Case Conference March 15th 2017

15-Mar-2017, Divisi Ginekologi Onkologi RSCM

CLINICOPATHOLOGY CONFERENCE

March 15^th, 2017

Mrs X

Endometrial cancer -- Discrepancies between the pre-operative pathology results and after operative pathology results

 

Case Description:

Patient complained of vaginal bleeding since a year ago. She was having 2 times curettage at Pelni hospital. The first curettage PA result was endometrial polyp and non-atipic hyperplasia endometrium with squomous metaplasia, mimic solid structure. The latter PA result was endometrioid carcinoma grade 2, unknown origin. Patient was referred to RSCM in April 2016 for further treatment. Review of the first curettage PA result reported adecarcinoma endometrium subtype endometrioid (type I) and the second curettage PA result reported carcinoma endometrioid poorly differentiated with atipic hyperplasia endometrium.  Patient came again after 4 months. On clinical examination, the uterus was within normal limit. Ultrasound examination showed endometrial malignancy with intra uterine echogenic mass size 36 x 20 mm, inhomogenous, irregular border and neovascularization. She was underwent hysteroscopy and the mass was seen intra uterine cavity. With risks of obese and PCO in this patient it was diagnosed with endometrial cancer IA low risk and to be given Megestrol acetate 2 x 320 mg, MPA 2 x 200 mg, and metformin 2 x 500 mg. Evaluation after 3 months, hysteroscopy showed papillary projection with bizarre vessels. MRI results in October 2016 were malignant endometrial mass, associate with stage 1A, no lymphadenopathy or mass ilfiltration to cervix, both ovaries within normal limit. The megestrol acetate dosage was up to 2 x 600 mg.  Patient was then brought up to discussion and it was decided to do hysterectomy due to endometrial cancer IA poorly differentiated. She was operated on 2^nd of February 2017. Result of pathology anatomy was servisitis with retention cyst, endometrium was under high progesterone influence, adenomiosis, multiple cysts on the right ovary.

 

Physical examination on March 8^th, 2017:

General status:

CM. BP: 110/70mmHg, HR: 90 bpm, RR: 20x/m, T:36^oC, Height 154cms, Weight 75kgs

Head: Pale conjungtiva (-/-)

Neck: supraclavicula lymph nodes (-/-)

Axilla: lymph nodes (-/-)

Thorax: symmetry shape and movement of hemithorax

Cardia: no murmur, no gallop

Abd: flat, no palpable mass

Extremity: inguinal lymph nodes (-/-)

Gyn state: 

Inspection: normal external genitalia

Inspeculum: vagina normal, vaginal stump normal

RVT:  normal vagina and vaginal stump, TSA and ampulla recti normal

 

Review Slides November 29^th, 2016

Pathology Result Numbers 1609402

Macro: 6 Slides

Conclusion:

Hystologic feature resembled Adenocarcinoma endometrium subtype endometrioid (type I) moderate differentiated.

Suggestion:

Regarding of patient’s age, how is the ovary? Is there any lesion that can caused hyperestrinisme?

 

Review Slides November 18^th, 2016

Pathology Results Numbers 1609094

Macro:  3 Slides

Conclusion:

Hystologic feature resembled endometrioid carcinoma poor differentiated, with atipic hyperplasia endometrium

 

Pathologic Results February 28^th, 2017

Pathologic Results Numbers 1701129

Conclusion:

Servisitis with retention cyst, endometrium was under high progesterone influence, adenomiosis, multiple cysts on the right ovary

 

MRI results December 30^th, 2016

Solis mass suggestive malignant on endometrium and posterior wall of the uterus. Lesi was suspected to infiltrate to miometrium at the posterior uterus. There was no infiltration outside uterus. No locoregional lymphadenopathy. Multiple cysts on both ovaries, possibly functional cysts. There were no other radio-pathologic patterns.

 Discussion

Based on the guidelines, the patient was considered to be endometrial cancer with high risk.

According to the last examination and supporting data, she was having endometrioid carcinoma poorly differentiated and last MRI result was the lesion has been suspected to be infiltrated to myometrium on the posterior uterus.

Accoording to the guidelines, there were several recommendations that provided in this case:

Recommendation 1: Standard surgery is total hysterectomy with bilateral salpingo-oophorectomy  without vaginal cuff, level of evidence: IV, strength of recommendation: A, consensus: 100% yes (37 voters)

Recommendation 2: Ovarian preservation can be considered in patients younger than 45 years old with grade 1 EEC with myometrial invasion G50% and no obvious ovarian or other extrauterine disease, level of evidence: IV, strength of recommendation: B, consensus: 100% yes (37 voters).

Recommendation 3: In cases of ovarian preservation, salpingectomy is recommended, level of evidence: IV, strength of recommendation: B, consensus: 100% yes (37 voters).

Recommendation 4: Ovarian preservation is not recommended for patients with cancer family history involving ovarian cancer risk (e.g. BRCA mutation, LS, etc.). Genetic counselling/testing should be offered, level of evidence: IV, strength of recommendation: B, consensus: 100% yes (37 voters).

Other guideline was actually in agreement with this consensus. Patient was already in high risk therefore the treatment recommended was Hysterectomy with consideration to leave the ovary since she was only 22 years old. 

Conclusion

 

There were discrepancies between the pre-operative pathologic results and post-operative pathologic results. Although, it was still debatable whether the high progesterone treatment could not be differentiated on the endometrial malignancy.

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