Synchronous Ovarian and Endometrial Cancer: A Cognitive Dissonance

Ankita Mallick; Mansi Shukla; Divya Kukreja; Kirti Srivastava; Madan Lal Brahma Bhatt

doi:10.4103/bjoc.bjoc_11_22

CASE REPORT

Year : 2022 | Volume : 2 | Issue : 1 | Page : 51-52

Synchronous Ovarian and Endometrial Cancer: A Cognitive Dissonance

Ankita Mallick¹, Mansi Shukla², Divya Kukreja³, Kirti Srivastava², Madan Lal Brahma Bhatt²
¹ Tata Medical Centre, Kolkata, India
² King George’s Medical University, Lucknow, India
³ Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Submission	23-Nov-2022
Date of Decision	06-Jan-2023
Date of Acceptance	02-Mar-2023
Date of Web Publication	31-Mar-2023

Correspondence Address:
Ankita Mallick
Department of Radiotherapy, Lala Lajpat Rai Memorial Medical College, Garh Road, Meerut 250004, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjoc.bjoc_11_22

Abstract

Synchronous ovarian and endometrial carcinoma, the name itself creates a huge confusion regarding the diagnosis or treatment strategy. We have reported a case of a 54-year-old female patient, who presented to our department with synchronous ovarian and endometrial carcinoma, and here we have discussed the management strategies, which were undertaken.

Keywords: Adjuvant treatment, brachytherapy, chemotherapy, ESGO-ESTRO, external beam therapy, histopathology, synchronous

How to cite this article:
Mallick A, Shukla M, Kukreja D, Srivastava K, Bhatt ML. Synchronous Ovarian and Endometrial Cancer: A Cognitive Dissonance. Bengal J Cancer 2022;2:51-2

How to cite this URL:
Mallick A, Shukla M, Kukreja D, Srivastava K, Bhatt ML. Synchronous Ovarian and Endometrial Cancer: A Cognitive Dissonance. Bengal J Cancer [serial online] 2022 [cited 2023 Jun 7];2:51-2. Available from: http://www.bengaljcancer.org/text.asp?2022/2/1/51/373312

Key Messages:

It is important to differentiate between synchronous malignancies and metastases from primary malignancy to a different site as it helps to guide a clinician about the prognosis and the appropriate management.

Introduction

The presence of two different malignancies in a person at the same time is termed as synchronous. Rarely, clinicians encounter synchronous ovary and endometrial carcinoma during their practice. As per literature reviews, 5% of “endometrial carcinomas” and 10% of “ovarian carcinomas” are associated with synchronous tumors in the ovary or endometrium, respectively.^[1] Ovarian cancer may be either a primary ovarian cancer or metastatic disease to ovary, and the diagnosis becomes a clinical and histological challenge often.^[2] This has prognostic and therapeutic implications. 5-year overall survival rates of 92% in women with synchronous cancers of the endometrium and ovary versus 48% in those with endometrial cancer with ovarian metastasis have been found.^[3]

This case study outlines the presentation, diagnosis, and subsequent management of a patient, who presented in the Radiotherapy Department of a tertiary care academic hospital in North India.

Case History

A 54-year-old post-menopausal lady with no known co-morbidities presented to us in April 2021 with a complaint of lower abdominal pain and vaginal spotting from the past 4 months. Magnetic resonance imaging of lower abdomen and pelvis showed—T1/T2 intermediate signal intensity lesion measuring of 21 × 17 × 20 mm³ in endometrial cavity with loss of endometrial interface in fundus and body region, with no infiltration of uterine serosa. No adnexal lesion was identified. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and bilateral pelvic lymph nodes dissection with infra-colic omentectomy.

On postoperative histopathologic examination, polypoidal mass of 1.7 × 1.5 × 1 cm³ in the endometrium showing serous carcinoma (grade III) was identified with less than 50% myometrium involvement. Cervix and parametrium were not involved. Lympho-vascular invasion was absent. Left adnexa showed no evidence of tumor. Right adnexa showed friable grey white tumor measuring 2.5 × 2.2 × 2 cm³ with serous histology. Pelvic lymph nodes were not involved bilaterally.

On the basis of pathological criteria set by Ulbright and Rothand,^[4] which was later modified by Herrington,^[5] a final diagnosis of synchronous primary serous carcinoma of ovary and endometrium was made by clinicopathological co-relation. Mutation testing for p53abn, POLEmut, and MMRd/NSMP were not done due to unavailability.

