Case Conference December 6th 2017

06-Dec-2017, Divisi Ginekologi Onkologi RSCM

 

 

Mrs. A, 52 yo, MR 4265363

 

Accuracy of Ultrasound, Hysteroscopy, and MRI for Detecting Low-Risk and High-Risk

 

Endometrial Cancer Stage II

 

PPDS: Citra Dewi (T3B - Oncology Rotation)

 

 

 

INTRODUCTION

 

For endometrial cancer, it is widely accepted that staging is done surgically. The main surgical treatment modalities are hysterectomy and bilateral salpingo-oophorectomy, whereas pelvic and/or paraaortic lymphadenectomy is performed mainly to ensure proper staging for the need of adjuvant therapy. Some centers also suggest radical hysterectomy for women with cervical involvement to ensure local control of the disease.

 

   

 

Preoperative staging is crucial to ensure the surgery performed matches patient’s disease stage. Well-defined preoperative staging would have an advantage in operative planning, selecting women for minimal invasive surgery, and in ensuring that any extensive surgery is performed by well-trained surgeons. That’s why method(s) to predict tumor grade, myometrial invasion, as well as cervical invasion is warranted to restrict extended surgery to women at high risk of metastatic disease

 

 

 

CASE ILLUSTRATION

 

Mrs. A, 52 years old, was referred from Fatmawati hospital with endometrial cancer stage II for radiation therapy.

 

Patient had irregular spotting since 1 year ago, went to midwife and was given oral medication to stop bleeding. No previous history of vaginal nor post-coital bleeding. Patient admitted had already had menopause since 4 years ago. No abdominal mass/pain, decrease of body weight, nor other symptoms. Spotting continued until 3 months and patient even had vaginal bleeding, 2-3pads/day, so she went to OBGYN, and was performed curettage which histopathology result showed atypical endometrial hyperplasia with endometrioid adenocarcinoma focus, well differentiated. She was then referred to Siloam hospital for operation but the perioperative preparation was stopped due to administrative isssues.

 

Two months before admission, patient was referred to Fatmawati hospital, diagnosed as endometrial cancer IB, performed laparotomy total hysterectomy and bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and omentectomy on 15^th Nov 2017. The histopathology result showed endometrioid cancer, grade I, omentum free of tumor cells

 

Patient was then referred to RSCM for radiation.

 

There was no current complaints of vaginal bleeding, nausea/vomiting, abdominal mass/pain. No previous nor family history of hypertension, diabetes mellitus, asthma, allergy. No family history of malignancy.

 

P5A2, previous C-section 1x (1998). No history of contraceptions.

 

 

 

Physical examination

 

CM, TD 120/80 mmHg, HR 88 x/menit, RR 18 x/menit, S 36.7’C

 

BW 75kg, BH 156cm, IMT 30.8 kg/m² ~ obese gr I

 

Abdomen: midline incision scar, abd  flat, supple, no mass/tenderness, bowel sound within

 

                  normal limit

 

Gynecologic examination

 

I   : vulva / uretra within norma limit

 

Io : vaginal vault and wall was smooth, fluor/fluxus (-)

 

VT: vaginal vault and wall was smooth, no pelvic mass/tenderness

 

RT: within normal limit

 

 

 

Supporting datas

 

1.      Mar 27^th 2017 – Husada hospital - Histopathology result

 

Macroscopic: Brownish white tissue, 8cc tissue

 

Microscopic: Endometrial tissue with glandular hyperplasia. Some glands consist of one layer columnar epithel, with most nucleus perpendicular to the basal membrane. Some glands show disrupted polarity, pleomorphic nucleus, with cribiformic pattern, viloglandular, and atypical mytotic process. Inflammatory cells and blood clot were also found inbetween those cells.

 

Conclusion: Histology corresponds to atypical endometrial hyperplasia with endometrioid

 

                          adenocarcinoma focus, well differentiated

 

2.      Chest X-Ray – Oct 30^th 2017

 

No radiologic abnormality seen on both heart and lungs

 

3.      Transvaginal Ultrasound -  Oct 13^th 2017

 

Uterus anteflexed, size 81x68x61 mm.  There was hyperechoic mass in uterine cavity with irregular border and neovascularization, sized 59x56x51mm, suggestive of endometrial malignancy, invading more than half of the myometrium thickness.

 

Portio and endocervix normal.

 

Right ovary normal, sized 26x22x21mm. Left ovary cannot be identified.

 

No abnormal mass at both adnexae.

 

No enlargement of paraaortic nor parailiac lymph nodes.

 

Liver and both kidneys are normal.

