Retrospective Diagnosis of Advanced Carcinoma Endometrium from Hepatic Nodule

Author Information

Panchbudhe Shruti*, More Vibha**, Mali Kimaya***, Satia MN****.

(* Assistant Professor, ** Assistant Professor, *** Assistant Professor, **** Professor Department of Obstetrics and Gynecology, Seth GS Medical College & KEM Hospital, Mumbai, India)

Abstract

We report an unusual case of a 34 year old, infertile, woman who presented in surgery outpatient department with abdominal distension and right shoulder pain. On clinical examination there was suspicion of subacute intestinal obstruction, and on evaluation with X-ray and ultrasonography, obstruction was ruled out. An incidental finding of liver nodule was noted on ultrasonography (USG) which was further confirmed on computerized tomography (CT). CT guided biopsy of liver nodule was suggestive of endometrioid carcinoma. Patient was referred to gynaecological department to rule out primary focus and was diagnosed retrospectively to have carcinoma endometrium on fractional curettage. This is an unusual presentation of advanced carcinoma endometrium in the third decade of life which in a normal situation is the malignancy of fifth and sixth decades of life with the only risk factor of nulliparity without any gynecological symptoms.

Introduction

Endometrial carcinoma has four histological subtypes of which the endometrioid subtype is the most common, affecting 75–80% of patients.  Endometrioid endometrial adenocarcinoma has a better prognosis than the other subtypes (papillary serous, clear cell or carcinosarcoma) and can metastasize to the lung, bone, brain or liver as solitary deposits amenable to resection.^[1] Liver metastases from endometrial cancer at the time of presentation represent true haematogenous spread. Histopathology of typical endometrioid adenocarcinoma is usually characterize by back to back arrangement of endometrial-type of glands of varying differentiation/atypia with no intervening stroma. . Endometrioid adenocarcinoma have three grades on histopathology. Grade 1 consists of 5% or less of nonsquamous or nonmorular solid growth (well differentiated), Grade 2 consists of 6% to 50% of solid growth
( moderately differentiated) , and Grade 3 consists of more than 50% of solid growth (poorly differentiated).The various variants of endometrioid adenocarcinoma includes villoglandular, secretory, ciliated cell, and adenocarcinoma with squamous differentiation type of pattern, each having a peculiar histopathology along with the usual features of typical endometrioid adenocarcinoma.^[1]

Case Report

A 34 year old nulliparous woman, married for 14 years, presented to the surgery outpatient department with complaints of chronic right sided shoulder pain for 1 year and abdominal distension for last 6 months.On general examination  she was averagely built and nourished. Her vital parameters were stable. She attained menarche at the age of 13 years and her past and present menstrual cycles were regular with average amount of flow. Abdominal examination revealed distension, moderate ascites, minimal guarding and no rigidity. A clinical impression of subacute intestinal obstruction was made. However plain radiograph of the abdomen AP view and USG ruled out intestinal obstruction. USG showed a cystic lesion in right lobe of liver with moderate ascites.  CT of abdomen also showed a heterogeneous mass about 3X3 cm in the right lobe of liver with ascites. Ascitic fluid tapping was done. It did not show any malignant cells. CT guided liver biopsy was done and tissue was sent for immunohistochemisty and histopathology. Immunohistochemistry revealed expression of Cdx2 protein.  Histopathological examination of the tissue showed small fragments composed of different glands with squamous differentiation. Hence a diagnosis of well differentiated endometrioid neoplasm was made and the patient was then referred to gynecology department to rule out primary focus of malignancy. On gynecological evaluation the patient was a case of primary infertility with history of diagnostic hysterolaparoscopy done 6 years ago. She had taken treatment for infertility, details of which were not available. Her menstrual cycles were normal. She was non diabetic and non hypertensive. On abdominal examination an infraumbilical scar of laparoscopy was present. There was moderate ascites. On speculum examination cervix and vagina were healthy and on bimanual examination the uterus was anteverted, bulky, soft, mobile and bilateral fornices were free. Rectal examination showed absence of any nodularity and free parametrium. Pap smear revealed chronic inflammation with few dysplastic cells. Ultrasonography of pelvis revealed uterus 10×7×6 cm with thick polypoidal endometrium of 2cm. Chest radiograph was normal. Other routine preoperative investigations were normal. A fractional curettage was performed. Histopathological report of the endometrial tissue was suggestive of well differentiated endometrioid adenocarcinoma of the endometrium. Hence the diagnosis of stage IV B carcinoma endometrium with hepatic metastasis was made. In view of advanced carcinoma endometrium the patient was referred to an oncology center for further treatment. She was advised cytoreductive surgery followed by adjuvant radiotherapy. But patient did not follow up and died after 8 months from diagnosis of advanced carcinoma endometrium.