Treatment

The patient received two cycles of chemotherapy in the form of two drug regimen—Injection Paclitaxel (175 mg/m²) and Injection Carboplatin (area under curve = 6), given three weekly. Chemotherapy was followed by external beam radiotherapy to pelvis (50 gray in 25 fractions, 2 gray per fraction, 5 days a week, over 5 weeks) and intravaginal brachytherapy (two fractions of 6 gray each). Radiation treatment was followed by two cycles of adjuvant chemotherapy (Injection Paclitaxel 175 mg/m² and Injection Carboplatin area under curve = 6). The patient had presented to us in April 2021, and her treatment was completed in December 2021. She has been on regular follow-up for the past 1 year and is currently disease-free.

Discussion

Synchronous malignancies refer to the case, in which a second primary malignancy is detected within 6 months of primary malignancy. To confirm this, the possibility that one is metastases from the other should be excluded. We have presented a rare case of synchronous primary cancer of ovary and endometrium. As per the literature, synchronous malignancy can be differentiated from metastases on the basis of genetic testing such as TP53 mutation and loss of heterozygosity patterns. Moreover, being a rare presentation, no standard treatment protocol is available for its management. It is important to differentiate between synchronous malignancies and metastases from primary malignancy to a different site as both have different prognosis. Metastatic disease usually has a poor prognosis, whereas synchronous tumors can have variable prognosis ranging from good to bad depending on the stage at which they are detected. Also, the intent of treatment can change from definitive to palliative if metastases is detected. The real dilemma for our case was to generate and deliver appropriate treatment. As mutation testing or next generation sequencing was not available, there was an uncertainty regarding whether it is a true synchronous primary of ovary and endometrium; or it is metastasis from endometrium going to ovary or vice versa. The tumor staging is IA if it is considered double primary tumor, and no further adjuvant treatment is required after surgery. But it is staged as IIIA based on the endometrial primary or as stage II based on the ovarian primary.^[6],[7] If diagnosed as stage IIIA or stage II, adjuvant treatment is required after surgery. Concin et al. stated patients with clonally related low-grade endometrioid carcinomas to be managed without adjuvant treatment (as if they were two independent primaries) when fulfilling the following criteria.^[8] (a) low-grade endometrioid morphology, (b) no more than superficial myometrial invasion, (c) absence of lympho vascular space invasion, and (d) absence of additional metastases.^[9] But in this case, as histopathology was serous so the above criteria were not fulfilled. The rationale of the treatment regimen was based on the fact that the diagnosis was made clinicopathologically without molecular testing, so adjuvant treatment should be given considering it as stage IIIA rather than stage IA. Moreover, grade III histology favored adjuvant treatment. The implementation of European guidelines without easy feasibility of advanced technologies in routine use in Indian practice is a debatable thing and should be considered weighing the benefit/risk of a patient in the long haul. That is why the discordance among personalized treatment exists.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Blake Gilks C, Singh N. Synchronous carcinomas of endometrium and ovary: A pragmatic approach. Gynecol Oncol Rep 2018;27:72-3.
2.	Moro F, Leombroni M, Pasciuto T, Trivellizzi IN, Mascilini F, Ciccarone F, et al. Synchronous primary cancers of endometrium and ovary vs endometrial cancer with ovarian metastasis: An observational study. Ultrasound Obstet Gynecol 2019;53:827-35.
3.	Oranratanaphan S, Manchana T, Sirisabya N. Clinicopathologic variables and survival comparison of patients with synchronous endometrial and ovarian cancers versus primary endometrial cancer with ovarian metastasis. Asian Pac J Cancer Prev 2008;9:403-7.
4.	Ulbright TM, Roth LM. Metastatic and independent cancers of the endometrium and ovary: A clinicopathologic study of 34 cases. Hum Pathol 1985;16:28-34.
5.	Herrington CS. Tumors of the Ovary, Maldeveloped Gonads, Fallopian Tube and Broad Ligament. Atlas of Tumor Pathology. Third Series, Fascicle 23 Robert E. Scully, Robert H. Young and Philip B. Clement. Armed Forces Institute of Pathology, Washington, DC, 1998. J Pathol 1999;189:145-145.
6.	Concin N, Matias-Guiu X, Vergote I, Cibula D, Mirza MR, Marnitz S, et al. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Int J Gynecol Cancer 2021;31:12-39.
7.	Shin W, Park SY, Kang S, Lim MC, Seo SS. How to manage synchronous endometrial and ovarian cancer patients? BMC Cancer 2021;21:489.
8.	Concin N, Matias-Guiu X, Vergote I, Cibula D, Mirza MR, Marnitz S, et al. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinomaInternational. J Gynecol Cancer 2021;31:12-39.
9.	Cree IA, White VA, Indave BI, Lokuhetty D. Revising the WHO classification: Female genital tract tumours. Histopathology 2020;76:151-6.