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Glassy cell carcinoma of the endometrium responsive to megestrol acetate
GYNECOLOGIC
ONCOLOGY
33, 121-124 (1989)
CASE REPORT Glassy Cell Carcinoma of the Endometrium Responsive to Megestrol Acetate ERIN C. DAWSON, M.D., JEROME L. BELINSON,
M.D.
,I AND KENNETH
LEE,
M.D.
Department of Obstetrics and Gynecology and Pathology, Medical Center Hospital of Vermont, University of Vermont College of Medicine, Burlington, Vermont 05401 Received October 22, 1987
A case.of glassy cell carcinoma of the endometrium with pulmonary metastasiswas responsiveto treatment with a progestational agent. We believe this to be the first reported case of glassy cell carcinoma of the endometrium responsive to this form of therapy. 0 1989 Academic
Press, Inc.
INTRODUCTION
Glassy cell carcinoma, a rarely reported cancer, most commonly originates in the uterine cervix. Glassy cell carcinoma arising in the endometrium was only recently described by Christopherson et al. in 1982 [l]. Glassy cell carcinoma is thought to be a poorly differentiated variant of mixed adenosquamous carcinoma. In Christopherson’s study, glassy cell tumors constituted 7.4% of adenosquamous tumors and only 0.5% of all endometrial carcinomas confirmed on review. Patients in this study were treated with radiation therapy alone or radiation therapy followed by hysterectomy. Four of the five tumors behaved in an aggressive manner. A review of the literature identified only one other report on the subject [2]. We report a case of glassy cell carcinoma of the endometrium metastatic to the lungs which was responsive to progestational therapy. CASE REPORT
A 96-year-old G2, P2002 female presented to her physician with a complaint of a recent episode of heavy vaginal bleeding. She was referred for evaluation to a gynecologist who performed a cervical biopsy which was ’ To whom reprint requests should be addressed.
negative followed by a D&C which revealed poorly differentiated adenocarcinoma, glassy cell type. (Fig. 1) On physical examination blood pressure was 180/95 with pulse of 80. Her weight was 91 pounds. The lungs were clear to auscultation and percussion. The cardiovascular exam was normal. Abdominal examination disclosed no masses. The pelvic exam revealed a soft retroverted uterus 6 weeks in size. The cervix and vagina were normal in appearance. The patient had a past medical history significant for carcinoma of the cervix 48 years ago treated with internal and external radiation therapy in a New Jersey hospital. These records were destroyed by fire. The patient underwent a staging evaluation which included a normal cystoscopy and sigmoidoscopy. Exam under anesthesia revealed a globular retroverted uterus approximately 6 weeks in size. An endocervical curettage revealed some necrotic tissue in the canal but no tumor. The chest X ray showed multiple nodules of varying size up to 1.5 cm in diameter occurring predominantly in the lower lobes (Fig. 2). These nodules were felt to be consistent with metastatic disease. A bone scan revealed an area of increased uptake in the region of L-5; however, AP view of the lumbar spine revealed no loss of bone in that area. The patient was treated with megestrol acetate 80 mg b.i.d. following her staging evaluation. Repeat chest X ray 9 weeks after starting therapy revealed a marked decrease in metastatic disease (Fig. 3). During this time the patient’s weight was stable and her energy level remained good. The patient continues to have a complete response by chest X ray 16 months after initiation of megestrol therapy.
121 0090~8258/89$1.50 Copyright 0 1989 by AcademicPress,Inc.
All rights of reproductionin any form reserved.
FIG. 1. Clusters of malignant cells demonstrate large nuclei with prominent nucleoli. Cytoplasm with abundant granular “glassy” (hematoxylin and cosin, x 380). FIG. 2. Multiple bilateral nodular densities, more prominent in the bases.
appearance
CASE REPORT
123
FIG. 3. Marked clearing of the nodular densities (Fig. 2 + 9 weeks).