Figure 1. Histopathological appearance of the tumor. A. Low power; B. High power.

Discussion

Endometrial cancer is a disease that occurs primarily in postmenopausal women in the sixth and seventh decades of life and is virulent with advancing age. The risk for endometrial cancer increases with unopposed estrogen. Various conditions associated with an increased risk of endometrial carcinoma include obesity, nulliparity, early menarche, and late menopause. Obesity appears to pose the greatest risk due to aromatization of androstenedione to estrone in peripheral fat. Diabetes mellitus, hypertension, high fat diet and family history of endometrial, colon, ovarian cancer have also been implicated as the  additional risk factors for endometrial carcinoma. Infertility and a history of irregular menses as a result of anovulatory cycles are also documented risk factors for developing endometrial cancer.^[2] Women with endometrial carcinoma have vaginal bleeding or discharge as the only presenting symptom in 90% of the cases and less than 5% of the women are asymptomatic. Sometimes women may experience pelvic pressure or discomfort due to uterine enlargement or extrauterine spread of the disease and rarely some may present with haematometra or pyometra due to cervical stenosis which is a poor prognostic indicator of endometrial carcinoma.^[3]. In contrast to the cervix, where cytological screening has been enormously successful in preventing cervical cancer, there is no effective general population screening of asymptomatic women for endometrial cancer. Endometrial carcinoma is usually detected in asymptomatic women due to abnormal Pap test, histopathology of the uterine specimen removed for some other indication or abnormal finding on abdominal and pelvic USG or CT scan obtained for an unrelated reason as it was seen in our case. Those women who have malignant cells on Pap test are likely to have a more advanced stage of disease.^[4] Physical examination does not have any positive finding, although obesity and hypertension are commonly associated constitutional factors. Abdominal examination does not show any abnormality, except in advanced cases in which ascites or hepatic or omental metastases may be palpable. A detailed gynaecological examination should be performed which includes inspection of vagina and cervix along with bimanual rectovaginal examination to evaluate the uterus for size and mobility, the adnexa for masses, the parametria for induration, and the cul-de-sac for nodularity. All patients with endometrial cancer should undergo surgical staging which includes selective pelvic and para-aortic lymph node dissection, in addition to hysterectomy and salpingo-oophorectomy, based on the intraoperative assessment of risk for lymph node metastasis or other extrauterine spread. Surgical staging identifies most patients with extrauterine disease and has a significant impact on treatment decision. Stage IV endometrial adenocarcinoma, in which tumor invades the bladder or rectum or extends outside the pelvis, makes up about 3% of cases.^[5,6,7] Several reports have noted a positive impact of cytoreductive surgery on survival, the median survival being about 3 times greater with optimal cytoreduction (18–34 months versus 8-11 months, respectively).^[8,9] In our case due to noncompliance of patient her survival was reduced to 8 months. Treatment for stage IVB endometrial cancer involves one of tumor-reduction or palliative chemotherapy or radiation. Tumor-reductive surgery is typically followed with adjuvant chemotherapy, hormonal therapy, and/or radiation therapy although radiotherapy is the treatment of choice. Resection of liver capsule metastases as part of cytoreductive surgery has been shown to be feasible and may prolong survival.^[10] Palliative radiotherapy and platinum-based chemotherapy regimens followed by progestogens can also be considered in patients with endometrial carcinoma with liver metastasis which is effective in both preventing recurrence and prolonging survival. Patients with suspected advanced stage endometrial carcinoma should be counseled on the potential benefits of optimal cytoreductive surgery and alternative treatment options should be considered in those  with surgically nonresectable disease.

References

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Citation

Panchbudhe S, More V, Mali K, Satia MN. Retrospective diagnosis of advanced Carcinoma Endometrium from hepatic nodule. JPGO 2014 Volume 1 Number 2 Available from: http://www.jpgo.org/2014/02/retrospective-diagnosis-of-advanced.html