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Computed tomography of uterine papillary serous carcinoma
Computerized Radrol. Printed in the U.S.A.
Vol. 8, No. All rights
2, pp. 79-83. reserved
1984 Copyright
0730-4X62/84 S3.00 + 0.00 ‘c: 1984 Pergamon Press Ltd
COMPUTED TOMOGRAPHY OF UTERINE PAPILLARY SEROUS CARCINOMA DEREK J. HAMLIN,’ EDWARD J. WILKINSON,’ LINDA S. MORGAN,’ FRANCIS A. BURGENER~
and JAMES W. WEAVER’ of Radiology, ZDepartment of Pathology, ‘Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL 32610 4Department of Radiology. University of Rochester School of Medicine and Dentistry, Rochester. NY 14627. U.S.A.
‘Department
(Receioed
16 Much
1983; receiwd fi)r puhliculion 9 August
1983)
Abstract-We describe the CT appearances of a fairly commonly encountered “special variant” carcinoma of the uterine corpus called uterine papillary serous carcinoma (UPSC). UPSC closely resembles ovarian papillary serous carcinoma microscopically but CT with contrast can differentiate between these two entities. In addition CT in this patient clearly showed the characteristic spread mode of this particularly aggressive form of endometrial carcinoma. Because UPSC has a significantly higher relapse rate than other histologic types of endometrial carcinoma it is important to recognize it at the time of the CT staging procedure. The spread pattern of UPSC suggests the need for adjuvant irradiation or chemotherapy. Uterine staging
Uterine neoplasms: neoplasms Uterus: computed tomography
computed tomographic diagnosis Computed tomography, technique
Uterine
neoplasms:
INTRODUCTION The computed tomographic features of a case of uterine papillary serous carcinoma (UPSC), a particularly aggressive form of endometrial carcinoma which closely resembles ovarian papillary serous carcinoma microscopically, are subject to this report. This “special variant” carcinoma of the distinct entity uterine corpus has been studied in 60 patients [l] and was found to be a morphologically with a specific spread pattern including deep myometrial invasion, lymphatic permeation, frequent extension to cervix and adnexa and a spread mode over peritoneal surfaces similar to that of ovarian surface epithelial carcinomas. These characteristic modes of tumor spread are demonstrated in the case presented, and aid in the differential diagnosis of this aggressive endometrial carcinoma from the histologically and, in many ways radiographically similar, ovarian carcinoma. This diagnosis is of practical importance, since this tumor has a significantly higher relapse rate than other histologic types of endometrial carcinoma. The spread pattern of the tumor suggests the need for adjuvant upper abdominal and pelvic irradiation or effective chemotherapy in patients with UPSC. CASE REPORT A 65-yr-old black patient presented at the Emergency room complaining of left-sided abdominal pain. On questioning, it was revealed that she had never really had a last menstrual period and had experienced continuous peri-menopausal spotting. Seven months previously she had brought this matter to the attention of a gynecologist at another clinic and was told that she had a growth which was removed vaginally. On examination she was found to have a 20-week size mass in the lower abdomen and also left supraclavicular and bilateral groin adenopathy. Pelvic examination revealed a firm cervix which appeared to be involved with tumor which was also palpable in the lower l/3 of the vagina. New cervical biopsies were taken and left supraclavicular nodes were aspirated under sterile technique, revealing UPSC. Radiographic evaluation of the patient included a chest X-ray which was normal and a CT scan of the abdomen and pelvis. The CT scan, as described more fully below, revealed what appeared to be a large, aggressive, necrotic uterine mass together with an intriguing spread pattern resembling ovarian carcinoma. The use of intravenous contrast facilitated evaluation of the uterine component of the tumor and differentiation of the tumor from an ovarian malignancy. 79
80
DEKEK
J. HAMLIN
r/ mi.
