Introduction

Carcinoma endometrium is typically a disease of the perimenopausal /postmenopausal women. The disease is rare in young women. Routine curettage and hysteroscopy guided biopsy is not recommended for oligomenorrhoea or abnormal uterine bleeding in adolescents and young women in their twenties. Medical management is prescribed for controlling and regularizing the cycles. Lack of clinical suspicion and reluctance to do an endometrial evaluation may delay this rare diagnosis of endometrial cancer in the young.

This is highlighted in this case report where an advanced endometrial cancer was encountered in a young woman with infertility.

Case Report

A 22 year old woman, married for 4 years, was being evaluated in a local hospital for infertility and oligomenorrhoea. She had two episodes of profuse vaginal bleeding for which curettage was done by her doctor. Her cycles had been infrequent since menarche. She was a healthy lady with a body mass index of 27/ Kgm². She neither had hypertension nor diabetes. Her general and systemic examinations were unremarkable. Pelvic examination findings were normal. The curettage done at the local hospital was reported as endometrial adenocarcinoma and she was referred to our tertiary center for further treatment. Magnetic Resonance Imaging of the pelvis showed markedly enlarged right iliac lymph nodes displacing and compressing the external iliac vessels (Fig 1).

Figure 1

Figure 1: Axial T1 weighted MR imaging of the pelvis shows enlarged right iliac lymph nodes (arrowhead) displacing and compressing the external iliac vessels (arrow).

The endometrium was unremarkable and the myometrium showed normal signal intensity (Fig 2). Both ovaries revealed multiple small cysts consistent with polycystic ovarian syndrome (PCOS).

Figure 2

Figure 2: Sagittal T2 weighted MR showed normal appearing endometrium (arrow) and myometrium.

Surgical staging done showed normal sized uterus and the adnexa. The strikingly enlarged pelvic and paraaortic lymph nodes extended up to the renal hilus. The cut section of the uterus showed a small endometrial growth near the right cornu. Total hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymphadenectomy was done. The histopathology was reported as Grade III adenocarcinoma, endometrioid type with malignant squamous differentiation, with pelvic and paraaortic lymph node involvement.

Based on the final diagnosis of adenocarcinoma endometrium stage III C (Grade 3), the patient received three courses of adjuvant chemotherapy containing Carboplatin 450mg and Paclitaxel 80mg, followed by radiotherapy (external beam radiotherapy 50Gy/ 25 fractions and four fractions of brachytherapy of 500cG each).

The patient is on regular follow up and the CT scan at the end of one year doesn't show any evidence of recurrence.

Discussion

Endometrial carcinoma in young nulliparous women poses a challenge for diagnosis and management. The diagnosis is often delayed and then conservation of the uterus is not feasible. In young women with low histological grade and early stage disease conservative hormonal therapy has been tried with close follow-up. There are reports of high dose medroxyprogesterone acetate (600mg/day) treatment with endometrial evaluation every 3 months to evaluate the effects of medication₁. Whenever the response has not been satisfactory hysterectomy is advocated. GnRH agonists have also been described for the treatment of atypical endometrial hyperplasia and endometrial adenocarcinoma₂. Nevertheless a close surveillance, planned pregnancy followed by definitive treatment with hysterectomy can be offered to these young women₁, ₂. Pregnancies have been reported in some patients following successful hormonal therapy in receptor positive tumors₁, ₂.

Considering the prognosis, endometrial cancer in young women doesn't differ from that of the older (>45 years) women when histopathology, grade, lymph node involvement and cervical extension are matched. Very often the myometrial involvement and the stage are significantly lower in younger women₃. Of late there are reports of women with PCOS with endometrial cancer at young age. The case reported had clinical evidence of PCOS. Farhi et al. noted consistent association of well differentiated adenocarcinomas with benign squamous differentiation in young women with PCOS₄.

This case highlights the need for endometrial sampling in young women with anovulatory cycles so that hyperplasia can be diagnosed and treated before frank invasion. Even if invasive disease is diagnosed early, at least fertility sparing conservative hormonal therapy can be tried.

Conclusion

Carcinoma endometrium should be kept in mind while evaluating young women with PCOS for abnormal uterine bleeding.

Correspondence to

Guruvare Shyamala Department of Obstetrics and Gynecology Kasturba Medical CollegeManipal- 576104 Phone: (91) 820-2922211 (91) 820-2922586 E mail:shyamala_doc@yahoo.co.in shyamalarajgopal@hotmail.com Fax: +91 820 2571934