The uterine radiation necrosis after definitive chemoirradiation - imaging and controversy, a single case report

Introduction/Background* distinguishing radiation necrosis of uterus and/or cervix from central rest/recurrence after definitive chemoradiation of locally advanced cervical cancer might be challenging, even for experienced clinicians, despite various diagnostic procedures. This is a rare condition and needs to be treated with intensive local care, while central recurrence requires specific oncological treatment with a good prognosis if operable.MethodologyWe present a woman, age 40 with severe acute lower abdominal pain, ten months after completing definitive chemoradiation of FIGO stage IIb cervical cancer, with an initially estimated complete treatment regression effect. Histologically, it was large cell nonkeratinizing HG2, NG2 planocellulare invasive carcinoma with a tumor-cervix diameter of 47 mm. Total transcutaneous (TRT) dose of 46 Gy in 25 fractions was delivered to the whole pelvis (Rapid arc planned), with 5 cycles of weekly Cisplatin-based chemotherapy (40 mg/m2) and 5 intracavitary brachytherapy applications, 1 weekly, with a dose of 7 Gy to reference point A/per application (central tube and two ovoids). After 10 months of complete regression of cancer, clinical exam, ultrasound (US), Positron emission tomography/computed tomography (PET/CT with standardized uptake value, SUV maximum 9.5) and computed tomography (CT) showed an inhomogeneous mass of the cervix, 5 cm in longitudinal dimension, propagating towards rectum, strongly suspected to recurrence. A biopsy was performed with a result of necrotic inflamed tissue.Result(s)*Due to the large scale of symptoms of inflammation, specific treatment was not conducted at the time. The patient was treated with supportive therapy, antibiotics, and intensive local care. Five months after the first symptoms, MR showed no signs of disease. The patient is scheduled for further MR control and follow-up.Conclusion*radiation necrosis must be included in consideration if the result of the biopsy is negative even if most of the diagnostic procedures point towards central recurrent disease.