DISCUSSION The most frequently encountered cancer of the uterine corpus is adenocarcinoma but, in fact, different histological patterns make up the morphologically heterogeneous group of tumors classified as endometrial carcinomas, including not only carcinomas composed of glands resembling endometrium (endometrioid carcinomas) but also differentiated epithelial neoplasms embryologically related to the Mullerian system. Thus primary uterine corpus carcinoma may have morphologic features identical to those of mutinous carcinoma of the ovary or endocervix, clear cell carcinoma of the vagina and ovary or squamous carcinomas of the cervix. These “special variant” carcinomas include a highly malignant form of endometrial carcinoma closely resembling ovarian papillary serous carcinoma and therefore appropriately termed uterine papillary serous carcinoma (UPSC). Twenty-six cases of UPSC were identified at the time of a review of 256 cases of pathologic Stage 1 uterine adenocarcinoma treated at Stanford University Hospital between 1960 and 1975: a further 34 cases were identified from surgical pathology reports from 1956 to 1980 [l]. These tumors are easily recognized pathologically and typically feature a high degree of cytologic anaplasia and a papillary growth pattern. Patients with UPSC were found to be postmenopausal, with a mean age of 66 yr and a range of 40-86 yr. (1) Myometrial
intiasion
The Stanford evaluation of uterine papillary serous carcinoma revealed myometrial invasion in 7OY;, of these cases studied microscopically using either endometrial curretage of biopsy. Of importance was the finding that the extent of myometrial invasion was often underestimated at the time of gross examination of the surgical specimen. Computed tomography has been shown to be accurate in determining the depth of myometrial invasion in patients with endometrial carcinoma [2,3] and this information was considered useful as a prognostic indicator and may prove to be valuable in optimizing the selection of appropriate surgical and/or therapeutic procedures. In this patient with UPSC myometrial invasion is extensive and this is clearly demonstrated by CT in Fig. I. This radiologically delineated deep myometrial invasion may also be seen with other histologic types of uterine adenocarcinoma, but it is worth noting that the Stanford study found that 4006 of the evaluable Stage 1 UPSC patients had deep myometrial invasion compared with 12% of those with other forms of adenocarcinoma. Other aspects of the spread pattern of this very aggressive tumor, documented by the Stanford UPSC study and delineated by CT on this patient include invasion of cervix and adnexa, lymphatic permeation and spread over the peritoneal surfaces as detailed below.
Fig. 1. A large uterine tumor is present, with central necrosis and marked invasion of the myometrium anteriorly. The uterus measured 13 cm in length and 11cm in transverse diameter at this level. Low density adnexal tumor (arrowheads) is extensive and is still present on this CT section of the midpelvis. Involvement of common iliac lymph nodes, particularly on the left, is present.
CT of uterine
papillary
serous
carcinoma
81
Fig. 2. The tumor has extended through the lower uterine segment to involve the cervix. The tip of a vaginal tampon (arrow) aids anatomic orientation. The posterior wall of the bladder is indented but is not invaded by tumor.
(2) Cervix, lower uterine segment and adnexal involvement This case shows that the patient has extensive involvement of the lower uterine segment and cervix (Fig. 2). the Stanford data indicates that UPSC involved the cervix and lower uterine segment in 34% of cases. Figure 3 shows extensive adnexal tumor, mostly of low attenuation value (30 Hounsfield units after contrast enhancement) and this bears a striking resemblance to an ovarian carcinoma. The large midabdominal (omental) tumor mass (Fig. 4) would also be consistent with an ovarian carcinoma. (3) Lymphatic invasion UPSC was shown by the Stanford study to frequently permeate the lymphatic spaces (37%). This lymphatic invasion was often underestimated at the time of gross examination of the surgical specimen. This case report shows extensive lymphadenopathy involving multiple pelvic node groups including obturator, external, internal and common iliac lymph nodes (Figs 1,2 and 3) and para-aortic lymph nodes (Fig. 4).
Fig. 3. Myometrial invasion was not adnexal mass (30 H.U. after contrast simulates on ovarian carcinoma such pelvic lymphadenopathy involving
as obvious on this Cl‘ sectron 6 cm caudad to Fig. 1, but the low density enhancement) is well seen and the overall CT appearance at this level as ovarian papillary serous carcinoma. There is also extensive bilateral the external and internal iliac and obturator lymph nodes (arrow).
