|Year : 2014 | Volume
| Issue : 2 | Page : 56-59
Low-grade endometrioid adenocarcinomas presenting as stage III carcinoma
Monika Rathi1, Satish K Budania2, Mohammad Khalid3
1 Department of Pathology, Lala Lajpat Rai Memorial Medical College, Meerut, Teerthanker Mahaveer Medical College and Research center, Moradabad, India
2 Department of Psychiatry, Lady Hardinge Medical College, New Delhi, India
3 Department of Surgery, Mayo Institute of Medical Sciences, Lucknow, India
|Date of Acceptance||06-Jul-2014|
|Date of Web Publication||21-Jan-2015|
228/16, Saket Colony, North Civil Lines, Muzaffarnagar 251 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Endometrioid adenocarcinomas are the most common form of endometrial adenocarcinoma in postmenopausal women. It is stressed that histological grade corresponds to the stage of the tumor and has an impact on the prognosis and survival of the patient. We present a case of 45-year-old female patient who presented with grade 1 endometrioid adenocarcinoma involving bilateral ovaries and peritoneal washings, corresponding to stage IIIa tumor. She also showed the synchronous presence of serous cystadenoma of the right ovary. We report this case as it is an advanced stage endometrioid adenocarcinoma with lower histological grade and also due to the synchronous presence of right ovarian serous cystadenoma.
Keywords: Endometrioid adenocarcinomas, low grade, stage IIIa
|How to cite this article:|
Rathi M, Budania SK, Khalid M. Low-grade endometrioid adenocarcinomas presenting as stage III carcinoma. Niger J Surg Sci 2014;24:56-9
| Introduction|| |
Endometrial cancer is the most common malignant tumor of female genital tract in the developed countries. Pathogenetically, it is thought to be associated with unopposed estrogen stimulation. Estrogen dependent endometrial tumors are usually associated with atypical hyperplasia and are low grade tumors. Majority of the patients present with abnormal uterine bleeding. Most of the patients are postmenopausal.  Most endometrial adenocarcinomas in women aged 40 years or younger are endometrioid type, low grade and early stage. Contrary to this, endometrial carcinomas in the elderly patients belong to a higher grade and higher stage at the time of diagnosis.  It is believed that endometrial cancers, which are low grade, are usually early stage cancers and carry a better prognosis.  We present a case of 45-year-old female, who presented with grade 1 endometrial adenocarcinoma. Despite low grade tumor, not only she presented with metastasis to bilateral ovaries but peritoneal fluid washings were also positive for malignant cells. However, cervix was free from tumor and myometrial invasion was seen in less than one-half of myometrium. We present this case to challenge the belief that histologically low grade tumors in young women are also early stage tumors.
| Case report|| |
A 45-year-old, Indian woman, para I; presented with menorrhagia and malodorous vaginal discharge for 6 months, per vaginal examination showed a vague lump measuring 10 cm × 6 cm on the left side, and right-sided ovarian cyst with tenderness. Computed tomography (CT) showed enlarged uterus with a heterogeneous postcontrast enhancement. Complex left ovarian cyst, large, simple right ovarian cyst and mild pelvic congestion was reported on CT [Figure 1]. Hence, a diagnosis of malignancy was considered, and total abdominal hysterectomy with bilateral oopherectomy was done. Pelvic, para-aortic lymph nodes and omentum were also sampled. Peritoneal fluid collection amounting to 10 mL was seen. This fluid was sent for cytological examination.
Gross examination revealed that the outer surface of the uterus was covered with numerous papillary projections. Uterus with cervix measured 9 cm × 5 cm. There was right ovarian cyst measuring 12 cm × 9 cm, which was filled with clear, serous fluid Bilateral Fallopian tube More Detailss and left ovary were normal [Figure 2]. Microscopic examination showed that endometrium was replaced by tubulo-glandular structures lined by columnar to cuboidal cells with mild atypia and few showing prominent nucleoli, infiltrating up to less than one-half of the myometrium and bilateral ovaries. Right ovary showed the presence of simple serous cyst lined by flattened cuboidal lining and infiltration by the tumor cells. Vascular invasion was seen [Figure 3]a-d. Lymphatic invasion was absent. Considering the fact that the tumor has not invaded the cervix and the myometrium also showed superficial invasion but the uterus showed numerous papillary projection on the outer surface, we did immunohistochemistry to rule out the synchronous presence of co-existing primary ovarian and primary endometrial cancer. Immunohistochemistry was done on endomyometrium and bilateral ovaries. The tumor showed positivity for cytokeratin and vimentin in bilateral ovaries and endomyometrium [Figure 4]a-e. The endometrioid tumor showed positivity for Her 2 neu oncogene, which is again seen in high grade and high-stage tumor and carries bad prognosis.  It is known that primary endometrial carcinoma and primary ovarian carcinoma, both are positive for estrogen receptor, progesterone receptor, cytokeratin 7 and epithelial membrane antigen. However, endometrial adenocarcinoma is positive for vimentin and weakly positive for carcinoembryonic antigen but primary ovarian carcinoma is negative for both. Hence, we concluded that this was primary endometrial adenocarcinoma infiltrating bilateral ovaries.  Ascitic fluid also showed the presence of endometrioid cells [Figure 5]. Pelvic and para-aortic lymph nodes were free of tumor cells. Since it was a high-stage tumor, the patient underwent chemotherapy and was followed-up for a period of 1-year. No recurrence was noted.
