Rare case of endometrioid adenocarcinoma arising from cystic adenomyosis

Intramural, Extra-endometrial Epithelial Tumor of the Uterine Corpus Associated With Adenomyosis: A Case Report of Clear Cell Carcinoma

An increasing number of case reports have been published regarding the occurrence of extra-endometrial epithelial tumors of the uterine corpus. The majority of these cases are endometrial cancers arising in adenomyosis (EC-AIA). This report describes the case of a postmenopausal woman who presented with a cystic tumor measuring 15 cm in diameter in the pelvic cavity. Prior to surgery, the tumor was considered to be a malignant ovarian cystic tumor with solid components based on imaging studies. A laparotomy was performed, revealing an intramural tumor of the uterine corpus. The intraoperative frozen section diagnosis was inconclusive. Consequently, a hysterectomy with bilateral salpingo-oophorectomy was performed without additional staging procedures. The final histopathological examination by permanent section revealed that the tumor was histologically composed of clear cell carcinoma, accompanied by adenomyotic foci in the surrounding myometrium. It is noteworthy that while most uterine intramural tumors are mesenchymal in nature, intramural extra-endometrial epithelial tumors such as EC-AIA can also manifest as uterine intramural tumors.

A Rare Case of Multiple Subserous Uterine Adenomyomas Misdiagnosed as an Ovarian Cyst, Diagnosed and Treated by Laparoscopy

Objective

To report a rare case of multiple subserous uterine adenomyomas diagnosed and treated by laparoscopy.

Case Report

A premenopausal 55-year-old woman was admitted presenting with bilateral adnexal cysts. Preoperative ultrasound and magnetic resonance imaging both indicated a right ovarian cyst. However, during the laparoscopic surgery, it was identified that the cyst was multiple subserosal uterine cystadenomas, which were located on the posterior wall of the uterus and adjacent to the right ovary. Postoperatively, the pathology revealed that it was a subserosal uterine cystadenoma.

Conclusion

Subserous adenomyomas, a rare subtype of uterine adenomyomas, are commonly reported in the literature as a single adenomyoma. Furthermore, no studies have reported the presence of multiple subserosal adenomyomas. This condition requires attention, and it is essential to differentiate it from ovarian cysts. Subserosal adenomyomas exceeding 8 cm in diameter are rare, with the literature documenting a mere six cases. Larger cysts are associated with a higher likelihood of malignancy. There is currently no effective drug treatment available for this disease. Laparoscopy is an effective method for treating this condition.

Unraveling Cystic Adenomyosis: Diagnostic Odyssey and Surgical Resolution in a Multiparous Woman

Cystic adenomyosis, a rare variant of adenomyosis, poses diagnostic challenges due to its resemblance to other uterine pathologies. We present the case of a 37-year-old multiparous woman with a history of cesarean sections, who presented with heavy menstrual bleeding and progressive pelvic pain. Despite initial medical management, symptoms persisted, prompting further investigation. Ultrasonography initially suggested fibroid degeneration or a neoplastic change, later confirmed by magnetic resonance imaging which showed degenerative changes in fibroid. However, worsening symptoms and failed medical management led to surgical intervention. The patient underwent a total abdominal hysterectomy, revealing cystic spaces filled with altered blood within the myometrium. Histopathological analysis postsurgery confirmed the diagnosis of cystic adenomyosis. This case highlights the diagnostic challenges and therapeutic considerations in managing cystic adenomyosis in multiparous women.

Occult clear cell carcinoma arising from oxidative stress‑exposed cystic adenomyosis: A case report

Although adenomyosis is a benign uterine disease, it can turn malignant in rare instances. Cystic adenomyosis is a rare variation of adenomyosis, arising from which 8 cases of clear cell carcinoma have been reported. However, to the best of our knowledge, there have been no previous reports describing the mechanism by which clear cell carcinoma develops from cystic adenomyosis. The present report documents a case of a 73-year-old woman who was referred to Kanazawa University Hospital (Kanazawa, Japan) because of cystic adenomyosis, with a solid part inside the cyst. The patient was diagnosed with cystic adenomyosis at Shonan Obstetrics and Gynecology Hospital (Hakusan, Japan) 17 years prior; however, the size of the cyst increased after menopause. Therefore, malignant transformation was suspected, which warranted simple abdominal hysterectomy and bilateral salpingo-oophorectomy. The final diagnosis of the present case was uterine corpus cancer, clear cell carcinoma, stage IA. Immunohistochemical staining revealed that the normal and transitional atypical epithelial cells lining the cyst wall, in addition to the clear cell carcinoma cells (which were inside mural nodules located on the cyst wall), were positive for 8-hydroxy-20-deoxyguanosine. This observation suggested the presence of chronic oxidative stress around the cystic adenomyosis. Therefore, the present case suggests the possible involvement of chronic oxidative stress in the malignant transformation of cystic adenomyosis to clear cell carcinoma. This mechanism of malignant transformation of cystic adenomyosis appears to be similar to that of the malignant transformation of endometriotic cysts. Therefore, if the size of the cystic adenomyosis increases after menopause or if the solid part appears in the cyst in future cases, then the possibility of malignant transformation should be considered.

