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Endometrial cancer associated with adenomyosis
76
Letters to the Editor
Endometrial cancer associated with adenomyosis
To the Editor September 3rd, 1993 Adenomyosis can frequently be observed in histologic specimens from endometrial cancer surgery. The idea of a link between adenomyosis and endometrial cancer is attractive because the two may have a common stimulus, such as estrogen [ 11. Recently we treated two endometrial cancer paconcomitant uterine tients showed who adenomyosis. Patient 1: a 60-year-old woman visited our hospital with complaints of atypical vaginal bleeding. Endometrial cytology at the time revealed atypia; curettaged specimens from both the endometrium and endocervix showed a well-differentiated adenocarcinoma. Tumor marker levels included a CA-125 of 62 U/ml, a CA-19-9 of 42 U/ml, and a CA-72-4 of 53 U/ml. CT and MRI examination showed no evidence of lymph node metastasis or cancer infiltration beyond the uterus, and radical abdominal hysterectomy was performed. Histology of the surgical specimen showed adenoacanthoma intermingled with adenomyosis. In one cancer-free area of the myometrium, an intact adenomyotic gland and stroma with distinct adenomyosis were seen. Nine days postoperatively, levels of CA- 125, CA-19-9, and, CA-72-4 were 28, 22 and 5.8 U/ml, respectively. A course of five cycles of chemotherapy was initiated postoperatively. Patient 2: a 67-year-old woman was admitted to our hospital with a diagnosis of endometrial cancer. Cytology was positive for adenocarcinoma; histdlogy revealed a well-differentiated adenocarcinoma. CT and MRI examination showed the neoplasm to be coilfined to the uterine corpus. All tumor markers were negative. Simple abdominal hysterectomy and bilateral salpingooophorectomy were performed. The histology of the tumor was determined to be well-differentiated adenocarcinema. In the deeper myometrium, adenomyotic glands and an adenocarcinomatous lesion with sparse stromal cells were seen (Fig. 1). She also Keywords:
Adenomyosis;
Endometrial
0020-7293/94/%07.00 @ 1994 International Federation Printedand Published in Ireland
cancer.
of Gynecology
and Obstetrics
Fig. 1. In the deeper myometrium one of the adenomyotic glands (arrow) was composed of cancer cells with normal appearing stromal cells (H&E, 400 x , Patient 2).
began a live-cycle course of chemotherapy postoperatively. We previously reported eight cases of endometrial cancer with concomitant adenomyosis, which we expected to provide a good model for the histological examination of endometrial cancer infiltration [l]. Recently we found by electron microscopy that adenomyotic glandular epitheliurn is somewhat less differentiated than proliferative endometrium and shares some similarities with endometrial cancer [2]. We also surveyed endometriotic lesions by scanning electron microscopy, with results suggesting derivation of the lesions
from the endometrium [3]. Histology for Patient 1, above, showed distinct adenomyosis in some areas free of cancer infiltration. Histology for Patient 2 revealed multifocal malignant changes of the adenomyotic glandular epithelia with a few normal appearing stromal ceils. Based on these results, we postulate that the adenomyotic glandular changes seen in adenomyosis may be a precursor to endometrial cancer. T. Hayata Y. Tanaka
Dept. of Obstetrics and Gynecology, Oita Medical University
I. Miyakawa
Japan
References I
dometriosis interna (uterine adenomyosis). Am J Obstet Gynecol 156: 663. 1987. Hayata T: Ultrastructural study of glandular epithelium in adenomyosis in comparison with those of proliferative endometrium and well-differentiated endometrial cancer. Am J Obstet Gynecol 165: 225. 1991. Hayata T, Matsu T. Kawano Y. Matsui N. Miyakawa I: Scanning electron microscopy of endometriotic lesions in the pelvic peritoneum and the histogenesis of endometriosis. Int J Gynecol Obstet 3Y: 31 I. 1992
Hayata T, Kawashima Y: Clinicopathologic eight cases of uterine body cancers associated
study of with en-
Correspondance to: T. Hayata Dept. of Obstetrics and Gynecology Oita Medical University I-1 Hasama Oita 879-55 Japan
Fetal reduction of quintuplet pregnancy
August
To the Editor
IOth, 1993
Ovulation induction and new reproductive techniques occasionally result in a multiple pregnancy [ 11. Grand-multiple pregnancies present an increased risk of potential complications [2]. In recent years multifetal pregnancy reduction (MPR) to a smaller and more manageable number of fetuses gives a better chance of improving the perinatal outcome, because the infants delivered are mature enough to survive and are not handicapped by marked prematurity. We present a patient who had a quintuplet pregnancy following IVF and ET, which was successfully reduced to twins between the 9th and 10th week by ultrasound (U/S) guided intrauterine technique, and resulted in the delivery of two healthy infants at the 35th week of gestation. A 24-year-old woman gravida 1 para 0 was submitted to an IVF program in our Department because of secondary infertility of 2 years duration due to tubal occlusion. The IVF stimulation protoKeywords: IVF; Multiple reduction.
