A 51-year-old woman was referred to the ENT department with a 2-week history of a lump on the right side of her neck. There was no history of change to her voice or dysphagia. She is a para 4 with all normal vaginal deliveries and has had normal cervical smears in the past. Her periods were regular and she gave no history of intermenstrual or post-coital bleeding. She smoked about 20–30 cigarettes per day. On further questioning in the clinic, she gave a history of increasing lethargy for the past 3 months and was also unable to report to work due to severe back pain. Five years before the present episode, she reported feeling unwell with significant weight loss and heavy periods. She was found to be anaemic and was given five units of blood. She was investigated for a possible colon cancer which proved to be negative. She was referred to a Menstrual Disorder Clinic but failed to attend the clinic twice. On examination, multiple cervical lymph nodes were palpable on both sides of the neck. Ultrasound scan of the neck revealed two large supraclavicular lymph nodes with several abnormal looking lymph nodes in the right carotid chain. An X-ray of the chest showed no abnormality. Fine needle aspiration of the lymph nodes yielded squamous carcinoma cells. Metastatic squamous cell carcinoma of an unknown primary tumour was suspected and investigations were performed to find a possible primary site. Clinical examination and endoscopy of the upper digestive tract did not yield an obvious primary tumour in the nasopharynx, larynx and hypopharynx. Computerised Tomography (CT) of the neck, chest and abdomen revealed marked mediastinal and para-aortic lymphadenopathy suggestive of spread of the known squamous cell carcinoma. There was evidence of dilatation of the collecting system bilaterally with dilatation of the proximal ureters suggesting an obstruction within the pelvis. A Positron Emission Tomography-CT (PET-CT) scan was performed which showed markedly increased uptake in the right cervical lymph nodes, as well as in the right paratracheal, anterior mediastinal, lower para-aortic, and bilateral iliac lymph nodes with an obturator node showing a photopaenic centre. In addition, there was a focal area of increased uptake in the pelvis, suggesting a lesion within the rectal wall or in the vaginal vault. Given the histology of squamous carcinoma, the PET scan suggested that the uptake in the pelvis may represent a primary gynaecological problem rather than a second malignancy in the rectum. But given the distribution of the disease which was very unusual for cervical carcinoma, a review of the histology was suggested with a differential diagnosis of lymphoma to be considered. The histology from fine needle aspiration of the cervical lymph node confirmed it to be carcinoma cells of squamous origin. Our patient was then referred to the gynae-oncology team. On examination, the uterus was anteverted, mobile and bulky corresponding to about 14 weeks' size with no palpable adnexal masses. Her cervix appeared normal to the naked eye and a smear was obtained which was reported as normal. Magnetic Resonance Imaging (MRI) of the pelvis and abdomen was performed which revealed a highly abnormal cervix, diffusely infiltrated by an intermediate to high T2 signal intensity mass measuring approximately 3 × 4 × 3.5 cm. The mass involved the endocervical canal and the stroma with suspected early parametrial invasion anteriorly. There was no convincing evidence to suggest bladder involvement and the rectum was clear of disease. Several small intramural fibroids were demonstrated within the myometrium as well as a submucosal fibroid in the anterior body of the uterus. There was extensive lymphadenopathy along both pelvic side walls, common iliac regions and the para-aortic regions but with no evidence of inguinal lymphadenopathy. Bilateral hydronephrosis was noted. No bony deposit was seen. In conclusion, the MRI reported that the appearance was consistent with a cervical carcinoma with extensive lymphadenopathy and hydronephrosis, stage FIGO 3b. Routine blood investigations before examination under anaesthesia showed her to be anaemic with a haemoglobin level of 6 g/dl. She was transfused with four units of blood. Her liver function tests and renal function tests were normal and serology showed her to be negative for HIV. She had an examination under anaesthesia, cervical biopsy and an endocervical and endometrial curettage. Examination under anaesthesia showed the cervix to be bulky with an intact surface epithelium. There was no parametrial involvement and the rectum and bladder were free. Hysteroscopy revealed a pedunculated fibroid on the anterior wall of the uterus. Large biopsies of the anterior and posterior lip of the cervix were taken which identified a poorly differentiated squamous cell carcinoma of the anterior lip of the cervix. The endocervical curettings were positive for squamous cell carcinoma and the endometrial curettings showed proliferative phase endometrium. With an impression of metastatic squamous cell carcinoma of the cervix, she was started on palliative chemotherapy with carboplatin and paclitaxel. She has responded well to the therapy with a reported decrease in the size of the neck nodes.