DI~KEK J. HAMIJN cr tri
Fig
4. A large
omental tumor mass (arrow) (arrowheads) is also present.
(4) Spread over the peritoneal
IS seen tn the midabdomen. Paraaorttc lymphadenopathy particularly on the left of the aorta (A)
sur$zces
In contrast to the usual endometrioid forms of corpus carcinoma which rarely spread over peritoneal surfaces UPSC has a tendency to spread over peritoneal surfaces. This spread pattern is very significant in terms of patient management. Therapeutic failures in these tumors may result from inadequate pretreatment assessment of the full extent of peritoneal spread. CT appears to be the radiologic procedure of choice in delineating peritoneal involvement or recurrences (Fig. 4). In conclusion, we would suggest that CT with contrast enhancement is the radiographic modalty of choice in both the initial staging of endometrial carcinoma (including “special variant” tumors as described above) and in the evaluation of tumor recurrence.
SUMMARY CT has been shown to be of value in both the initial staging of endometrial carcinoma and in the evaluation of tumor recurrence. Specifically, CT with contrast enhancement has been shown to be accurate in determining the depth of myometrial invasion. This information is of prognostic value and also optimizes selection of the appropriate therapeutic procedure. We describe the CT appearances of an important “special variant” carcinoma of the uterine corpus called uterine papillary serous carcinoma (UPSC). This tumor has a significantly higher relapse rate than other histologic types of endometrial carcinoma and adjuvant upper abdominal and pelvic irradiation or effective chemotherapy is therefore needed. The CT features of this tumor variant include deep myometrial invasion, lymphatic involvement, extension to cervix and adnexa and a spread mode over peritoneal surfaces similar to that of ovarian surface epithelial carcinomas. The depiction of myometrial invasion by CT clearly differentiates ovarian carcinoma from UPSC.
REFERENCES M. Hendrickson. J. Ross, P. Eifel, A. Martinez and R. Kempson, Uterine papillary serous carcinoma. Am. J. Surg. Pathol. 6, 93-108 (1982). D. J. Hamlin, F. A. Burgener and J. B. Beecham, CT of intramural endometrial carcinoma: Contrast enhancement is essential, Am. J. Roentg. 137, 551-554 (1981). K. Hasumi, M. Matsuzawa, H. F. Chen, M. Takahashi and M. Sakura, Computed tomography in the evaluation and treatment of endometrial carcinoma, Cancer 50, 904-908 (1982).
CT of uterine
papillary
serous carcinoma
About the Author-DEREK J. HAMLIN. M.D. gradulated in medicine from the University of Cape Town. South Africa. His initial appointment in radiology was at the University of Rochester School of Medicine and Dentistry (1977-1980). He is currently Associate Professor of Radiology and is Chief of Oncologic Radiology and Body CT at the University of Florida College of Medicine. Gainesville. Florida. About the Author-EDWARD
J. WILKINSON received is currently Professor of Pathology and Gynecology Medicine. Gainesville. Florida.
his M.D. from the Medical College of Wisconsin. He and Obstetrics at the University of Florida College of
About the Author-LINDA S. MORGAN received her M.D. from the Medical College of Pennsylvania. After fellowship at Massachusetts General Hospital she commenced her current appointment as Assistant Professor. Oncology Division of Obstetrics and Gynecology. IJniversity of Florida College of Medicine. Gainesville. Florida. the Author-FRANCIS A. BURCENER received his M.D. degree from the University of Berne. Switzerland. He is currently Professor of Radiology at the University of Rochester School of Medicine and Dentistry, Rochester. New York.
