Case Conference September 13th 2017

13-Sep-2017, Divisi Ginekologi Onkologi RSCM

CASE CONFERENCE

 

September 13^th, 2017

Mrs W

 

I. Case Description

Patient was admitted to hospital because of post menopausal bleeding bleeding. From the US examination, the result was uterine cavity filled with blood clot  with unknown etiology, non visualized right ovary, endometriosis cyst from left ovary, adenomyosis and uterine fibroid at posterior corpus.  Patient underwent hysteroscopy, but due to a lot of blood clot, difficult to  evacuate, patient was planned for procedure in OT. Patient underwent curettage in RSCM on 15^th May 2017, with the result was endometrium carcinoma type II, mixed: serosum carcinoma and clear cell carcinoma. From the MRI result, there was malignant solid mass from endometrium with extension of >50% myometrium with multiple lymphadenopathy in the bilateral illiac and right obturator, and multiple node in the right lobe of liver. From chest xray, there were multiple nodule in the both lungs.

 

II.      Physical examination on September 4^th, 2017:

a.   General status:

CM. BP: 120/84 mHg, HR: 86 x/min, T: 36,5 C, RR: 20 x/min,

Head: Pale conjunctiva (-/-) icteric sclera (-/-)

Thorax: symmetry shape and movement of hemithorax

Lung: vesicular breath sound on both lungs, no wheezing or rhales

Cardia: no murmur, no gallop

Abdomen: there was a mass, sized head of baby, fixated.

b.   Gynecology examination:

RVT: There was a mass in the distal part of the cervix, adhered to posterior vagina, there was a nodule and mass extend from the anterior part.

 

III.     Ultrasound Examination on April 11^th 2017

Description:  Anteflexed uterus with normal shaped and enlarged size. In the right corpus, there was a mass with no clear border, sized 77 mm, accordance to adenomyosis appearance. In the back corpus, there was a hypoechoic mass with clear border, sized 25 mm, correspond to uterine fibroid. The opening of  uterine cavity contained blood clots and blood (stasis), etiology was not known yet. Portio and endocervix were normal. Right ovary was not visualized. Left ovary was cystic enlarged, contained homogev ecointerna material, sized 64 mm.

Conclusion: Right ovary was not visualized. Left ovary endometriosis cyst. Right corpus adenomyosis and back corpus myoma. The open uterine cavity contained blood clots and blood (stasis), cause not known yet.

 

IV.    MRI Result on June 6^th 2017

Description: liver was enlarged (19,8 cm), normal location, smooth surface. There were multiple hypointense T1WI lesion, hyperintense T2WI, that didn’t contrast enhance, scattered around right lobe liver, largest sized 3,7 x 3,6 x 3,2 cm. Intra and extrahepatic biliarry duct were not dilated. Portal vein was normal. Gall bladder showed normal shaped, sized and smooth border with homogenous signal intensity. Spleen superior pole to inferior pole 11,4 cm, reguler border. There was solitary cystic lesion, diameter sized 0,4 cm. Homogenous parenchymal signal intensity in the spleen. Sized and location of pancreas was normal. Caput, corpus and cauda with homogenous signal intensity. Pancreatic duct was not dilated/narrowed. Sized and position of both kidneys were normal. Kidney parenchymal showed normal internal structure. Normal renal pelvis and calyx. Pelviocalyx and ureter were not dilated. Position and sized of both adrenal were normal. Aorta and paraaorta were normal. There was heterogenous lobulated mass, dominated solid, that was contrast enhancemet with diffusion restriction, not clear border, irreguler edge, sized 9,2 x 8,7 x 14 cm in the endometrium, with mass extension of >50% to myometrium and didn’t extend to the uterine serosa and cervix. In the anterior region, the mass pushed bladder to left anterolateral, in the posterior region the mass attached to rectum, in the superior region, the mass reached abdominal cavity and attached to mesentery. Vascular dilation prominent around the mass. There was multiple enlarged lymph node in the right-left illiac and right obturator with largest short axis, 2,6 cm in the right illiac. Intestinal structur was normal, no sign of intestinal wall thickening. The bladder was pushed to left anterolateral without wall thickening. There were multiple hyperintense T2WI lesions, hypointense T2FS, that didn’t contrast ehance in the left side of sacrum and sacrum. Shaped of femoral head and acetabulum were normal. Bone marrow was normal. No abnormalities in the soft tissue.

