Case Conference Mei 23rd 2018

23-Mei-2018, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

May 16^th, 2018

Mrs. M, 56 y.o, P1A0, 430-48-18

Endometrial cancer stage II and Ovarian neoplasm susp malignant

 

Case Description:

Referred from Arifin Achmad Hospital in Pekanbaru with cervical cancer stage IIIB. Patient has been complained vaginal bleeding since 8 months ago. She also has been complained abdominal enlargement since 2 months ago. There were no miction and defecation problem.  

No history of systemic disease. Menopause for 6 years.

 

Physical Examination on May 14^th, 2018:

General state:

CM. BP: 130/80 mmHg, HR: 96 x/min, T: 36.5°C, RR: 20 x/min, Height 164 cms, Weight 58 kgs

Head : pale conjungtiva (-/-) icteric sclera (-/-)

Thorax : symmetry shape and movement of hemi thorax

Lung : vesicular breath sound on both lungs, neither wheezing nor rhales

Cardia : no murmur, no gallop

Abdomen : ascites (+)  

Extremity : warm, no edema

Gyn state:  

Inspection : vulva/urethra normal

Inspeculo : seen mass on cervix, fragile, infiltration to left vagina wall

RVT : cervical mass, fragile, infiltration to left vagina wall,

  uterus was enlarge, palpable right adnexal mass Ø 10 cm,

  adhere to posterior of the uterus,

  palpable left adnexal mass Ø 5 cm,  ascites (+)

  rectal mucosa was smooth

    

Pathology Anatomy Result, Prodia, April 19^th 2018

Makroskopis: Diterima 1 botol jaringan tanpa keterangan berisi keping-keping jaringan sebanyak kurang lebih 3 cc, warna putih kecoklatan. Semua cetak 1 kaset.

Mikroskopis: Sediaan dari biopsi tampak berupa massa tumor terdiri atas sel-sel bentuk bulat, oval/lonjong dan spindel berkelompok, beberapa bagian menyusun papiler. Ratio inti sitoplasma besar, hiperkhromatis, polimorfik, ditemukan mitosis. Stroma jaringan ikat fibrokolagen tipis dengan area-area nekrosis dan sebukan sel-sel limfosit dan sel histiosit.

Kesimpulan: Histopatologis sesuai Adenokarsinoma differensiasi buruk invasif cervix.

 

US, RSCM, May 7^th 2018

Description: The uterus was enlarged with the uterine cavity contains of a solid mass with size 37 x 33 mm, irregular edge, derived from malignant endometrium. The invasion of mass up to the amount of mass that fills the cervical canal with size 30 x 10 mm. The stratum basale of endometrium was difficult to assess, the impression: irregular with suspect of invasive. The portio was normal. Both ovaria contains of solid-papillary mass with irregular shaped, size 105 x 74 mm (right) and 35 x 35 mm (left), and derived from bilateral neoplasms. In the left adnexal region, there was an irregularly solid mass (from the left ovary) which has attached to the peritoneum with a 5 mm of thickness, derived from the mass of the spread. There were no enlarged of the paraaorta and parailliac lymph nodes. The liver and both kidney were normal.

Conclusions: The malignancy mass of endometrium with invasion to the stratum basale and cervical canal. The ascites and bilateral solid ovarian neoplasms were suitable with malignancy and the mass spread around the adnexa (left).

 

Chest X-Ray, RSCM, May 7^th 2018

Description: Inadequate inspiration. The heart was not enlarged. The aorta and the superior mediastinum were not widened. The trachea relatively in the middle. Both hila were not thickened. There were a visible fibrosis in the lower field of the right lung and fibroinfiltrate in the upper field of the left lung. There were a shadow of nodular opacity in the upper and middle field of the left lung which was superposition with the 4th and 5th left costae. The diaphragm arch and the costophrenic angle were normal. The bones were still good.

Conclusion: There was a fibrosis in the lower field of the right lung. There was a fibroinfiltrate in the upper field of the left lung, suspect pulmonary TB. There were a nodular opacity in the upper and the middle field of the left lung, DD / Tuberculoma, pulmonary nodules.

 

Laboratories, RSCM, May 7^th 2018

CBC : 11.8/36.3/13440/613000

Ur/Cr : 12/0.7

Albumin : 4.25

SGOT/PT : 32/12

RBS : 151

PT : 10.3 (11)

APTT : 35.2 (31.7)

Ca 125 : 433

 

 

 

 

 

 

Introduction

The coexistence of carcinoma in the ovary and endometrium is a relatively uncommon, but not rare, event which occurs in about 10% of patients with ovarian carcinoma and in slightly more than 5% of patients with endometrial carcinoma. Currently, no surgical or histologic criteria exist by which to define whether this process reflects synchronous malignant transformation in the ovary and endometrium, metastasis from the endometrium to the ovary, or even metastasis from the ovary to the endometrium. Consequently, the prognosis is uncertain for these patients, and their treatment remains highly variable from one institution to another.

