Isolated metastasis to the foot as an extremely rare presenting feature of primary endometrial cancer

Prognostic factors in endometrial cancer patients with bone metastasis

OBJECTIVES

This study aims to examine the pattern and prognosis of osseous involvement and the role of orthopedic surgery in patients with endometrial cancer (EC) and to evaluate the quality of life, local tumor control, and survival of patients.

PATIENTS AND METHODS

Between January 2011 and December 2018, a total of 14 patients (median age: 60.5 years; range, 55 to 73 years) who were surgically treated for osseous metastasis of EC and followed for minimum 12 months were retrospectively analyzed. All patients were evaluated for their primary malignancy, characteristics of bone metastasis, and type of treatment related to musculoskeletal involvement. For evaluating the functional outcomes, the Visual Analog Scale (VAS) for pain and Eastern Cooperative Oncology Group (ECOG) performance status scale were used in the pre- and postoperative period.

RESULTS

The median follow-up was 34.5 (range, 9 to 89) months. All patients had advanced-stage disease (FIGO Stage III-IV). Four patients had solitary and 10 patients had multiple bone metastases. The mean VAS score and ECOG performance status grades improved (p<0.001 and p<0.05, respectively). The median survival after detection of bone metastasis was 61 (range, 41 to 82) months.

CONCLUSION

Endometrial cancer patients with musculoskeletal pain should be investigated for the possibility of bone metastasis to tailor a prompt treatment and to achieve a better prognosis. Appropriate surgical treatment of bone metastasis may improve both pain and performance status in carefully selected patients.

Leptin receptor expression during the progression of endometrial carcinoma is correlated with estrogen and progesterone receptors

INTRODUCTION

The hormone leptin, which is produced in the adipose tissue, may influence tumorigenesis directly via its receptor (Ob-R). Thus, a role for Ob-R in endometrial carcinogenesis has been proposed. However, most studies neither included samples of the entire histological progression of endometrial carcinoma nor examined Ob-R jointly with the estrogen and progesterone receptors (ER and PR, respectively).

MATERIAL AND METHODS

To determine the fluctuations of Ob-R, ER, and PR during the histological progression of endometrial carcinoma, we assessed their expression via immunohistochemistry (IHC) in six histological types of endometrium (proliferative, secretory, nonatypical and atypical hyperplasia, and endometrioid and nonendometrioid endometrial carcinoma), in which we performed histopathological and digital scoring for the quantification of receptors.

RESULTS

We found that Ob-R expression was positively correlated with that of ER and PR (r = 1, p < 0.001; r = 0.943, p < 0.005, respectively), and there was a significant difference in Ob-R expression among proliferative normal endometrium, hyperplasias, and carcinomas, according to their relative digitally scored Ob-R expression (p < 0.001). In addition, we observed that Ob-R expression in the secretory endometrium was more similar to that of carcinomas than to its proliferative counterpart.

CONCLUSIONS

These results indicate that Ob-R expression fluctuates during endometrial carcinogenesis in correlation with ER and PR, suggesting that Ob-R expression in vivo is highly dependent on estrogen and progesterone activities in the endometrium and on its ER and PR status, as suggested previously by in vitro studies.

Endometrial study in patients with postmenopausal metrorrhagia

INTRODUCTION

The aim of the study was to devise a strategy to diagnose malign endometrial pathologies (adenocarcinoma or atypical hyperplasia) that minimizes the number of invasive tests done (hysteroscopy, aspiration biopsy or curettage) with no loss of its detection efficiency.

MATERIAL AND METHODS

We retrospectively studied the clinical histories of 779 postmenopausal women at the University Hospital Complex of Albacete, for whom an endometrial study had been done (hysteroscopy, aspiration biopsy or curettage) with a 1-year follow-up between 1 March 2006 and 31 March 2008.

RESULTS

There were 77 cases of a malignant pathology (66 adenocarcinomas and 11 hyperplasias with atypia); 96.1% had metrorrhagia, and there were only 3 cases of asymptomatic patients (all 3 presented endometrial thickness of > 5 mm: 10, 12 and 15 mm). The sensitivity and specificity of the transvaginal ultrasound, with a 5 mm cut-off point to diagnose a malignant pathology, were 98.4% and 30.1%, respectively; 89.1% and 99.6%, respectively, for aspiration biopsy; 83.9% and 99.1%, respectively, for hysteroscopy without biopsy; and both were 100% for biopsy. Statistical significance was considered at p < 0.05 and confidence intervals were calculated at 95%.

CONCLUSIONS

In postmenopausal women with metrorrhagia, the first action to take is to do a transvaginal ultrasound, followed by en endometrial study, but only if the endometrium is irregular or endometrial thickness is ≥ 5 mm; in asymptomatic women, the cut-off point should be set at 10 mm. The immediate method of choice is an ambulatory biopsy.

An Unusual Solitary Metatarsal Metastasis from an Endometrioid Endometrial Adenocarcinoma

Patient: Female, 62

Final Diagnosis: Metatarsal metastasis from an endometroid endometrial adenocarcinoma

Symptoms: Painful • swelling hard mass • fixed to the underlying bone of the left foot

Medication: —

Clinical Procedure: Clinical and Gynecological examination • CT scan • left foot MRI • percutaneous core biopsy

Specialty: Oncology

Primary bone metastasis as initial presentation of endometrial cancer (stage IVb)

INTRODUCTION

Endometrial cancer is the most common malignancy among females in developed countries. Abnormal uterine bleeding is the leading symptom in approximately 90 % of cases. The incidence of stage IV disease is approximately 5-10 % with a 5-year overall survival of less than 10 %.

MATERIALS AND METHODS

A rare case presented with femoral pathological fracture and underlying endometrial cancer. We discuss the diagnosis, management and literature review for this extremely rare entity which can be present even in the absence of vaginal bleeding.

RESULTS

Literature search revealed 28 cases with primary bone metastasis and all were symptomatic at the time of diagnosis. Eighty percent of them had tumour on the lower limb and the majority did not have vaginal bleeding. The predominant histopathological type was endometrioid (72.4 %) and grade 1-2 (59 %). Treatment had been individualised and 57 % of the cases underwent surgery with removal of uterus and adnexa and only three patients (10.7 %) received pelvic radiotherapy. Bone tumour was treated with radiotherapy in 80 % of the cases, alone (28 %), or combined with primary surgery (12 %) or chemotherapy (40 %). Overall, 54 % of patients received chemotherapy and 46 % received hormone therapy. The mean survival of patients who presented with single-bone metastasis was significantly better than those with multiple extrauterine metastatic sites: mean 85.7 months (SE: 9.2) versus 22.9 months (SE: 5.2), p < 0.003, CI 95 %. These two different survival patterns are more likely to reflect two different biological disease behaviours. Those with advanced local and widespread disease progress quicker, in contrast to those with a single-bone extrauterine metastatic site and local disease limited to the uterus, which continues to behave as early stage endometrial cancer.

CONCLUSIONS

Although extremely rare, endometrial cancer can present as initial bone pathology. Endometrial biopsy should be included in the patient's workup when investigating for metastatic bone adenocarcinoma of unknown origin, even when gynaecological symptoms are lacking, as this rare presentation of stage IVb endometrial cancer appears to have good survival outcomes.