Conclusion: Malignant solid mass from endometrium with extension of >50% myometrium and not extend to uterine serosa and cervix, with multiple lymphadenopathy in the bilateral illiac and right obturator, and multiple node in the right lobe of liver, accordance to T1BN1M1. Solitary cytic spleen. No hydroureter and hydronephrosis. Multiple hyperintense T2WI lesion, hypointense T2FS, that didn’t enhance post contrast enhance in the left side of pelvic and sacrum. DD/ fatty infiltration.

                    

V.      Patholoy Anatomy on May 15^th 2017

Macroscopic: Received 1 pouch of Nani Wardiningsih, without note, contained tissued with volume ± 3 cc, brownish black, elastic, all copy, 1 cassette.

Microscopic: uterine cavum scraping with note “AUB susp hiperplasia endometrium curiga keganasan”, consisted of blood clot and atrophy endometrium tissue. In other area, there were tissue contained malignant tumor mass forming papillary structure, glandular, covered by cilliated collumnar epithelium. Tumor cell with pleomorphic nucleus, rough cromatine, hyperchromatic arranged stacked. Eosinophilic cytoplasm. Hobnail nucleus appearance was found. There was a tumor, arranged by solid structure with polygonal cell, large nucleus, pleomorphic, rough cromatine, hiperchromatic. A lot of cytoplasm and pale eosinophilic to clear. Mitosis was found. Stromal connective tissue with edema area.

Topography: C55.9               Morphology: M8380/3

Conclusion: Histology correspond to endometrial carcinoma type II, mixed: serosum carcinoma and clear cell carcinoma. Lymphovascular space involvement was not found.

 

 

VI.       Thorax Xray on April 25^th 2017

Description: heart was not enlarged, cardiothoracic ratio <50%. Aorta and superior mediastinum were not dilated. Trachea in the center. Both hilar not thicken. Vascular streak in the both lungs were normal. No infiltration/nodule. There was round shadow in the right lower lung at the level of right perihiler and right anterior 7^th costae. Bones were normal.

Conclusion: round shadow in the right lower lung at the level of right perihiler and right anterior 7^th costae, DD/ vascular, metastasis nodule. No apparent radiological abnormalities in the heart

 

 

VII.   Chest Xray on July 20^th 2017

Description: enlarged of heart, cardiothoracic ratio 53%. Aorta and superior mediastinum were not dilated. Trachea in the center. Both hilar not thicken. Multiple nodule in the both of lungs with sized variation. Bones were normal.

Conclusion: compared to radiograph thorax on the April 25^th 2017, currently: nodules increase. Heart with CTR 53%. Multiple nodule in the both of lung with sized variation. DD/ metastasis.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Problems to be discussed

Is surgery continue with chemoradiation is better than radiation only in endometrial cancer stage IV serous and clear cell type?

 

Clinical question in this case will be developed by PICO approach

Patient	endometrial cancer stage IV serous - clear cell type
Intervention	surgery and chemoradiation
Comparison	surgery and radiation
Outcome	overall survival

 

 

 

 

METHODS

Search strategy

In order to answer the question above, we conduct a searching in PubMed site by using keywords, endometrial cancer stage IV serous clear cell type AND surgery AND chemoradiation AND radiation. The search was conducted on PubMed on September, 12th 2017

 

Search strategy in PubMed conducted on

 

Engine	Search terms	Results
PubMed	endometrial cancer stage IV serous - clear cell type AND surgery AND chemoradiation AND radiation	2

 

 

 

 

 

 

 

 

FIgure 1. Flowchart of search strategy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Critical Appraisal

Article 1

Binder PS et al. Adult Comorbidity Evaluation 27 score as a predictor of survival in endometrial cancer patients. Am J Obstet Gynecol 2016

 

Article 2

Scarfone G. Clear cell and papillary serous endometrial carcinomas: survival in a series of 128 cases. Arch Gynecol Obstet (2013) 287:351–356

 

 