Whether surgical procedure can improve the prognosis of endometrial cancer arising in adenomyosis (EC-AIA)? A systematic review and meta-analysis

PURPOSE

Endometrial cancer arising in adenomyosis (EC-AIA) is frequently detected accidentally following a general hysterectomy for adenomyosis. Whether supplemental lymphadenectomy in patients with EC-AIA can improve the survival outcome remains inconclusive. Herein, the authors summarized the data of patients with EC-AIA and further explored the impact of lymphadenectomy on the prognosis of these patients.

METHODS

Five electronic databases, namely MEDLINE, Web of Science, PubMed, Embase, and the Cochrane Library were employed for searching articles from inception to May 2023.

RESULTS

In total, 38 eligible studies enrolling 56 patients were included. Of these, 44 patients had a traceable prognosis. Kaplan-Meier curves demonstrated that patients who had undergone lymphadenectomy had a better progression-free survival (PFS) compared with those who had not undergone lymphadenectomy ( P =0.016), but there was no difference in overall survival. Univariable ( P =0.025, HR=0.25, 95% CI=0.08-0.84) and multivariable ( P =0.042, HR=0.13, 95% CI=0.020-0.930) Cox regression analyses revealed that lymphadenectomy was an independent protective factor for PFS.

CONCLUSION

For patients diagnosed with EC-AIA following hysterectomy for benign disease, further supplementary lymphadenectomy is recommended to improve PFS.

Endometrioid adenocarcinoma arising from adenomyosis: two case reports and a literature review

Background

Endometrioid adenocarcinoma is usually diagnosed by endometrial curettage with a positive rate of 94%, while a hysteroscopic examination can increase the positive rate. Differently, endometrioid adenocarcinoma arising from adenomyosis (EAAFA) is always misdiagnosed, even after endometrial curettage or hysteroscopy. EAAFA is rarely reported.

Case description

We reported two cases of EAAFA with long-term follow-ups of 9-10 years. The two cases were misdiagnosed even if endometrial curettage or hysteroscopy was performed. One case complained of postmenopausal vaginal bleeding with elevated CA199, and she was diagnosed by fast-frozen pathology during hysterectomy, followed by bilateral salpingo-oophorectomy and pelvic lymphadenectomy. In another case, a premenopausal woman with acquired progressive dysmenorrhea was diagnosed as EAAFA by the histopathological result after a transvaginal hysterectomy and had to undergo reoperation. The FIGO stage was IB in both cases. Chemotherapy or radiotherapy was performed after the operation. Patients were followed up for 9-10 years, with no metastasis or recurrence being observed.

Conclusion

The diagnosis of EAAFA is always delayed because of tumor-free eutopic endometrium and negative results of the endometrial curettage or hysteroscopy examination. Fast-frozen pathology of the whole uterus helps diagnose EAAFA precisely and avoids reoperation. Adenocarcinoma foci of EAAFA usually involve the myometrium deeply. A better prognosis of EAAFA should be expected due to good differentiation and negative lymphovascular space invasion.

Endometrial Cancer Arising in Adenomyosis (EC-AIA): A Systematic Review

Endometrial cancer arising in adenomyosis (EC-AIA) is a rare uterine disease characterized by the malignant transformation of the ectopic endometrium within the adenomyotic foci. Clinicopathological and survival data are mostly limited to case reports and a few cohort studies. We aimed to assess the clinicopathological features and survival outcomes of women with EC-AIA through a systematic review of the literature. Six electronic databases were searched, from 2002 to 2022, for all peer-reviewed studies that reported EC-AIA cases. Thirty-seven EC-AIA patients from 27 case reports and four case series were included in our study. In our analysis, EC-AIA appeared as a rare disease that mainly occurs in menopausal women, shares symptoms with endometrial cancer, and is challenging to diagnose preoperatively. Differently from EC, it shows a higher prevalence of the non-endometrioid histotype, advanced FIGO stages, and p53-signature, which might be responsible for its worse prognosis. Future studies are necessary, to confirm our findings and further investigate this rare condition.