|Figure 2: Uterus covered with papillary projections on its outer surface with right sided serous cystadenoma|
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|Figure 3: (a) Endometriod adenocarcinoma infiltrating myometrium (H and E, ×100). (b) Endometrioid adenocarcinoma infiltrating left ovary (H and E, ×100). (c) Right ovary showing serous cystadenoma and endometrioid tumor. (d) Ovarian blood vessel involvement by endometrioid adenocarcinoma|
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|Figure 4: (a) Cytokeratin positive endometrioid carcinoma in endometrium (×100). (b) Vimentin positive endometrioid carcinoma in endometrium (×100). (c) Left ovary showing cytokeratin positive ovarian tumor. (d) Left ovary showing vimentin positive ovarian tumor. (e) Her 2 neu positivity in endometrioid carcinoma (×100)|
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| Discussion|| |
Endometrioid adenocarcinoma is the most common type of endometrial cancer. Grossly, the tumor is either localized polypoidal tumor or diffuse tumor involving the entire endometrial surface.  Microscopically, endometrial adenocarcinomas  and are divided into well differentiated (grade 1 ≤5% solid growth in glandular component excluding squamous component), moderately differentiated (grade 2 = between 5% and 50% solid growth) and poorly differentiated (grade 3 = displaying more than 50% solid growth).  In cases of pronounced nuclear atypia, the grade is raised by one.  This grading is based on the proportion of glandular and solid areas. The frequency and extent of myometrial invasion depends on the microscopic grade of the tumor. High grade tumors are also associated with cervical and lymphovascular invasion. 
The two obvious sites of direct spread of endometrial carcinoma are myometrium and cervix. The most common extrauterine spread in endometrial carcinoma of the endometrioid type are pelvic, para-aortic lymph nodes and ovaries. Approximately, 8% of endometrioid endometrial adenocarcinoma present with co-existent ovarian carcinoma.  Microscopic features suggesting the possibility of metastasis include bilaterality, multinodular growth, implants on the surface of ovary, numerous emboli in the lymphovascular space.  Immunohistochemistry is of limited value. 
According to TNM staging T1 implies that the tumor is limited to the corpus. T2 implies that the tumor has invaded the cervix but has not extended beyond the uterus. T3a implies that the tumor has involved the serosa or adnexa (by direct extension or metastasis) and/or the cancer cells are positive in peritoneal washings or vaginal involvement. T3b means that the vaginal involvement has occurred. T4 implies that the tumor involves the bladder or bowel. N1 means regional lymph node metastasis. M1 means distant metastasis (excluding metastasis to vagina, adnexa and serosa). As per TNM classification our tumor was classified as T3aN0M0. It corresponds to stage IIIA tumor. 
Hence, according to the histological grading system and TNM staging, our case belonged to grade 1 and stage IIIa. The interesting thing about this case is that despite being stage III, it has not involved the cervix. Even myometrial involvement is less than one half. So this is an example of low grade and advanced stage tumor (stage III).
Treatment of endometrial carcinoma includes total abdominal hysterectomy with bilateral salpingo-opherectomy along with surgical staging (including biopsy of para-aortic, pelvic lymph nodes and peritoneal washings). Since it was a high grade tumor, the patient underwent chemotherapy. Relapse of the tumor may occur in the form of local recurrence (50%) or distant metastasis (28%) within a period of 1-2 years. Fortunately, this case was followed-up for a period of 1-year and no relapse was noted.
Factors deciding the prognosis of the tumor include tumor stage, tumor grade, lymphovascular invasion, and Her 2 neu expression.  Although this case had poor prognostic factors like advanced tumor stage, lymphovascular invasion, and Her 2 neu expression but recurrence was not noted on closely following it for 1-year.
| Conclusion|| |
Even low grade endometrioid adenocarcinoma in young women may present with higher stage advanced disease.
| References|| |
Silverberg SG, Kurman RJ, Nogales F, Mutter GL, Kubik-Huch RA, Tavassoli FA. Tumours of the uterine corpus. In: Fattaneh A, editor. Who Classification of Tumours. Tumours of the Breast and Female Genital Organs. France: IARC Press; 2003. p. 219-25.
Rosai J. Female reproductive system. In: Rosai J, editor. Rosai and Ackerman's Surgical Pathology. 10 th
ed. USA: Elsevier Mosby; 2011. p. 1492-501.
Eswari V, Geetha P, Ansari IA, Bhanumathy V, Gomathi P. Endometrioid carcinoma of the ovary and uterus: Synchronous primaries or metastasis: A case report. J Clin Diagn Res 2011;5:875-9.
Zaloudek CF. Tumours of the female genital tract. In: Fletcher CD, editor. Diagnostic Histopathology of Tumours. 3 rd
ed. USA: Churchill Livingstone Elsevier; 2007. p. 660-1.
Lee KR, Young RH. The distinction between primary and metastatic mucinous carcinomas of the ovary: Gross and histologic findings in 50 cases. Am J Surg Pathol 2003;27:281-92.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]