	1st art	2nd art
A. Are the study results valid
1.  Was there a representative and well-defined sample patients at a similar point in the course of disease?	yes	yes
2. Was follow-up sufficiently long and complete?	yes	no
3. Were objective and unbiased outcome criteria used?	yes	yes
4. Was there adjustment for important prognostic factors?	yes	yes
B. What were the results?
1. How large is the likelihood of the otcome events in a specific period of time?	N/A	N/A
2. How precise are the estimates of likelihood? (consider 95% CI)	N/A	N/A
C. Can the results be applied to your patients?
1. Were the study patients similar to my own?	yes	yes
2. Are the results useful for reassuring or counseling patients?	yes	yes
3. Is the treatment feasible in my setting?	yes	yes
D. Conclusions
1. The results or recommendation are valid?	yes	yes
2. The results clinically important?	yes	yes
3. The results are relevant to my practice?	yes	yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Discussion

 

Binder et al. performed a retrospective cohort study of women who had been diagnosed with EC from 2000 - 2012. After Institutional Review Board approval was obtained, patients were identified from the prospectively maintained Siteman Cancer Center Tumor Registry. The analysis included patients with stages I- IV disease who had been treated surgically. Only patients with endometrioid, serous, and clear cell adenocarcinoma were included in the analysis. Thus, we excluded patients with uterine sarcomas. Patients who were treated primarily with hormones, radiation, or chemotherapy were excluded. Patients with missing ACE-27 data were excluded.

The primary outcome was OS, and the secondary outcome was RFS. OS was calculated from the date of diagnosis to date of death or last follow-up evaluation. Patients who were alive at last follow-up evaluated were censored for OS analysis. RFS was calculated from the date of diagnosis to date of recurrence (after remission) or progression (despite primary treatment) or death. Recurrence and progression were determined by computed tomography imaging or biopsy.

There was an anticipated significant interaction between stage and treatment type. As expected, most stage I patients (83%) did not receive adjuvant therapy. Stage II patients were more likely to receive radiation (46%); most stage III patients (41%) received a combination of chemotherapy and radiation, and most stage IV patients (73%) received chemotherapy alone (P<.001).

Adjuvant treatment with chemotherapy was associated with a 35% reduction in risk of death (HRadj, 0.65; 95% CI, 0.47 - 0.90) and with combination chemoradiation therapy was associated with a 51% reduction in risk of death (HRadj, 0.49; 95% CI, 0.35 - 0.70), when compared with patients not receiving adjuvant therapy, after adjusting for the covariates included in multivariable analysis.

Scarfone et al performed a study where all women with a histologically confirmed clear cell (CC) and papillary serous (PS) endometrial cancer, who underwent primary surgery at the Mangiagalli Clinic, Milan (1985–2004), S. Paolo Hospital, Milan (2006), S.Raffaele Hospital, Segrate-Milan (1988–2006), S.Matteo Hospital, Pavia (1980–2003) and Ospedali Riuniti, Bergamo (2000–2006), were eligible for the study. These cases are considered in the present anal- ysis. Information regarding adjuvant treatment, if any, site of recurrence and vital status in December 2007 was collected.

Stage, histological grading and myometrial invasion were defined according to the FIGO classification. Adjuvant treatment was cisplatin plus doxorubicin plus cyclophosphamides or paclitaxel plus anthracyclines.

In this study including CC and PS endometrial cancers, the 5-year survival from surgery was 59.5 %. The PS carcinoma showed a 5-year survival of 56.9 %. For the CC cases, the percentage was 67.4 %.

In the interpretation of these data, limitations should be considered. This is a retrospective study. Patients were treated with different types of surgery and intensive staging was performed in a small percentage of cases. Further adjuvant treatment was chosen by the clinical centre, and CT and radiation were applied without a standardized treatment plan. Furthermore, in some cases the follow-up was of only 1 year, thus, it is difficult to draw conclusion on the treatment success.

The efficacy of a postoperative therapy for patients affected by a tumour in its first stage is still an open debate. In the study, the number of relapses for tumours at an early stage suggests that an adjuvant therapy may be useful. Tumour relapses were frequent and often localized in the extrapelvic area.

If we compare our results to those in literature, our study seems to be in contrast with Elit et al.’s  findings, where the number of relapses in patients affected by I stage PS carcinoma was higher among patients treated with post-operative CT than in those who did not receive CT. Other studies, on the other hand, showed an effectiveness of CT and RT .

Finally, this study does not show more advantages in the combined use of CT and RT compared to CT alone. However, the number of cases concerning this kind of adjuvant therapy is too small to draw any conclusion.

 

For this patient, we can perform surgery and then give the patient chemoradiation afterward. 

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