Carcinosarcoma of the uterus, derived from subserous cystic adenomyosis, presenting as an acute abdomen: A case report and review of the literature

When a woman presents with an acute abdomen with cystic lesions in the abdominal cavity, the differential diagnosis includes torsion or rupture of an ovarian tumor. We report our experience with a 54-year-old nulliparous woman who underwent emergency surgery for a suspected ruptured ovarian tumor. Intraoperative examination revealed disruption of a cystic tumor that had developed externally from the fundus of the uterus. The patient, who was taking aspirin because of a history of medullary infarction, reported lower abdominal discomfort for several days. When she sought care, she was referred to the gynecology department where transvaginal ultrasonography and contrast-enhanced computed tomography showed a poorly toned mass with a maximum diameter of 20 cm posterior to the uterus. She also had a large amount of ascites reaching around the liver and the spleen. She underwent an emergency laparotomy for a presumed diagnosis of acute abdomen caused by a ruptured ovarian tumor with intra-abdominal bleeding. Intraoperative examination revealed normal adnexae bilaterally, but there was a cystic tumor in the pouch of Douglas that was strongly adherent to the surrounding intestines. This mass was connected to the posterior uterus by a stalk and appeared to be continuous with the uterine tissue. The postoperative pathological diagnosis was carcinosarcoma derived from subserous cystic adenomyosis. This is the first case report of carcinosarcoma developing from subserous cystic adenomyosis in the English literature as far as we know.

Subserous Cystic Adenomyosis: A Case Report and Review of the Literature

Introduction

Cystic adenomyosis is a rare type of adenomyosis that often occurs in adolescents or women of childbearing age. Due to the few reports of this case, its clinical characteristics have not been clearly established.

Case Presentation

We treated a 32-year-old married patient with cystic adenomyosis that reported persistent abdominal pain and massive vaginal bleeding, so an emergency laparotomy was performed. The intraoperative findings and post-operative pathology proved that the diagnosis was correct. The prognosis of the patient is good, and there is no recurrence within 3 months after surgery.

Results

Surgery is the most effective way to treat cystic adenomyosis. Ultrasound and magnetic resonance are the most effective auxiliary examinations for diagnosing the disease.

Conclusion

Cystic adenomyosis is a sporadic disease. This article summarizes this condition's clinical manifestations, pathological features, diagnosis, treatment, and prognosis by reviewing the existing literature and the case presented in this report. It is noteworthy that early diagnosis and individualized treatment strategies can improve patients' quality of life.

Ciliated Cell Variant of Endometrial Carcinoma in an Adenomyoma in Uterus

Ciliated cell variant of endometrioid adenocarcinoma (CCVEA) is an extremely rare tumor that has been seldom reported in the literature as low-grade endometrioid carcinoma with a favorable prognosis. CCVEA is characterized by neoplastic glands composed predominantly of ciliated cells with relatively little nuclear atypia. Recognition of the ciliated component is the key to the diagnosis of CCVEA but it can lead to diagnostic confusion with tubal metaplasia especially on endometrial biopsies. Herein, we report the case of a 56-year-old woman who presented with post-menopausal vaginal bleeding. Endometrial biopsy revealed extensive atypical complex endometrial hyperplasia composed predominantly of ciliated cells. The patient subsequently had a hysterectomy and bilateral salpingo-oophorectomy that revealed a large adenomyoma, adherent to the right ovary. The adenomyoma was extensively involved by CCVEA with some extension to the endometrial cavity. To the best of our knowledge, this is the first report of CCVEA that appears to arise in an adenomyoma.