About
About the Author-JAMES
W. WEAVER received his A.B. degree from Duke University in 1969 and his M.D. degree from Tulane University in 1973. Dr Weaver served as the Chief of Radiology at the Naval Regional Medical Center in Naples, Italy from 1977 to 1980 when he commenced his appointment as Assistant Professor of Radiology at the University of Florida College of Medicine. He is currently Chief of GI Radiology at the University of Florida College of Medicine. Gainesville, Florida.
x3
Vol. 8, No. All rights
2, pp. 79-83. reserved
1984 Copyright
0730-4X62/84 S3.00 + 0.00 ‘c: 1984 Pergamon Press Ltd
COMPUTED TOMOGRAPHY OF UTERINE PAPILLARY SEROUS CARCINOMA DEREK J. HAMLIN,’ EDWARD J. WILKINSON,’ LINDA S. MORGAN,’ FRANCIS A. BURGENER~
and JAMES W. WEAVER’ of Radiology, ZDepartment of Pathology, ‘Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL 32610 4Department of Radiology. University of Rochester School of Medicine and Dentistry, Rochester. NY 14627. U.S.A.
‘Department
(Receioed
16 Much
1983; receiwd fi)r puhliculion 9 August
1983)
Abstract-We describe the CT appearances of a fairly commonly encountered “special variant” carcinoma of the uterine corpus called uterine papillary serous carcinoma (UPSC). UPSC closely resembles ovarian papillary serous carcinoma microscopically but CT with contrast can differentiate between these two entities. In addition CT in this patient clearly showed the characteristic spread mode of this particularly aggressive form of endometrial carcinoma. Because UPSC has a significantly higher relapse rate than other histologic types of endometrial carcinoma it is important to recognize it at the time of the CT staging procedure. The spread pattern of UPSC suggests the need for adjuvant irradiation or chemotherapy. Uterine staging
Uterine neoplasms: neoplasms Uterus: computed tomography
computed tomographic diagnosis Computed tomography, technique
Uterine
neoplasms:
INTRODUCTION The computed tomographic features of a case of uterine papillary serous carcinoma (UPSC), a particularly aggressive form of endometrial carcinoma which closely resembles ovarian papillary serous carcinoma microscopically, are subject to this report. This “special variant” carcinoma of the distinct entity uterine corpus has been studied in 60 patients [l] and was found to be a morphologically with a specific spread pattern including deep myometrial invasion, lymphatic permeation, frequent extension to cervix and adnexa and a spread mode over peritoneal surfaces similar to that of ovarian surface epithelial carcinomas. These characteristic modes of tumor spread are demonstrated in the case presented, and aid in the differential diagnosis of this aggressive endometrial carcinoma from the histologically and, in many ways radiographically similar, ovarian carcinoma. This diagnosis is of practical importance, since this tumor has a significantly higher relapse rate than other histologic types of endometrial carcinoma. The spread pattern of the tumor suggests the need for adjuvant upper abdominal and pelvic irradiation or effective chemotherapy in patients with UPSC. CASE REPORT A 65-yr-old black patient presented at the Emergency room complaining of left-sided abdominal pain. On questioning, it was revealed that she had never really had a last menstrual period and had experienced continuous peri-menopausal spotting. Seven months previously she had brought this matter to the attention of a gynecologist at another clinic and was told that she had a growth which was removed vaginally. On examination she was found to have a 20-week size mass in the lower abdomen and also left supraclavicular and bilateral groin adenopathy. Pelvic examination revealed a firm cervix which appeared to be involved with tumor which was also palpable in the lower l/3 of the vagina. New cervical biopsies were taken and left supraclavicular nodes were aspirated under sterile technique, revealing UPSC. Radiographic evaluation of the patient included a chest X-ray which was normal and a CT scan of the abdomen and pelvis. The CT scan, as described more fully below, revealed what appeared to be a large, aggressive, necrotic uterine mass together with an intriguing spread pattern resembling ovarian carcinoma. The use of intravenous contrast facilitated evaluation of the uterine component of the tumor and differentiation of the tumor from an ovarian malignancy. 79
80
DEKEK
J. HAMLIN
r/ mi.
