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Retrograde seeding of endometrial carcinoma during hysteroscopy
GYNECOLOGIC
ONCOLOGY
44, 116-118 (1992)
CASE REPORT Retrograde Seeding of Endometrial Carcinoma during Hysteroscopy S. ROMANO, Y. SHIMONI, D. MURALEE,* AND E. SHALEV Department
of Obstetrics
and Gynecology
and *Department
of Pathology,
Central
Emek
Hospital,
Afula
18 101, Israel
Received June 7, 1991
line irrigation) were performed and adenocarcinoma of the endometrium, grade 2, was diagnosed. Further investigation included intravenous pyelography, blood chemistry, and liver function tests, which were within normal range. With the diagnosis of clinical stage IA grade 2, laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy and pelvic selective lymph node biopsies were performed. Cytology from peritoneum was obtained and found to be positive (Fig. 1). Pathologic examination of the specimen revealed papillary adenocarcinoma of the endometrium with minimal stromal invasion (Fig. 2). The postoperative period was uneventful, and no adjuvant therapy was suggested. One year later, a small polyp was observed on the vaginal stump. A Pap smear was taken and malignant adenocarcinomas were observed. A biopsy was done, recurrent adenocarcinoma was confirmed, and radiation therapy was started.
Fractional dilatation and curettage remain the most reliable methodsin the diagnosisof endometrialcarcinomain the symptomatic patient. In the past few years hysteroscopyhas become a helpful method, improving the specificity of the diagnosisof this pathology. We report a caseof clinical stage IA grade 2 endometrialadenocarcinomadiagnosedby hysteroscopyand endometrialbiopsy. Surgkal stagingrevealedpositive cytology. We suggestthat irrigation of the endometrialcavity during the hysteroscopicprocedurewith salinemay disseminatethe diseaseto the abdominal cavity and may change the prognosisand the courseof treatment. 0 1992 hdemic prrss, I~C.
INTRODUCTION Endometrial adenocarcinoma is the second most common gynecological malignancy in Israel. Classical fractional curettage as a method for diagnosing this malignancy was improved with the addition of hysteroscopy and directed biopsies. During hysteroscopy the dissemination of endometrial cells is frequently seen and the possibility of dissemination of malignant cells exists as well, We report a case of endometrial adenocarcinoma diagnosed with direct biopsy under hysteroscopy. Further surgical treatment and staging revealed stage IA grade 2 adenocarcinoma, with positive malignant cells in the peritoneal fluids. Endometrial irrigation during hysteroscopy may be the means of entry of those cells into the peritoneal cavity. The recurrence of the disease 1 year later raises questions regarding the safety of this procedure and the need for further radiation treatment postoperatively in these patients.
CASE REPORT DD, 58 years old, GlPl, was admitted to the ward for investigation of postmenopausal bleeding. Fractional curettage and directed biopsy under hysteroscopy (with sa-
DISCUSSION It is well accepted that retrograde passage of endometrial tissue through the fallopian tube to the peritoneal space occurs [l]. Although Yazigi et al. [2] and others [3-51 demonstrated that the presence of malignant cells in peritoneal fluid (which is positive in 14.5% of patients) in stage I endometrial carcinoma is not a useful prognostic factor and no additional treatment is necessary and although Menczer et al. [6] demonstrated the presence of endometrial cancer cells in the fallopian tube in patients with endometrial carcinoma and found no correlation with other prognostic factors, Creasman et al. [7] and Mazurka et al. [S] found a poorer prognosis when endometrial carcinoma cells were found in peritoneal fluids. In the past decade, with the introduction of hysteroscopy as an additional method for diagnosing endometrial carcinoma,
116 0090-8258/92 $1.50 Copyright 0 1992 by Academic Press, Itic. All rights of reproduction in any form reserved.
117
CASE REPORT
FIG. 1. Cytology of pouch of Douglas washing revealing a cluster of malignant cells bearing close resemblance to the endometrial (Papanicolaou, X 200).
the possibility of dissemination of carcinoma cells in the peritoneal cavity has increased. Beyth et al. [9] and others [lo] demonstrated the reflux of endometrial tissue during irrigation of the endometrial cavity or during hysteroscopy. The prognostic significance of this reflux in cases of endometrial carcinoma is unknown and needs further investigation; it may be innocent, although it can be very
tumor
dangerous if a poor prognosis is found. In our case the dissemination of malignant cells by the hysteroscopic procedure is highly possible but not a certainty. The question of further treatment as suggested by DiSaia and Creasman [ll] or observation only was raised. The recurrence of the disease in our case may be bad luck, or a sign that the presence of these cells has di-
FIG. 2. Histologic section showing a papillary adenocarcinoma of the endometrium. corner (H&E, x200).
Minimal
stromal invasion is seen at the lower right
118
ROMAN0
agnostic meaning. Whether the prognosis is good or is without significance, there is no doubt that further investigation is required.
ET AL.
6.
7.
REFERENCES Bartosik, D., Jacobs, S. L., and Kelly, L. J. Endometrial tissue in peritoneal fluid, Fe&. Steril. 46(5), 796-800 (1986). 2. Yazigi, R., Piver, M. S., and Blumenson, L. Malignant peritoneal cytology as prognostic indication in stage I endometrial cancer, 1.
Obstet. 3.
Gynecol.
62, 359-362
Gynecol.
73(3),
335-338
8.
9,
(1983).