Pathology and Pathogenesis of Adenomyosis

Adenomyosis represents a unique pathophysiological condition in which normal-appearing endometrial mucosa resides within myometrium and is thus protected from menstrual shedding. The resulting ectopic presence of endometrial tissue composed of glands and stroma is thought to affect normal contractile function and peristalsis of uterine smooth muscle, causing menometrorrhagia, infertility, and adverse obstetric outcomes. Since the first description of adenomyosis more than 150 years ago, pathologists have studied this lesion by examining tissue specimens, and have proposed multiple explanations to account for its pathogenesis. However, as compared with endometriosis, progress of adenomyosis research has been, at best, incremental mainly due to the lack of standardized protocols in sampling tissue and a lack of consensus diagnostic criteria in pathology practice. Despite these limitations, recent advances in revealing the detailed anatomy and biology of eutopic endometrium offer an unprecedented opportunity to study this common but relatively understudied disorder. Here, we briefly summarize the pathological aspects of adenomyosis from an historical background, and discuss conventional morphology and recent tissue-based molecular studies with a special emphasis on elucidating its tissue of origin from a pathologist's perspective. We also discuss unmet needs in pathology studies that would be important for advancing adenomyosis research.

Subserosal adenomyotic cysts and peritoneal inclusion cysts - Unusual differential diagnoses of multicystic pelvic masses: A review of two cases

Background

Multiloculated pelvic cysts are commonly misdiagnosed as ovarian tumors or malignancies. We report 2 patients diagnosed with subserosal adenomyotic cysts and peritoneal inclusion cysts, mimicking multiloculated pelvic tumors. We discuss their clinical presentation, investigations, operation findings, and histopathology, present a literature review.

Cases

Case 1 was a 44-year-old patient with abnormal uterine bleeding. Imaging showed an enlarging multiloculated cystic structure over the right uterine wall. She underwent a diagnostic laparoscopy and right salpingo-ophorectomy. Intra-operatively, she was found to have multiple subserosal uterine cysts, diagnosed as adenomyotic cysts on histology.

Case 2 was a 50-year-old patient with history of laparoscopic cystectomy done 20 years ago. She was incidentally found to have a multiloculated cystic lesion in the pelvis. The lesion was located midline, anterior and superior to the uterus and bladder. She underwent a total abdominal hysterectomy, bilateral salpingo-ophorectomy, and bladder peritonectomy. Intra-operatively, multiple cystic lesions were noted over the anterior and fundus of uterus, bladder peritoneum, and pelvic side walls. The condition was confirmed to be peritoneal inclusion cysts on histology.

Conclusion

Subserosal adenomyotic cysts are a rare presentation of adenomyosis. They typically occur in premenopausal women. Treatment is usually by hormonal medications or surgical excision.

Many patients with peritoneal inclusion cysts have a history of peritoneal insults. Surgical excision is the most commonly described management as they often mimic malignancy. Both conditions are unusual presentations of multiloculated pelvic masses. A high recurrence rate is found, hence long-term follow-up with imaging is essential.

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Adenomyotic cysts can present as multiple cystic lesions found within the uterine myometrium, submucosal or subserosal layers, lined with endometrial epithelium and stroma.

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Patients with adenomyotic cysts commonly present with dysmenorrhoea or dysfunctional uterine bleeding. These cysts are usually excised surgically or treated with hormonal methods.

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Peritoneal inclusions cysts are benign aggregate masses of variable sized, fluid-filled, mesothelial lined cysts of the pelvis and abdomen, commonly with a history of previous insult to the peritoneum

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Surgical excision of the peritoneal inclusion cysts is the most common treatment option, often for histological diagnosis as it mimics malignancy.

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Recurrence is common for both conditions, hence long term follow ups with imaging should be considered.

Endometrial cancer arising from adenomyosis: Case report and literature review of MRI findings

Endometrial cancer arising from adenomyosis (EC-AIA) is extremely rare, and the typical magnetic resonance imaging (MRI) findings of EC-AIA have not been established. We report a case of EC-AIA that was detected preoperatively on MRI and conduct a literature review of the MRI findings of EC-AIA.

Malignant changes in adenomyosis in patients with endometrial adenocarcinoma: A case series

The aim of the study is to describe the clinical characteristics and prognosis of malignant transformation of adenomyosis in patients with endometrial cancer.In this retrospective descriptive study, the clinical data of patients with endometrial cancer (n = 127) who were admitted at our hospital between January 2006 and December 2013 were evaluated.Among the 127 patients with endometrial cancer, 24 patients had endometrial cancer concurrently with adenomyosis. Among these 24 patients, 3 were diagnosed with malignant transformation of adenomyosis. Postoperative pathological investigations in the cancer+adenomyosis group revealed endometrial adenocarcinoma of Grade I (n = 21) and II (n = 3). The patients with malignant transformation of adenomyosis were relatively younger than the other patients. In those 3 patients, both the estrogen and progesterone receptors were strongly expressed in eutopic endometrium and were weakly positive in ectopic endometrium.Although adenomyosis is usually benign, it might also be a precursor of malignant disease. As the incidence of adenomyosis malignant transformation is low, and its clinical manifestations are nonspecific, it may only be confirmed by postoperative pathological examination. Further investigations on larger sample size may provide additional data about prognosis of adenomyosis malignant transformation.

