In March 2007, a 59-year-old patient with 3-0-3-3 parity presented to our hospital with the chief complaint of blood tinged vaginal discharge for four to five months. The general condition of the patient was good and the physical examination and medical history were unremarkable. On gynecological examination, the uterus was the size of a woman's fist and irregularly shaped baseball sized masses were palpated in both adnexae. In the uterine cervix, a cauliflower shaped mass 4×4 cm in size was detected (Fig. 1). The cervical mass extended to the posterior vaginal wall and bled easily when touched. Routine blood testing, biochemical testing, urine analysis and electrocardiography were normal. The results of tumor marker analysis were as follows: carcinoembryonic antigen (CEA) 3.24 ng/ml, squamous cell carcinoma (SCC) 0.69 ng/ml, CA 19-9 16.9 u/ml, CA 125 44.70 U/ml, tissue polypeptide-specific antigen 70.03 I/U and Alpha-Fetoprotein 1.04 ng/ml. HPV testing performed on the cervix, revealed the presence of the HPV type 18. On MRI, the parametrium was not involved (Fig. 2A). The dilated endometrial cavity was filled with a poorly defined, cotton-ball like mass. Both adnexae showed multiseptated large ovarian cystic tumors suspected to be mucinous cystadenocarcinomas or borderline malignancies (Fig. 2B). Such findings made it difficult to determine the primary organ from which the cancer developed. We performed gastroendoscopy and colonoscopy and both were also negative. Considering the possibility of both synchronous cancer and metastatic cancer, type III radical hysterectomy with bilateral salpingo-oophorectomy, pelvic lymph node dissection and omentectomy were performed.

By macroscopic examination, the masses from the uterine cervix and the endometrium revealed a thickened papillary growth (Fig. 3A). Both ovaries were multicystic masses with cavities filled with mucin. Both fallopian tubes were hardened and expanded to 1.3 cm in diameter; a light brown papillary structure protruded toward the inner cavity during resection (Fig. 3B). Microscopically, the tumor is composed of malignant glands showing papillary, micropapillary and cribriform growth (Fig. 4). The ovarian capsule was intact other than the local infiltration. Among 25 pelvic lymph nodes, metastases were detected in 11 lymph nodes. The immunohistochemical staining performed on the uterine cervix and the ovarian mass had an identical staining pattern that was vimentin negative, CEA negative and CK7 negative. CK20 was positive in only some areas of the uterine cervix. The possibility of a primary ovarian cancer was thought to be relatively low, because despite its advanced stage there was no accompanying carcinomatous peritonei and the infiltration into the ovarian capsule was local. The possibility of uterine endometrial cancer was also assessed to be low because the endometrial lesion showed diffuse infiltration without forming a distinct mass, and the immunohistochemical findings with CEA and vimentin. Metastases from a colorectal carcinoma are usually CK20 positive, but we could not find any lesion in the colon or the rectum during operation. Nevertheless, the possibility of an ovarian cancer or metastatic cancer from remote organs could not be completely ruled out, and we needed further study to confirm the diagnosis. Finally, we evaluated the HPV status using the HPV DNA chip and demonstrated that all lesions in the uterus and the ovary were HPV 18 positive. Therefore, the patient was diagnosed with stage IV cervical adenocarcinoma with metastases. The patient is receiving combination chemotherapy with platinum and taxane.