DISCUSSION The most frequently encountered cancer of the uterine corpus is adenocarcinoma but, in fact, different histological patterns make up the morphologically heterogeneous group of tumors classified as endometrial carcinomas, including not only carcinomas composed of glands resembling endometrium (endometrioid carcinomas) but also differentiated epithelial neoplasms embryologically related to the Mullerian system. Thus primary uterine corpus carcinoma may have morphologic features identical to those of mutinous carcinoma of the ovary or endocervix, clear cell carcinoma of the vagina and ovary or squamous carcinomas of the cervix. These “special variant” carcinomas include a highly malignant form of endometrial carcinoma closely resembling ovarian papillary serous carcinoma and therefore appropriately termed uterine papillary serous carcinoma (UPSC). Twenty-six cases of UPSC were identified at the time of a review of 256 cases of pathologic Stage 1 uterine adenocarcinoma treated at Stanford University Hospital between 1960 and 1975: a further 34 cases were identified from surgical pathology reports from 1956 to 1980 [l]. These tumors are easily recognized pathologically and typically feature a high degree of cytologic anaplasia and a papillary growth pattern. Patients with UPSC were found to be postmenopausal, with a mean age of 66 yr and a range of 40-86 yr. (1) Myometrial
intiasion
The Stanford evaluation of uterine papillary serous carcinoma revealed myometrial invasion in 7OY;, of these cases studied microscopically using either endometrial curretage of biopsy. Of importance was the finding that the extent of myometrial invasion was often underestimated at the time of gross examination of the surgical specimen. Computed tomography has been shown to be accurate in determining the depth of myometrial invasion in patients with endometrial carcinoma [2,3] and this information was considered useful as a prognostic indicator and may prove to be valuable in optimizing the selection of appropriate surgical and/or therapeutic procedures. In this patient with UPSC myometrial invasion is extensive and this is clearly demonstrated by CT in Fig. I. This radiologically delineated deep myometrial invasion may also be seen with other histologic types of uterine adenocarcinoma, but it is worth noting that the Stanford study found that 4006 of the evaluable Stage 1 UPSC patients had deep myometrial invasion compared with 12% of those with other forms of adenocarcinoma. Other aspects of the spread pattern of this very aggressive tumor, documented by the Stanford UPSC study and delineated by CT on this patient include invasion of cervix and adnexa, lymphatic permeation and spread over the peritoneal surfaces as detailed below.
Fig. 1. A large uterine tumor is present, with central necrosis and marked invasion of the myometrium anteriorly. The uterus measured 13 cm in length and 11cm in transverse diameter at this level. Low density adnexal tumor (arrowheads) is extensive and is still present on this CT section of the midpelvis. Involvement of common iliac lymph nodes, particularly on the left, is present.
CT of uterine
papillary
serous
carcinoma
81
Fig. 2. The tumor has extended through the lower uterine segment to involve the cervix. The tip of a vaginal tampon (arrow) aids anatomic orientation. The posterior wall of the bladder is indented but is not invaded by tumor.
(2) Cervix, lower uterine segment and adnexal involvement This case shows that the patient has extensive involvement of the lower uterine segment and cervix (Fig. 2). the Stanford data indicates that UPSC involved the cervix and lower uterine segment in 34% of cases. Figure 3 shows extensive adnexal tumor, mostly of low attenuation value (30 Hounsfield units after contrast enhancement) and this bears a striking resemblance to an ovarian carcinoma. The large midabdominal (omental) tumor mass (Fig. 4) would also be consistent with an ovarian carcinoma. (3) Lymphatic invasion UPSC was shown by the Stanford study to frequently permeate the lymphatic spaces (37%). This lymphatic invasion was often underestimated at the time of gross examination of the surgical specimen. This case report shows extensive lymphadenopathy involving multiple pelvic node groups including obturator, external, internal and common iliac lymph nodes (Figs 1,2 and 3) and para-aortic lymph nodes (Fig. 4).
Fig. 3. Myometrial invasion was not adnexal mass (30 H.U. after contrast simulates on ovarian carcinoma such pelvic lymphadenopathy involving
as obvious on this Cl‘ sectron 6 cm caudad to Fig. 1, but the low density enhancement) is well seen and the overall CT appearance at this level as ovarian papillary serous carcinoma. There is also extensive bilateral the external and internal iliac and obturator lymph nodes (arrow).