indicating to them that this type of tumor is not actually poorly differentiated and might originate from endocervical Glassy cell carcinoma was first described by Gluckman or isthmic mucosal cells. They also noted an absence of and Cherry in 1956 as a highly malignant form of cervical keratin and prekeratin suggestingthat glassy cell carcinoma cancer [3]. Subsequent reports of this tumor type con- may not be a variant of adenosquamous carcinoma. Glassy cell carcinoma of the cervix appears to be a cerned those of cervical origin only. However, in 1982 Christopherson et al. described five patients with mixed highly aggressive tumor with a poor response to surgery adenosquamous carcinoma with glassy cell features orig- and/or radiation therapy. In Christopherson’s study of inating in the endometrium [ 11.The authors reported that the endometrial variety this poor response to therapy seen in the cervical cancers was also observed. Four the cervix was grossly normal in all five patients. Glassy cell carcinoma is felt by most authors to be a patients had Stage I disease and one had Stage III disease. poorly differentiated variant of mixed adenosquamous The patient with Stage III disease was treated with racarcinoma originating in the cervix or endometrium [4]. diation alone and died at 5 months. Two patients with However, Arends et al. [2], in 1984found immunoreactive Stage I disease were treated with radiation followed by secretory component and lysozyme in the tumor cells hysterectomy and died at 5 months and 32 months. One DISCUSSION
124
DAWSON, BELINSON,
patient with Stage I disease treated with radiation followed by hysterectomy died of pneumonia at 72 months without evidence of disease. The final patient committed suicide at 7 months after diagnosis, no treatment or disease status was described. The case reported here of a 96-year-old female with Stage IV disease appears to be the only reported case in which a progestational agent resulted in a rapid response. A search of the literature failed to identify other reports on the use of progestational agents in the treatment of glassy cell carcinoma of the endometrium or cervix. Thus, in this seemingly aggressive tumor in which treatment modalities such as radiation therapy and surgery appear to be suboptimal, megesterol acetate may provide another therapeutic option, especially in the patient with advance disease. In this context, hormone receptor studies of this tumor would be of interest. It would also be
AND LEE
interesting to evaluate response to progestin of the more common glassy cell carcinoma of the cervix. REFERENCES Christopherson, W. M., Alberhasky, R. C., and Connelly, P. J. Glassy cell carcinoma of the endometrium, Hum. Pathol. 13(5), 418-421 (1982). Arends, J. W., Willebrand, D., Dekoning Cans, H. J., Swaen, G. J. W., and Bosman, F. T. T. Adenocarcinoma of the endometrium with glassy cell featuresImmunohistochemica1 observations, Hisropafhology 8, 873-879 (1984). Gluckman, A., and Cherry, C. P. Incidence, histology and response to radiation of mixed carcinomas (Adenocanthomas) of the uterine cervix, Cancer 9, 971-979 (1956). Littlman, P., Clement, P. B., Henricksen, B., Wang, C. C., Robboy, S. J., Taft, P. D., Ulfelder, H., and Scully, R. Glassy cell carcinoma of the cervix, Cancer 37, 2238-2246 (1976).
ONCOLOGY
33, 121-124 (1989)
CASE REPORT Glassy Cell Carcinoma of the Endometrium Responsive to Megestrol Acetate ERIN C. DAWSON, M.D., JEROME L. BELINSON,
M.D.
,I AND KENNETH
LEE,
M.D.
Department of Obstetrics and Gynecology and Pathology, Medical Center Hospital of Vermont, University of Vermont College of Medicine, Burlington, Vermont 05401 Received October 22, 1987
A case.of glassy cell carcinoma of the endometrium with pulmonary metastasiswas responsiveto treatment with a progestational agent. We believe this to be the first reported case of glassy cell carcinoma of the endometrium responsive to this form of therapy. 0 1989 Academic
Press, Inc.
INTRODUCTION
Glassy cell carcinoma, a rarely reported cancer, most commonly originates in the uterine cervix. Glassy cell carcinoma arising in the endometrium was only recently described by Christopherson et al. in 1982 [l]. Glassy cell carcinoma is thought to be a poorly differentiated variant of mixed adenosquamous carcinoma. In Christopherson’s study, glassy cell tumors constituted 7.4% of adenosquamous tumors and only 0.5% of all endometrial carcinomas confirmed on review. Patients in this study were treated with radiation therapy alone or radiation therapy followed by hysterectomy. Four of the five tumors behaved in an aggressive manner. A review of the literature identified only one other report on the subject [2]. We report a case of glassy cell carcinoma of the endometrium metastatic to the lungs which was responsive to progestational therapy. CASE REPORT
A 96-year-old G2, P2002 female presented to her physician with a complaint of a recent episode of heavy vaginal bleeding. She was referred for evaluation to a gynecologist who performed a cervical biopsy which was ’ To whom reprint requests should be addressed.