pregnancy:
0020-7293/94/$07.00 0 1994 International Federation Printed and Published in Ireland
Quintuplets:
of Gynecology
Pregnancy
and Obstetrics
co1 was as described by Loutradis et al. [3]. Fifteen mature oocytes were recovered, and 20 h after insemination, five of the oocytes were fertilized, and all were transfered. The reason for the 5 embryos transfer was due to the fact that cryopreservation was not available in our unit. Considering the high perinatal morbidity and mortality associated with quintuplet pregnancy the couple in consultation with us decided to have a MPR, and gave their written consent. An attempt to reduce the quintuplet to a twin pregnancy in three different sessions at 5-day intervals was agreed upon. The first attempt was done at 9 weeks’ gestation and our purpose was to reduce these embryos which were placed in the upper part of the uterus, far away from the internal cervical OS. Under direct U/S visual observation with the transducer (Sector 5 MHz, Siemens SL-2) held by the operator. a 21-G spinal needle tip was placed into the fetal heart. One to two milliliters of potassium chloride (1 mEq/ml) was then injected and fetal heart was observed until cardiac cessation. Two days after the final fetal reduction, a follow-up U/S study demonstrated a normally appearing intrauterine twin gestation as well as three sacs each showing
Letters to the Editor
Endometrial cancer associated with adenomyosis
To the Editor September 3rd, 1993 Adenomyosis can frequently be observed in histologic specimens from endometrial cancer surgery. The idea of a link between adenomyosis and endometrial cancer is attractive because the two may have a common stimulus, such as estrogen [ 11. Recently we treated two endometrial cancer paconcomitant uterine tients showed who adenomyosis. Patient 1: a 60-year-old woman visited our hospital with complaints of atypical vaginal bleeding. Endometrial cytology at the time revealed atypia; curettaged specimens from both the endometrium and endocervix showed a well-differentiated adenocarcinoma. Tumor marker levels included a CA-125 of 62 U/ml, a CA-19-9 of 42 U/ml, and a CA-72-4 of 53 U/ml. CT and MRI examination showed no evidence of lymph node metastasis or cancer infiltration beyond the uterus, and radical abdominal hysterectomy was performed. Histology of the surgical specimen showed adenoacanthoma intermingled with adenomyosis. In one cancer-free area of the myometrium, an intact adenomyotic gland and stroma with distinct adenomyosis were seen. Nine days postoperatively, levels of CA- 125, CA-19-9, and, CA-72-4 were 28, 22 and 5.8 U/ml, respectively. A course of five cycles of chemotherapy was initiated postoperatively. Patient 2: a 67-year-old woman was admitted to our hospital with a diagnosis of endometrial cancer. Cytology was positive for adenocarcinoma; histdlogy revealed a well-differentiated adenocarcinoma. CT and MRI examination showed the neoplasm to be coilfined to the uterine corpus. All tumor markers were negative. Simple abdominal hysterectomy and bilateral salpingooophorectomy were performed. The histology of the tumor was determined to be well-differentiated adenocarcinema. In the deeper myometrium, adenomyotic glands and an adenocarcinomatous lesion with sparse stromal cells were seen (Fig. 1). She also Keywords:
Adenomyosis;
Endometrial
0020-7293/94/%07.00 @ 1994 International Federation Printedand Published in Ireland
cancer.
