Case Introduction

Cervical space-occupying lesions are common in gynecological practice, and the pathological diagnosis directly determines the treatment direction. While cervical cancer and cervical lymphoma may overlap in clinical presentation and imaging characteristics, their pathological nature, treatment principles, and prognosis differ profoundly. Cervical cancer is managed with surgery combined with chemoradiotherapy, whereas cervical lymphoma is treated with chemotherapy-based comprehensive regimens. A misdiagnosis at the outset can lead to catastrophic treatment errors and severely compromise outcomes. This case illustrates how Arion's MDT approach, leveraging advanced ultrasound diagnostics and guided biopsy, avoided unnecessary surgery and delivered the correct treatment — leading to clinical cure.

I. Case Overview: Baseline and Core Challenges

Baseline Status

A 53-year-old woman presented with irregular menstruation for 2 months. External hospital ultrasound revealed a cervical mass, and MRI further delineated a cervical lesion measuring 8.0 × 5.7 × 4.3 cm, considered malignant. The mass invaded the uterine body, upper vaginal segment, and left parametrial tissue; lymph nodes in the presacral region and bilateral iliac vascular zones were suspected metastatic; small bilateral inguinal lymph nodes were also considered possible metastasis. Tumor markers were all within normal range. TCT showed atypical squamous cells of undetermined significance (ASC-US) with mild inflammation. HPV testing was entirely negative.

Physical examination: cervical surface relatively smooth, 4–5 cm in diameter, firm in consistency, involving the vaginal fornix at 7–9 o'clock positions. Parametria negative; uterine body involved. The patient had no significant prior medical history.

Core Challenges

Diagnostic dilemma: A cervical mass was found, malignant in appearance, but existing pathology could not establish a definitive histological type.

Patient dilemma: Without a clear diagnosis, treatment direction was ambiguous and the care pathway had stalled.

Therapeutic dilemma: In the absence of a definitive pathological diagnosis, no precise treatment plan could be formulated.

II. Decision-Making: MDT Core Analysis and Strategy Deliberation

The multidisciplinary team conducted a comprehensive evaluation: imaging strongly suggested a malignant cervical lesion, but the existing pathological results were insufficient to characterize the lesion. The team postulated that the initial biopsy may have been superficial or missed the cell-rich core. The key to resolving this case lay in obtaining a definitive pathological diagnosis.

Further evaluation — MRI or ultrasound? Repeat pathology — radiology/interventional or ultrasound-guided? After deliberation, the team decided on a two-pronged approach: a senior ultrasound physician would re-evaluate the cervical lesion and parametrial involvement, while simultaneously leveraging the advantages of ultrasound-guided biopsy — its safety and targeted precision — to maximize the success rate of pathological sampling.

III. The Breakthrough: Ultrasound Re-Evaluation and Guided Biopsy

Ultrasound Re-Assessment

The cervix was markedly enlarged, with the parenchyma showing diffuse hypoechoic texture in a conglomerate pattern, measuring approximately 5.6 × 7.0 × 4.0 cm overall, with poorly defined borders. Multiple confluent hypoechoic areas were present, involving the posterior fornix and upper vaginal wall, with the outermost margin extending to the parametrial tissue. The cervical canal wall remained clearly visible with relatively preserved continuity; the cervical canal was separated, with a maximum width of 0.6 cm.

Color Doppler flow imaging (CDFI) revealed abundant "flower-like" blood flow signals within the hypoechoic areas. Pulsed wave (PW) Doppler measured arterial flow spectrum: PI 0.51, RI 0.38.

Based on these ultrasound features, the diagnostic impression was: cervical lymphoma highly probable; cervical carcinoma to be excluded. Recommendation: puncture biopsy for pathological confirmation.

Biopsy Pathology Results

Transvaginal ultrasound-guided biopsy of the cervical lesion yielded the following:

Diagnosis: Non-Hodgkin diffuse large B-cell lymphoma, NOS, GCB type. The tissue showed medium-to-large atypical lymphocytes diffusely infiltrating. The immunohistochemical panel was as follows:

This profile confirmed a Germinal Center B-cell (GCB) type DLBCL, NOS — a completely different therapeutic entity from cervical carcinoma.

IV. Treatment and Outcome

After initial presentation to the gynecology department, the patient had been trapped in a diagnostic deadlock. The MDT collaborative model broke through single-disciplinary limitations. Through multidisciplinary evaluation, the team selected the least invasive ultrasound-guided biopsy approach, successfully establishing a definitive pathological diagnosis.

Once the diagnosis was confirmed as lymphoma, the patient was transferred to the lymphoma department for targeted treatment. Ultrasound not only provided the critical imaging evidence for diagnosis but also played an irreplaceable role in the biopsy sampling process.

The patient received rituximab-based therapy for 6 months and was clinically assessed as achieving clinical cure (complete response). She was discharged from active treatment and entered the surveillance phase. Follow-up ultrasound showed no abnormal sonographic findings.

V. Case Insights

Diagnostic Thinking

Although cervical lymphoma and cervical cancer share some overlapping ultrasound features, this case demonstrated several key distinguishing characteristics: a 7-cm non-exophytic cervical mass with preserved normal cervical canal echogenicity, which explained why the initial TCT yielded only ASC-US. In clinical practice, clinicians must break free from the single-track assumption that "cervical mass equals cervical cancer" and broaden differential diagnostic thinking by integrating ultrasound features — such as diffuse hypoechoic texture, abundant flower-like blood flow, and cervical canal integrity.

MDT Collaborative Model

This MDT practice, through multidisciplinary synergistic effort, effectively prevented the patient from undergoing unnecessary surgery. Under the premise of minimal invasiveness, precision diagnosis and effective treatment were achieved, ultimately leading to clinical cure. This case fully embodies the core value of the MDT model in the management of complex diseases.

Expert Commentary

Prof. Wu Ming

Department of Gynecology, Peking Union Medical College Hospital (PUMCH)

Pathological diagnosis of cervical masses is the key to all subsequent treatment. For exophytic tumors, the diagnosis is usually straightforward. However, for endophytic (intrinsic) lesions, establishing a definitive diagnosis is relatively difficult, primarily because tissue sampling is inadequate. Sometimes repeated cervical cone biopsies are required, and in rare cases a hysterectomy may be performed solely to obtain a diagnostic specimen.

The MDT model opens up new diagnostic pathways and offers more precise and less invasive approaches. Ultrasound-guided biopsy is a prime example. Beyond its role in distinguishing cervical masses, it can perform targeted puncture of suspicious deep-seated cervical tumors, yielding sufficient tissue for pathological diagnosis. Crucially, this precision approach can generate adequate specimens for comprehensive molecular testing, providing a solid foundation for precision therapy.

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