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Should Biopsy Be Repeated To Obtain A More Definitive Diagnosis For Cancer?
Question: I am a US physician (internal medicine), and I have a question about my 37F cousin who was recently diagnosed with cancer of her vagina/cervix. She had been experiencing 1 mo of pelvic pain and was found on ultrasound to have fibroids. On a subsequent physical examination, she was found to have palpable masses in her vagina (anterior, posterior and both fornix), as well as the parametrium.
She then underwent surgery to remove a large fibroid as well as to obtain a biopsy of the suspicious area. The biopsy revealed "infiltrates of poorly differentiated carcinoma, more of squamoid nature, further assessment advised." She then underwent MRI which showed a "Inhomogeneous lobulated T2W heterogeneously hypertintense, T1W hypo-to-isointense lesion at distal body and cervix encroaching into endometrial cavity with irregular stranding and thickening of the bilateral parametrial fat planes. There was also a mild degree of bilateral internal iliac lymphadenopathy" Based on this, she was given a diagnosis of stage IIIB cervical cancer. However, this seems hard to believe since her hymen was intact on physical exam, and we do not believe she has been sexually active before.
1) What is the full differential of what her cancer could be (besides cervical cancer)? I ask this because we do not think she has been sexually active, and the pathology seems to be somewhat ambiguous. The oncologist said that the sample obtained may not have been optimal. For example, could vaginal cancer be a possibility here?
2) Is it worth it to get a repeat biopsy to obtain a more definitive diagnosis? If a repeat biopsy is obtained, is there a risk of seeding the tissue bed further with tumor? I know that this is the case with certain cancers.
3) Her oncologist is advising concurrent chemoradiation 40 mg/m2 cisplatin weekly + XRT at 5000 cGy in 25 fractions, followed by vaginal brachytherapy. This treatment presumes that this is cervical cancer. Do you think she should start her treatment immediately, or should she wait for more definitive pathology? For other cancers on the differential (ie vaginal), would the treatment be much different?
4) We would like to get a PET CT for full staging, but she will have to travel to a different city (Hyderabad) to get this done. Should she start treatment now and then get the PET-CT, or should she delay the treatment until the PET/CT results can be obtained? The question here is whether the treatment plan would be significantly altered.
5) Is there any situation in which surgery might be considered?
She then underwent surgery to remove a large fibroid as well as to obtain a biopsy of the suspicious area. The biopsy revealed "infiltrates of poorly differentiated carcinoma, more of squamoid nature, further assessment advised." She then underwent MRI which showed a "Inhomogeneous lobulated T2W heterogeneously hypertintense, T1W hypo-to-isointense lesion at distal body and cervix encroaching into endometrial cavity with irregular stranding and thickening of the bilateral parametrial fat planes. There was also a mild degree of bilateral internal iliac lymphadenopathy" Based on this, she was given a diagnosis of stage IIIB cervical cancer. However, this seems hard to believe since her hymen was intact on physical exam, and we do not believe she has been sexually active before.
1) What is the full differential of what her cancer could be (besides cervical cancer)? I ask this because we do not think she has been sexually active, and the pathology seems to be somewhat ambiguous. The oncologist said that the sample obtained may not have been optimal. For example, could vaginal cancer be a possibility here?
2) Is it worth it to get a repeat biopsy to obtain a more definitive diagnosis? If a repeat biopsy is obtained, is there a risk of seeding the tissue bed further with tumor? I know that this is the case with certain cancers.
3) Her oncologist is advising concurrent chemoradiation 40 mg/m2 cisplatin weekly + XRT at 5000 cGy in 25 fractions, followed by vaginal brachytherapy. This treatment presumes that this is cervical cancer. Do you think she should start her treatment immediately, or should she wait for more definitive pathology? For other cancers on the differential (ie vaginal), would the treatment be much different?
4) We would like to get a PET CT for full staging, but she will have to travel to a different city (Hyderabad) to get this done. Should she start treatment now and then get the PET-CT, or should she delay the treatment until the PET/CT results can be obtained? The question here is whether the treatment plan would be significantly altered.
5) Is there any situation in which surgery might be considered?
Brief Answer:
Confirm diagnosis by second opinion and IHC
Detailed Answer:
Dear sir,
1]The histopathology report undifferentiated type with squamoid differentiation.As she is aged only 37 years this may be a rare variety of tumor.Because we often see tumors like Mixed mullerian tumor,neuroendocrine tumors etc.SO please take second opinion of biopsy,also immunohistochemistry may help.
2]repeat biopsy may help.Biopsy may not lead to further seeding as it is already stage IIIB disease.
3]The suggested treatment is correct if it is ca.cervix or vagina.If the diagnosis is different treatment may differ depending on histopathology.
4]Ideally treatment should start after confirming histopathological diagnosis and do PET CT before starting any treatment.
Confirm diagnosis by second opinion and IHC
Detailed Answer:
Dear sir,
1]The histopathology report undifferentiated type with squamoid differentiation.As she is aged only 37 years this may be a rare variety of tumor.Because we often see tumors like Mixed mullerian tumor,neuroendocrine tumors etc.SO please take second opinion of biopsy,also immunohistochemistry may help.
2]repeat biopsy may help.Biopsy may not lead to further seeding as it is already stage IIIB disease.
3]The suggested treatment is correct if it is ca.cervix or vagina.If the diagnosis is different treatment may differ depending on histopathology.
4]Ideally treatment should start after confirming histopathological diagnosis and do PET CT before starting any treatment.
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Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
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