of Gynecology
and Obstetrics
Fig. 1. In the deeper myometrium one of the adenomyotic glands (arrow) was composed of cancer cells with normal appearing stromal cells (H&E, 400 x , Patient 2).
began a live-cycle course of chemotherapy postoperatively. We previously reported eight cases of endometrial cancer with concomitant adenomyosis, which we expected to provide a good model for the histological examination of endometrial cancer infiltration [l]. Recently we found by electron microscopy that adenomyotic glandular epitheliurn is somewhat less differentiated than proliferative endometrium and shares some similarities with endometrial cancer [2]. We also surveyed endometriotic lesions by scanning electron microscopy, with results suggesting derivation of the lesions
from the endometrium [3]. Histology for Patient 1, above, showed distinct adenomyosis in some areas free of cancer infiltration. Histology for Patient 2 revealed multifocal malignant changes of the adenomyotic glandular epithelia with a few normal appearing stromal ceils. Based on these results, we postulate that the adenomyotic glandular changes seen in adenomyosis may be a precursor to endometrial cancer. T. Hayata Y. Tanaka
Dept. of Obstetrics and Gynecology, Oita Medical University
I. Miyakawa
Japan
References I
dometriosis interna (uterine adenomyosis). Am J Obstet Gynecol 156: 663. 1987. Hayata T: Ultrastructural study of glandular epithelium in adenomyosis in comparison with those of proliferative endometrium and well-differentiated endometrial cancer. Am J Obstet Gynecol 165: 225. 1991. Hayata T, Matsu T. Kawano Y. Matsui N. Miyakawa I: Scanning electron microscopy of endometriotic lesions in the pelvic peritoneum and the histogenesis of endometriosis. Int J Gynecol Obstet 3Y: 31 I. 1992
Hayata T, Kawashima Y: Clinicopathologic eight cases of uterine body cancers associated
study of with en-
Correspondance to: T. Hayata Dept. of Obstetrics and Gynecology Oita Medical University I-1 Hasama Oita 879-55 Japan
Fetal reduction of quintuplet pregnancy
August
To the Editor
IOth, 1993
Ovulation induction and new reproductive techniques occasionally result in a multiple pregnancy [ 11. Grand-multiple pregnancies present an increased risk of potential complications [2]. In recent years multifetal pregnancy reduction (MPR) to a smaller and more manageable number of fetuses gives a better chance of improving the perinatal outcome, because the infants delivered are mature enough to survive and are not handicapped by marked prematurity. We present a patient who had a quintuplet pregnancy following IVF and ET, which was successfully reduced to twins between the 9th and 10th week by ultrasound (U/S) guided intrauterine technique, and resulted in the delivery of two healthy infants at the 35th week of gestation. A 24-year-old woman gravida 1 para 0 was submitted to an IVF program in our Department because of secondary infertility of 2 years duration due to tubal occlusion. The IVF stimulation protoKeywords: IVF; Multiple reduction.
pregnancy:
0020-7293/94/$07.00 0 1994 International Federation Printed and Published in Ireland
Quintuplets:
of Gynecology
Pregnancy
and Obstetrics
co1 was as described by Loutradis et al. [3]. Fifteen mature oocytes were recovered, and 20 h after insemination, five of the oocytes were fertilized, and all were transfered. The reason for the 5 embryos transfer was due to the fact that cryopreservation was not available in our unit. Considering the high perinatal morbidity and mortality associated with quintuplet pregnancy the couple in consultation with us decided to have a MPR, and gave their written consent. An attempt to reduce the quintuplet to a twin pregnancy in three different sessions at 5-day intervals was agreed upon. The first attempt was done at 9 weeks’ gestation and our purpose was to reduce these embryos which were placed in the upper part of the uterus, far away from the internal cervical OS. Under direct U/S visual observation with the transducer (Sector 5 MHz, Siemens SL-2) held by the operator. a 21-G spinal needle tip was placed into the fetal heart. One to two milliliters of potassium chloride (1 mEq/ml) was then injected and fetal heart was observed until cardiac cessation. Two days after the final fetal reduction, a follow-up U/S study demonstrated a normally appearing intrauterine twin gestation as well as three sacs each showing