negative followed by a D&C which revealed poorly differentiated adenocarcinoma, glassy cell type. (Fig. 1) On physical examination blood pressure was 180/95 with pulse of 80. Her weight was 91 pounds. The lungs were clear to auscultation and percussion. The cardiovascular exam was normal. Abdominal examination disclosed no masses. The pelvic exam revealed a soft retroverted uterus 6 weeks in size. The cervix and vagina were normal in appearance. The patient had a past medical history significant for carcinoma of the cervix 48 years ago treated with internal and external radiation therapy in a New Jersey hospital. These records were destroyed by fire. The patient underwent a staging evaluation which included a normal cystoscopy and sigmoidoscopy. Exam under anesthesia revealed a globular retroverted uterus approximately 6 weeks in size. An endocervical curettage revealed some necrotic tissue in the canal but no tumor. The chest X ray showed multiple nodules of varying size up to 1.5 cm in diameter occurring predominantly in the lower lobes (Fig. 2). These nodules were felt to be consistent with metastatic disease. A bone scan revealed an area of increased uptake in the region of L-5; however, AP view of the lumbar spine revealed no loss of bone in that area. The patient was treated with megestrol acetate 80 mg b.i.d. following her staging evaluation. Repeat chest X ray 9 weeks after starting therapy revealed a marked decrease in metastatic disease (Fig. 3). During this time the patient’s weight was stable and her energy level remained good. The patient continues to have a complete response by chest X ray 16 months after initiation of megestrol therapy.
121 0090~8258/89$1.50 Copyright 0 1989 by AcademicPress,Inc.
All rights of reproductionin any form reserved.
FIG. 1. Clusters of malignant cells demonstrate large nuclei with prominent nucleoli. Cytoplasm with abundant granular “glassy” (hematoxylin and cosin, x 380). FIG. 2. Multiple bilateral nodular densities, more prominent in the bases.
appearance
CASE REPORT
123
FIG. 3. Marked clearing of the nodular densities (Fig. 2 + 9 weeks).
indicating to them that this type of tumor is not actually poorly differentiated and might originate from endocervical Glassy cell carcinoma was first described by Gluckman or isthmic mucosal cells. They also noted an absence of and Cherry in 1956 as a highly malignant form of cervical keratin and prekeratin suggestingthat glassy cell carcinoma cancer [3]. Subsequent reports of this tumor type con- may not be a variant of adenosquamous carcinoma. Glassy cell carcinoma of the cervix appears to be a cerned those of cervical origin only. However, in 1982 Christopherson et al. described five patients with mixed highly aggressive tumor with a poor response to surgery adenosquamous carcinoma with glassy cell features orig- and/or radiation therapy. In Christopherson’s study of inating in the endometrium [ 11.The authors reported that the endometrial variety this poor response to therapy seen in the cervical cancers was also observed. Four the cervix was grossly normal in all five patients. Glassy cell carcinoma is felt by most authors to be a patients had Stage I disease and one had Stage III disease. poorly differentiated variant of mixed adenosquamous The patient with Stage III disease was treated with racarcinoma originating in the cervix or endometrium [4]. diation alone and died at 5 months. Two patients with However, Arends et al. [2], in 1984found immunoreactive Stage I disease were treated with radiation followed by secretory component and lysozyme in the tumor cells hysterectomy and died at 5 months and 32 months. One DISCUSSION
124
DAWSON, BELINSON,
patient with Stage I disease treated with radiation followed by hysterectomy died of pneumonia at 72 months without evidence of disease. The final patient committed suicide at 7 months after diagnosis, no treatment or disease status was described. The case reported here of a 96-year-old female with Stage IV disease appears to be the only reported case in which a progestational agent resulted in a rapid response. A search of the literature failed to identify other reports on the use of progestational agents in the treatment of glassy cell carcinoma of the endometrium or cervix. Thus, in this seemingly aggressive tumor in which treatment modalities such as radiation therapy and surgery appear to be suboptimal, megesterol acetate may provide another therapeutic option, especially in the patient with advance disease. In this context, hormone receptor studies of this tumor would be of interest. It would also be
AND LEE
interesting to evaluate response to progestin of the more common glassy cell carcinoma of the cervix. REFERENCES Christopherson, W. M., Alberhasky, R. C., and Connelly, P. J. Glassy cell carcinoma of the endometrium, Hum. Pathol. 13(5), 418-421 (1982). Arends, J. W., Willebrand, D., Dekoning Cans, H. J., Swaen, G. J. W., and Bosman, F. T. T. Adenocarcinoma of the endometrium with glassy cell featuresImmunohistochemica1 observations, Hisropafhology 8, 873-879 (1984). Gluckman, A., and Cherry, C. P. Incidence, histology and response to radiation of mixed carcinomas (Adenocanthomas) of the uterine cervix, Cancer 9, 971-979 (1956). Littlman, P., Clement, P. B., Henricksen, B., Wang, C. C., Robboy, S. J., Taft, P. D., Ulfelder, H., and Scully, R. Glassy cell carcinoma of the cervix, Cancer 37, 2238-2246 (1976).