosis compared with usual HPV-associated adenocarcinoma. Because tumor development is not driven by high-risk HPV, the disease is often not detected by cytology- and HPV-based screening and is diagnosed at a more advanced stage. Surveillance following multimodal treatment is at least as challenging as the diagnostic process, because radical surgery and radiotherapy may lead to inflammatory, ulcerative, and fibrotic changes that clinically and radiologically mimic recurrent disease. Case: A 55-year-old woman was evaluated after ASC-H was detected on cervical cytology and HPV type 16 and other high-risk HPV types were found to be positive. Following LEEP and endocervical curettage, histopathological examination demonstrated a 2.8-cm HPV-independent endocervical adenocarcinoma favoring gastric-type adenocarcinoma, with lymphovascular space invasion and tumor located adjacent to the endocervical resection margin. The patient underwent type III radical hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph-node assessment, sentinel lymph-node ultrastaging, omentectomy, and appendectomy. Final pathology revealed a 2.3-cm, grade 2 gastric-type endocervical adenocarcinoma involving all cervical quadrants, with 9-mm stromal invasion within a 10-mm-thick cervical wall, lymphovascular space invasion, and extension into the lower uterine segment and myometrium. The parametria, vaginal cuff, uterine serosa, surgical margins, and all lymph nodes were negative; the tumor was classified as pT1b2 pN0, FIGO 2018 stage IB2. Postoperatively, external-beam radiotherapy, vaginal brachytherapy, and concurrent cisplatin-based chemotherapy were administered. During surveillance, vaginal cuff biopsies obtained on three separate occasions demonstrated inflammatory, ulcerative, regenerative, and fibrotic changes without malignancy. Approximately 15 months after radical surgery, ^18F-FDG PET/CT demonstrated a newly developed focal hypermetabolic lesion immediately inferior to the right vaginal cuff with an SUVmax of 5.8, raising concern for local recurrence. In contrast, pelvic MRI performed during the same period showed a normal vaginal cuff. Following multidisciplinary evaluation, laparoscopic vaginectomy was performed; histopathological examination showed eroded tissue with active chronic inflammatory infiltration and fresh and old hemorrhagic foci at the vaginal surgical margin, while the tissue excised above the vaginal cuff consisted of fibrolipomatous tissue. No residual or recurrent malignancy was identified. Conclusion: This case highlights the diagnostic difficulty of distinguishing local recurrence from post-treatment inflammatory and fibrotic changes during surveillance of HPV-independent gastric-type cervical adenocarcinoma. Focal FDG uptake at the vaginal cuff in previously irradiated patients should be interpreted cautiously, even in aggressive subtypes. Histopathological confirmation is particularly important when PET/CT findings are discordant with MRI and previous biopsies; an unverified imaging-based diagnosis of recurrence may expose the patient to highly morbid salvage surgery or unnecessary systemic therapy.

Anahtar Kelimeler

• gastric-type endocervical adenocarcinoma
• hpv-independent cervical adenocarcinoma
• cervical canser

Kaynakça

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