A Case of Cervical Squamous Cell Carcinoma with Ambiguous Radiological Staging

Case at a Glance

A 55-year-old female with a recent biopsy-proven diagnosis of squamous cell carcinoma of the cervix presented for treatment planning. Her staging was complicated by conflicting pelvic MRI reports, causing significant distress for the patient and her family and delaying the initiation of definitive therapy.

Patient's Story

A 55-year-old woman, otherwise in good health, was recently diagnosed with cervical cancer following a workup for abnormal vaginal bleeding. The diagnosis was confirmed via cervical biopsy. The patient and her family were understandably anxious but prepared to proceed with treatment. However, their confidence was shaken when the pelvic MRI report, crucial for staging the cancer, was issued and then revised, with the changes and their implications not being clearly communicated by the initial radiological team.

Initial Assessment

The patient's initial diagnosis was established through a colposcopy-directed biopsy. The pathology report identified: 'Differentiated squamous cell carcinoma, poorly keratinizing, infiltrating, arising in a background of high-grade squamous intraepithelial lesion (HSIL/CIN III/Carcinoma in Situ).'

The Diagnostic Journey

Following the biopsy, a pelvic MRI with contrast was performed for local staging to determine tumor size, parametrial invasion, and regional lymph node status. The initial preliminary report suggested a tumor confined to the cervix. However, a subsequent, final report introduced significant ambiguity.

The family reported confusion and noted discrepancies between the reports, raising questions about the true extent of the disease. The primary concern was whether the tumor had spread beyond the cervix to the surrounding parametrial tissue or involved pelvic lymph nodes, as this would fundamentally alter the treatment approach from potential surgery to primary chemoradiation.

Faced with this uncertainty and a lack of clear explanation, the family sought a second opinion on the imaging to establish a definitive clinical stage before committing to a treatment plan. The clinical question from the consulting team was to clarify the findings of the MRI, specifically addressing tumor dimensions, parametrial status, and any suspicious lymphadenopathy.

Final Diagnosis

Cervical Squamous Cell Carcinoma. The definitive FIGO (International Federation of Gynecology and Obstetrics) stage was pending clarification of the radiological findings. The differential staging considerations based on the ambiguous reports included Stage IB vs. Stage IIB (with parametrial invasion) or Stage IIIC1 (with pelvic lymph node metastasis).

Treatment Plan

Given the diagnostic uncertainty, the immediate plan was to obtain a formal second-opinion review of the pelvic MRI by a radiologist specializing in gynecologic oncology. It was also recommended that the case be presented at a multidisciplinary tumor board meeting, including gynecologic oncologists, radiation oncologists, and radiologists.

Depending on the re-interpretation of the MRI, a PET-CT scan could be considered to provide further functional information regarding suspicious lymph nodes or distant disease, which would resolve the staging dilemma and guide the final treatment recommendation (e.g., radical hysterectomy vs. definitive chemoradiation).

Outcome and Follow-up

The case is ongoing at the time of presentation. The immediate outcome hinges on the second-opinion radiological review and the multidisciplinary team discussion. This will establish a consensus on the clinical stage, allowing for a clear, evidence-based treatment plan to be presented to the patient and her family. Follow-up will be determined by the final stage and the chosen treatment modality, involving regular clinical examinations and surveillance imaging to monitor treatment response and detect any potential recurrence.