DI~KEK J. HAMIJN cr tri
Fig
4. A large
omental tumor mass (arrow) (arrowheads) is also present.
(4) Spread over the peritoneal
IS seen tn the midabdomen. Paraaorttc lymphadenopathy particularly on the left of the aorta (A)
sur$zces
In contrast to the usual endometrioid forms of corpus carcinoma which rarely spread over peritoneal surfaces UPSC has a tendency to spread over peritoneal surfaces. This spread pattern is very significant in terms of patient management. Therapeutic failures in these tumors may result from inadequate pretreatment assessment of the full extent of peritoneal spread. CT appears to be the radiologic procedure of choice in delineating peritoneal involvement or recurrences (Fig. 4). In conclusion, we would suggest that CT with contrast enhancement is the radiographic modalty of choice in both the initial staging of endometrial carcinoma (including “special variant” tumors as described above) and in the evaluation of tumor recurrence.
SUMMARY CT has been shown to be of value in both the initial staging of endometrial carcinoma and in the evaluation of tumor recurrence. Specifically, CT with contrast enhancement has been shown to be accurate in determining the depth of myometrial invasion. This information is of prognostic value and also optimizes selection of the appropriate therapeutic procedure. We describe the CT appearances of an important “special variant” carcinoma of the uterine corpus called uterine papillary serous carcinoma (UPSC). This tumor has a significantly higher relapse rate than other histologic types of endometrial carcinoma and adjuvant upper abdominal and pelvic irradiation or effective chemotherapy is therefore needed. The CT features of this tumor variant include deep myometrial invasion, lymphatic involvement, extension to cervix and adnexa and a spread mode over peritoneal surfaces similar to that of ovarian surface epithelial carcinomas. The depiction of myometrial invasion by CT clearly differentiates ovarian carcinoma from UPSC.
REFERENCES M. Hendrickson. J. Ross, P. Eifel, A. Martinez and R. Kempson, Uterine papillary serous carcinoma. Am. J. Surg. Pathol. 6, 93-108 (1982). D. J. Hamlin, F. A. Burgener and J. B. Beecham, CT of intramural endometrial carcinoma: Contrast enhancement is essential, Am. J. Roentg. 137, 551-554 (1981). K. Hasumi, M. Matsuzawa, H. F. Chen, M. Takahashi and M. Sakura, Computed tomography in the evaluation and treatment of endometrial carcinoma, Cancer 50, 904-908 (1982).
CT of uterine
papillary
serous carcinoma
About the Author-DEREK J. HAMLIN. M.D. gradulated in medicine from the University of Cape Town. South Africa. His initial appointment in radiology was at the University of Rochester School of Medicine and Dentistry (1977-1980). He is currently Associate Professor of Radiology and is Chief of Oncologic Radiology and Body CT at the University of Florida College of Medicine. Gainesville. Florida. About the Author-EDWARD
J. WILKINSON received is currently Professor of Pathology and Gynecology Medicine. Gainesville. Florida.
his M.D. from the Medical College of Wisconsin. He and Obstetrics at the University of Florida College of
About the Author-LINDA S. MORGAN received her M.D. from the Medical College of Pennsylvania. After fellowship at Massachusetts General Hospital she commenced her current appointment as Assistant Professor. Oncology Division of Obstetrics and Gynecology. IJniversity of Florida College of Medicine. Gainesville. Florida. the Author-FRANCIS A. BURCENER received his M.D. degree from the University of Berne. Switzerland. He is currently Professor of Radiology at the University of Rochester School of Medicine and Dentistry, Rochester. New York.
About
About the Author-JAMES
W. WEAVER received his A.B. degree from Duke University in 1969 and his M.D. degree from Tulane University in 1973. Dr Weaver served as the Chief of Radiology at the Naval Regional Medical Center in Naples, Italy from 1977 to 1980 when he commenced his appointment as Assistant Professor of Radiology at the University of Florida College of Medicine. He is currently Chief of GI Radiology at the University of Florida College of Medicine. Gainesville, Florida.
x3