Metastatic squamous cell carcinoma in a patient outside the screening age: a case report

¹Federal University of Pelotas, Pelotas, Rio Grande do Sul, Brazil, ²Department of Gynecology and Obstetrics, Federal University of Pelotas, Pelotas, Rio Grande do Sul, Brazil

^&Corresponding author
Gabriel Canhete Machado, Federal University of Pelotas, Pelotas, Rio Grande do Sul, Brazil

Introduction    

Cervical cancer continues to be one of the leading causes of cancer mortality among women, particularly in developing countries where access to screening and human papillomavirus (HPV) vaccination is limited [1]. Although the Brazilian Ministry of Health recommends screening with the Pap test starting at age 25, there has been an increasing incidence of cervical carcinoma in younger women, such as the patient in this case report, who was only a 23-year-old [2]. This situation highlights a concerning trend and the need for greater awareness and investigation regarding cervical health in ages considered outside the standard screening range [3]. This case is unique as it describes the rapid progression of a cervical lesion in a young patient without a prior history of HPV-related diseases, emphasizing the importance of thorough clinical evaluation, even in patients outside the traditional screening age [4]. Additionally, the report includes surgical interventions and adjuvant therapies, which resulted in a positive response and prolonged follow-up without signs of recurrence, thus contributing to the scientific literature on the management of cervical carcinoma in young populations [5]. This case also reinforces the necessity for health education programs to promote HPV vaccination and awareness of cervical cancer symptoms, aiming for early detection [6]. Ultimately, the presentation of this case underscores the importance of primary and secondary screening strategies, as well as the urgency for an integrated approach to prevent cervical cancer, especially in young women who, as demonstrated, can be adversely affected by this disease [7].

Patient and observation     

Patient information: a 23-year-old sexually active female presented with complaints of abnormal uterine bleeding that had persisted for the past year. Her symptoms included both intermenstrual bleeding and increased menstrual flow. She had no significant past medical history, no family history of gynecological cancers, and no known genetic disorders. The patient also had no history of smoking or substance abuse. She lived with supportive family members and had undergone regular gynecological exams, including normal Pap smears, before her current symptoms. There was no previous history of significant medical interventions related to her reproductive health.

Clinical findings: upon physical examination, a visible lesion on the cervix was noted. The lesion was described as an irregular, exophytic mass measuring approximately 2 cm. During speculum examination, friable tissue was observed on the cervix. A bimanual examination revealed no adnexal masses or cervical motion tenderness; the remaining physical findings were unremarkable.

Timeline of current episode: the patient's abnormal uterine bleeding began 12 months before her presentation. Six months prior, she sought medical advice and was referred for a gynecological evaluation. Three months before the current encounter, a Pap smear and cervical biopsy were performed, diagnosing her with a high-grade squamous intraepithelial lesion (HSIL). One month prior, she underwent cervical conization, which revealed invasive squamous cell carcinoma, initially staged as pT1b1. During a planned surgical intervention, lymph node metastasis was detected, leading to an updated staging of IIIC1.

Diagnostic assessment: initial diagnostic testing included a Pap smear, which indicated a high-grade squamous intraepithelial lesion (HSIL), and a cervical biopsy that confirmed invasive squamous cell carcinoma. Imaging studies, including an MRI of the pelvis, were performed to assess the extent of the disease and determine lymph node involvement. Financial constraints delayed access to specialized imaging, which contributed to a slight delay in diagnosis. Despite this, the diagnostic workup eventually confirmed advanced cervical cancer.

Diagnosis: the final diagnosis was cervical squamous cell carcinoma, staged as IIIC1, based on both biopsy results and intraoperative findings. Initially, the diagnosis was stage pT1b1, but the discovery of lymph node metastasis during surgery led to a revised staging. Other possible diagnoses, such as cervical dysplasia and benign cervical polyp, were considered but ruled out through biopsy and imaging studies. The prognosis for the patient emphasized curative intent, and treatment plans included both chemotherapy and radiotherapy.

Therapeutic interventions: the patient underwent cervical conization as the initial surgical intervention, followed by a planned radical trachelectomy. However, intraoperative findings of lymph node metastasis prompted a change in the treatment plan, which included ovarian suspension and the preparation for adjuvant therapy. Chemotherapy was administered with cisplatin, dosed at 75 mg/m² intravenously every three weeks. Radiotherapy was also part of the treatment regimen, consisting of 45 Gy in 25 fractions to the pelvis, followed by brachytherapy. The therapeutic goal was to achieve a complete curative response.