Endometrial cancer arising in adenomyosis versus endometrial cancer coexisting with adenomyosis: are these two different entities?

PURPOSE

While adenomyosis is one of the most common benign histologic findings in hysterectomy specimens of endometrial cancer, demographics of endometrial cancer arising in adenomyosis (EC-AIA) has not been well elucidated. The aim of this study is to evaluate histopathological findings and disease-free survival (DFS) of EC-AIA in comparison to endometrial cancer coexisting with adenomyosis (EC-A).

METHODS

EC-AIA cases were identified via a systematic literature search (n = 46). EC-A cases were identified from a historical cohort that underwent hysterectomy-based surgical staging in two institutions (n = 350). Statistical comparisons of the two groups were based on univariate and multivariate analyses.

RESULTS

The EC-AIA group was significantly older than the EC-A group (58.9 versus 53.8, p = 0.002). As to tumor characteristics, 63.6% of EC-AIA cases reported tumor within the myometrium without endometrial extension. The EC-AIA group was significantly associated with more non-endometrioid histology (23.9 versus 14.8%; p = 0.002) and deep myometrial tumor invasion (51.6 versus 19.4%; p < 0.001) than EC-A. Tumor grade, stage, and nodal metastasis risk were similar (all, p > 0.05). In a univariate analysis, the EC-AIA group had a significantly decreased DFS compared to EC-A (5-year rates, 72.2 versus 85.5%, p = 0.001). After controlling for age, histology, tumor grade, and stage, EC-AIA remained an independent prognostic factor associated with decreased DFS compared to EC-A (adjusted-hazard ratio 2.87, 95% confidence interval 1.44-5.70, p = 0.031).

CONCLUSION

Our study demonstrated that EC-AIA has distinct tumor characteristics and a poorer survival outcome compared to EC-A. This suggests a benefit of recognition of this unique entity as an aggressive variant of endometrial cancer.

Tumor Characteristics and Survival Outcome of Endometrial Cancer Arising in Adenomyosis: An Exploratory Analysis

BACKGROUND

Endometrial cancer arising in adenomyosis (EC-AIA) is a rare entity of endometrial cancer, and its clinical significance has not been well studied. This study aimed to examine the tumor characteristics and survival outcomes of EC-AIA.

METHODS

An exploratory analysis was performed to compare EC-AIA and historical control cases. For this study, EC-AIA cases were identified via a systematic literature search using PubMed/MEDLINE with entry keywords "endometrial cancer OR uterine cancer" AND "adenomyosis" (n = 46). The control group comprised consecutive non-EC-AIA cases from four institutions that had hysterectomy-based surgical staging (n = 1294). Patient demographics, pathology results, and survival outcomes were evaluated between the two groups.

RESULTS

The EC-AIA group was significantly older than the control group (58.9 vs. 55.3 years; P = 0.032). In terms of tumor characteristics, 56.5% of the EC-AIA cases showed tumor within the myometrium without endometrial extension, and the EC-AIA group was significantly more likely to have tumors with more than 50% myometrial invasion (51.6 vs. 26.6%; P = 0.002) and serous/clear cell histology (22.2 vs. 8.2%, P = 0.002) while less likely to express estrogen receptor (14.3 vs. 84.6%; P < 0.001). Grade and stage distributions were similar (P > 0.05). In the univariate analysis, the EC-AIA group had a significantly poorer disease-free survival than the control group (5-year rate: 71.4 vs. 80.6%; P = 0.014). In the multivariate analysis, with control for age, ethnicity, histology, grade, and stage, EA-CIC remained an independent prognostic factor for decreased disease-free survival (adjusted hazard ratio, 3.07; 95% confidence interval 1.55-6.08; P = 0.001).

CONCLUSIONS

The study suggested that endometrial cancer arising in adenomyosis may be an aggressive variant of endometrial cancer.