 

Problem to be discussed

What is the appropriate management for this patient (Endometrial cancer stage II and Ovarian neoplasm susp malignant)?

 

Discussion

Historically, it was thought that women with stage II endometrial carcinoma (tumor invades stromal connective tissue of the cervix but does not extend beyond uterus) had a high risk of parametrial involvement; this was based upon an assumption that endometrial carcinoma would follow a pattern of spread similar to cervical cancer. Thus, these patients have been treated with radical hysterectomy at some institutions. However, it appears that lymphovascular space invasion is a better predictor of parametrial extension than cervical involvement. This was illustrated in the largest study, a retrospective series of 334 women with endometrial carcinoma who underwent radical hysterectomy. Lymphovascular spread was present in all 28 women (8.4 percent) with parametrial spread. Most of these women (26 of 28) had lymphovascular space invasion in addition to one or more of the following findings: invasion of more than half the myometrial depth (19 women), cervical invasion (10), ovarian metastases (six), or pelvic or paraaortic lymph node metastases (19), or positive peritoneal cytology (13). Thus, for women with stage II endometrial carcinoma, some experts suggest performing a simple hysterectomy (extrafascial class I) with lymphadenectomy rather than radical hysterectomy. The exceptions to this are women with gross cervical involvement in whom performing a simple hysterectomy would cut through the tumor (all gross disease should be removed) and/or those in whom it is uncertain whether the primary is cervical or uterine.

Synchronous primary cancers of the endometrium and ovary are found in 5 percent of women with endometrial carcinoma and 10 percent of women with ovarian cancer. For women with endometrial carcinoma, the risk appears to be higher in premenopausal women, in whom 5 to 29 percent have a synchronous ovarian malignancy. Histology is often the same in both the endometrium and ovary, making it unclear whether there are two separate primary tumors or a metastasis from the endometrium to the ovary, or, less frequently, from the ovary to the endometrium. Metastatic disease to the ovary, rather than a synchronous primary, should be suspected when ovarian disease is small, bilateral, or multinodular with surface implants and angiolymphatic invasion at the ovarian cortex. Staging and surgical treatment is the same regardless of whether the patient has metastatic disease or synchronous primaries. In cases with synchronous primary tumors of both ovary and endometrium, treatment is based on the combined treatment recommendations for each cancer according to stage.

Women with synchronous primary cancers of the endometrium and ovary are unlike women with endometrial or ovarian cancer alone. The initial challenge in studying this population of women is making the diagnosis of independent primary tumors. Pathologists including Scully et al. have delineated histologic criteria to aid pathologists when evaluating these tumors. In the future, molecular profiling of the tumors in the endometrium and ovary may improve how we determine which patients have independent primary cancers. Study by Zaino, Et al (2001), almost 90% of tumors identified in the ovary and in the endometrium were of endometrioid cell type (with or without foci of squamous differentiation). While this is about the expected frequency for adenocarcinomas arising in the endometrium, serous carcinomas are the most common cell type of carcinomas originating in the ovary in isolation, and endometrioid adenocarcinomas usually represent only about 10-20% of ovarian carcinomas in the United States. These findings are in striking contrast to the observations of 34 and 55% concomitant endometrioid carcinomas in the ovary and endometrium reported by Zaino et al. in a retrospective study of 34 patients, as well as a retrospective study of 29 patients by Eifel et al.  The histologic cell type was concordant in both sites in 93% of cases in this study, including 64 cases of endometrioid carcinoma with or without squamous differentiation, 2 cases of mucinous carcinomas, and 2 cases of serous carcinomas. These data alone, however, do not indicate whether the tumors in the ovary were metastatic from the endometrium or arose as independent primaries consequent to the same stimulus acting in multiple sites.

 

Conclusion

1. For women with stage II endometrial carcinoma, suggest performing a simple hysterectomy (extrafascial class I) with lymphadenectomy rather than radical hysterectomy. The exceptions to this are women with gross cervical involvement in whom performing a simple hysterectomy would cut through the tumor (all gross disease should be removed) and/or those in whom it is uncertain whether the primary is cervical or uterine.

2. Staging and surgical treatment is the same regardless of whether the patient has metastatic disease or synchronous primaries. In cases with synchronous primary tumors of both ovary and endometrium, treatment is based on the combined treatment recommendations for each cancer according to stage.

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