Follow-up and outcome of interventions: the patient tolerated chemotherapy and radiotherapy well, without experiencing significant acute adverse effects. At the three-year follow-up, imaging studies (CT scans) confirmed a complete response to therapy. The patient adhered to the treatment protocol, attending all follow-up visits as scheduled, and there were no reports of significant adverse events. Her overall outcome was favorable, and regular follow-up assessments continued to demonstrate sustained remission.

Patient perspective: the patient expressed profound gratitude for her timely diagnosis and effective treatment. She initially experienced fear and uncertainty, particularly given her young age and the seriousness of her diagnosis. However, throughout the treatment process, she felt supported by both her healthcare team and her family. The patient emphasized her desire to raise awareness about cervical health among young women, urging them to pay attention to early symptoms and seek prompt medical evaluation when abnormalities arise.

Informed consent: informed consent was obtained from the patient for all diagnostic procedures, including biopsies, surgeries, and treatment plans. The patient was fully informed about the details of the procedures, the associated risks, and the potential benefits. All information was communicated thoroughly to ensure the patient understood her diagnosis and the available treatment options, and she actively participated in decisions regarding her care.

Discussion     

This case report presents a rare instance of cervical squamous cell carcinoma in a young woman outside the recommended screening age, contributing to the existing literature on cervical cancer incidence in younger populations. Cervical cancer, primarily caused by persistent infection with oncogenic strains of human papillomavirus (HPV), is usually diagnosed in women aged 25 and older, following the guidelines set forth by health organizations. The patient's age and the diagnosis of invasive cancer highlight significant strengths and limitations relevant to this case. One of the strengths of this case is the prompt diagnosis and initiation of treatment, which is critical for improving outcomes in cervical cancer. Early identification of abnormal cervical changes through careful evaluation of abnormal bleeding allowed for timely intervention, which is essential given that early-stage cervical cancer can be successfully managed with surgical procedures such as conization or trachelectomy. Additionally, the thorough investigation of lymph node involvement during the surgical procedure underscored the importance of accurate staging in determining prognosis and treatment strategies [8].

However, there are notable limitations associated with this case. The patient´s young age raises questions about the adequacy of screening protocols and public awareness regarding cervical cancer symptoms in younger women. Furthermore, access to healthcare resources, including timely imaging and specialist consultations, may have influenced the diagnosis and treatment timeline, emphasizing systemic barriers in healthcare. The rarity of this presentation means that similar cases may not be well-documented, limiting the ability to draw broad conclusions or establish comprehensive treatment guidelines for young patients [9]. Relevant literature indicates that HPV vaccination can significantly reduce the incidence of cervical cancer and precursors in young women. However, despite increased vaccination rates, cervical cancer cases continue to be reported in populations outside the traditional screening age, suggesting that ongoing education and awareness campaigns are necessary. Additionally, this case serves as a reminder that abnormal vaginal bleeding in younger women should be taken seriously, necessitating further investigation rather than attributing symptoms to benign causes [10]. In conclusion, this case emphasizes the need for heightened awareness of cervical cancer among healthcare providers and the importance of considering cervical cancer in young patients presenting with relevant symptoms. Continued research and discussion are essential to better understand the epidemiology of cervical cancer in younger women, particularly regarding risk factors, screening strategies, and the impact of HPV vaccination programs.

Conclusion     

This case report highlights the importance of recognizing cervical cancer as a potential diagnosis in younger women, even those outside the traditional screening age. It underscores the necessity for healthcare providers to remain vigilant about abnormal symptoms, such as unusual vaginal bleeding, regardless of the patient´s age. Timely diagnosis and intervention are crucial for improving outcomes, particularly in cases where early-stage cervical cancer is identified. Additionally, this case emphasizes the need for enhanced public awareness and education regarding cervical cancer and its symptoms, alongside the continued promotion of HPV vaccination to prevent cervical cancer and its precursors. Ultimately, it serves as a reminder of the complexities involved in diagnosing and treating cervical cancer in younger patients, necessitating a comprehensive and proactive approach in clinical practice.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Gabriel Canhete Machado: wrote the article, performed the literature review, and coordinated the submission process. Ana Carolina Fernandes Dala Riva: Contributed to the clinical management of the patient, provided critical insights during the case discussion, and reviewed the manuscript for important intellectual content. Bruna Mariah Martins Batista Lopes: assisted in the collection of patient data, contributed to the analysis of clinical findings, and helped revise the manuscript for clarity and coherence. Luísa de Oliveira e Silva: contributed to the manuscript revision process, assisted in the collection of patient data, and contributed to the analysis of clinical findings. Glaucia Alves de Carvalho: Conceived the study, provided expertise in gynecology and obstetrics, facilitated discussions on treatment outcomes, and reviewed the manuscript for scientific accuracy and relevance. All the authors have read and agreed to the final manuscript.

References