 

Conclusion: intrauterine cavity mass ~ endometrial malignancy

 

4.      Laparotomy total hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy, omentectomy (Nov 15^th, 2017)

 

 

 

5.      Oct 16^th 2017 – Fatmawati hospital - Histopathology result

 

Macroscopic: - Uterus with cervix, sized 10x8.5x5cm, already dissected, with tumor

 

                           mass intrauterine Æ 6.5cm, with both tubes, ovaries, and parametria

 

      - Irregular yellowish tissue ±300 cc, tagged as “omentum”

 

Microscopic: - Uterus: tumor tissue consists of columnar epithelial proliferation with

 

                         pleomorphic, hyperchromatic nucleus, invading > ½ myometrium

 

                         thickness, until lower segment of uterus

 

                 - Cervix: consists of endocervical glands tissue with the same tumor cells

 

                   found in the uterus

 

    -  No tumor cell implantation on both ovaries, parametria, omentum, and

 

       lymph nodes

 

 Conclusion:   Endometrioid carcinoma, grade I, tumor invading > ½ myometrium

 

                        thickness and until lower segment of uterus and cervix

 

 

 

CLINICAL QUESTION

 

What would be the most accurate preoperative staging modalities for detecting low-risk and high-risk endometrial cancer stage II?

 

 

 

Table 1. PICO analysis

 

 

 

METHODS

 

Literature searching was conducted on Pubmed, ScienceDirect and Cochrane Library on October 30^th, 2017, using the search tool containing the keywords “Endometrial cancer, accuracy, ultrasound, hysteroscopy, MRI” Search results were filtered by the engine according to the following criteria: articles published in English language with human population, and last 5 years publsihed articles. Search strategy, result, and the inclusion and exclusion criteria are shown in the flowchart (Figure 1).

 

 

 

 

 

Figure 1. Flowchart of searching strategy

 

 

 

The filtered results were screened using the inclusion criteria and only 1 article was finally included for appraisal.

 

CRITICAL APPRAISAL

 

 

 

Table 2. Critical appraisal

 

 

 

DISCUSSION

 

The search for methods able to predict tumor grade, myometrial invasion, as well as cervical invasion is warranted to restrict extended surgery to women at high risk of metastatic disease. The method must have high accuracy because the lack of lymph node resection may introduce an increased risk of recurrence, whereas unnecessary lymph node resection may increase the risk of surgical complications and also the risk of life-long lymph edema. A well-designed preoperative method would  have an advantage in operative planning, in selecting women for minimal invasive surgery, and in ensuring that any extensive surgery is performed by well-trained surgeons.

 

In this literature, they aim to evaluate the preoperative methods of hysteroscopically directed biopsies, transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) for the evaluation of tumor grade, myometrial invasion, and cervical involvement in women referred due to atypical hyperplasia or endometrial cancer.

 

They found that, with an accuracy of 92%, hysteroscopy-directed biopsy was significantly better than endometrial biopsy (58%) in differentiating atypical endometrial hyperplasia from cancer, whereas no differences were found when differentiating grade 3 tumor from grade 1–2 or grade 0–2 tumors.(Table 3).

 

 

 

Table 3. Accuracy of dirrerent diagnostic tests for differentiating atypical endometrial hyperplasia from carcinoma (grade 1, 2, or 3)

 

 

 

The estimation of deep myometrial invasion (>50%) was significantly better using MRI (accuracy: 82%) than using TVS (accuracy: 74%), while the estimation of cervical involvement was significantly more accurate using hysteroscopy-directed biopsy (accuracy: 95%) than MRI (84%) or TVS (80%), even though the sensitivity using hysteroscopy-directed biopsies for identifying women with cervical involvement was only 73% (Table 4).

 

 

 

Table 4. Accuracy of different diagnostic tests for evaluating low- and high-risk features of uterus myometrial invasion and cervical involvement.

 

 

 

When combined, MRI and hysteroscopy-directed biopsies revealed significantly better accuracy (81%) than all other combinations of tests, except MRI and revised biopsy, for the differentiation between true low-risk women and true high-risk women, with a sensitivity of 83% and a specificity of 79% (Table 5).

 

 

 

Table 5. Combination of different diagnostic tests for predicting apparent and true low- and high-risk endometrial carcinoma

 

 

 

CONCLUSION

 

Preoperative staging with MRI and hysteroscopy-directed biopsy have the highest efficacy for differentiating between low- and high-risk endometrial cancer (accuracy 81%).

 

Hysteroscopy-directed biopsies had the highest accuracy for identifying cervical invasion.

 

Optimal preoperative method would have the advantage of:

 

ü   preparing patient for the extent of surgery needed

 

ü   differentiating level of surgical expertise present in OR

 

ü   allocating patient to minimal invasive surgery

 

ü   preserving radical hysterectomy for those with cervical involvement

 

,