Hiram, Y., Fujimoto, I., Yamauchi, K., et al. Peritoneal fluid cytology and prognosis in patients with endometrial carcinoma, Obstet.
10.
(1989).
Ide, P. Prognostic value of peritoneal fluid cytology in patients with endometrial cancer stage I, Eur. J. Obstet. Gynecol. Reprod. Biol. 18, 343-349 (1984). 5. Keettel, E., Pixley, E., and Buchsbaum, H. J. Experience with
peritoneal cytology in the management of gynecologic malignancies, J. Obstet. Gynecol. 120, 174-178 (1974). Menczer, J., Modan, M., and Goor, E. The significance of positive tubal cytology in patients with endometrial adenocarcinoma, Gynecol. Oncol. 10, 249-252 (1980). Creasman, W. T., DiSaia, P. J., Blessing, J., et al. Prognostic significance of peritoneal cytology in patients with endometrial cancer and preliminary data concerning therapy with intraperitoneal radiopharmaceuticals, Am. J. Obstet. Gynecol. 141,921-929 (1981). Mazurka, J. L., Krepart, G. V., and Lotocki, R. J. Prognostic significance of positive peritoneal cytology in endometrial carcinoma, Am. J. Obstet. Gynecol. 158, 3036 (1988). Beyth, Y., Yaffe, H., Levis, I. S. H., et al. Retrograde seeding of endometrium, sequela of tubal flushing, Fertil. Steril. 26, 1094 (1975). Nagel, T. C., Kopher, R. A., Tagate, G. E., et al. Tubal retlux of endometrial tissue during hysteroscopy, in Hysteroscopy: Principles and practice (A. M. Sigler and H. J. Lindemann, Eds.), Lippincott, Philadelphia, p. 45 (1984). DiSaia, P. J., and Creasman, W. T. In Clinical gynecologic oncology, (S. Bircher, Ed.), Mosby, St. Louis, 3rd ed., p. 175 (1989). Am.
4.
11.
ONCOLOGY
44, 116-118 (1992)
CASE REPORT Retrograde Seeding of Endometrial Carcinoma during Hysteroscopy S. ROMANO, Y. SHIMONI, D. MURALEE,* AND E. SHALEV Department
of Obstetrics
and Gynecology
and *Department
of Pathology,
Central
Emek
Hospital,
Afula
18 101, Israel
Received June 7, 1991
line irrigation) were performed and adenocarcinoma of the endometrium, grade 2, was diagnosed. Further investigation included intravenous pyelography, blood chemistry, and liver function tests, which were within normal range. With the diagnosis of clinical stage IA grade 2, laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy and pelvic selective lymph node biopsies were performed. Cytology from peritoneum was obtained and found to be positive (Fig. 1). Pathologic examination of the specimen revealed papillary adenocarcinoma of the endometrium with minimal stromal invasion (Fig. 2). The postoperative period was uneventful, and no adjuvant therapy was suggested. One year later, a small polyp was observed on the vaginal stump. A Pap smear was taken and malignant adenocarcinomas were observed. A biopsy was done, recurrent adenocarcinoma was confirmed, and radiation therapy was started.
Fractional dilatation and curettage remain the most reliable methodsin the diagnosisof endometrialcarcinomain the symptomatic patient. In the past few years hysteroscopyhas become a helpful method, improving the specificity of the diagnosisof this pathology. We report a caseof clinical stage IA grade 2 endometrialadenocarcinomadiagnosedby hysteroscopyand endometrialbiopsy. Surgkal stagingrevealedpositive cytology. We suggestthat irrigation of the endometrialcavity during the hysteroscopicprocedurewith salinemay disseminatethe diseaseto the abdominal cavity and may change the prognosisand the courseof treatment. 0 1992 hdemic prrss, I~C.
INTRODUCTION Endometrial adenocarcinoma is the second most common gynecological malignancy in Israel. Classical fractional curettage as a method for diagnosing this malignancy was improved with the addition of hysteroscopy and directed biopsies. During hysteroscopy the dissemination of endometrial cells is frequently seen and the possibility of dissemination of malignant cells exists as well, We report a case of endometrial adenocarcinoma diagnosed with direct biopsy under hysteroscopy. Further surgical treatment and staging revealed stage IA grade 2 adenocarcinoma, with positive malignant cells in the peritoneal fluids. Endometrial irrigation during hysteroscopy may be the means of entry of those cells into the peritoneal cavity. The recurrence of the disease 1 year later raises questions regarding the safety of this procedure and the need for further radiation treatment postoperatively in these patients.
CASE REPORT DD, 58 years old, GlPl, was admitted to the ward for investigation of postmenopausal bleeding. Fractional curettage and directed biopsy under hysteroscopy (with sa-
DISCUSSION It is well accepted that retrograde passage of endometrial tissue through the fallopian tube to the peritoneal space occurs [l]. Although Yazigi et al. [2] and others [3-51 demonstrated that the presence of malignant cells in peritoneal fluid (which is positive in 14.5% of patients) in stage I endometrial carcinoma is not a useful prognostic factor and no additional treatment is necessary and although Menczer et al. [6] demonstrated the presence of endometrial cancer cells in the fallopian tube in patients with endometrial carcinoma and found no correlation with other prognostic factors, Creasman et al. [7] and Mazurka et al. [S] found a poorer prognosis when endometrial carcinoma cells were found in peritoneal fluids. In the past decade, with the introduction of hysteroscopy as an additional method for diagnosing endometrial carcinoma,
116 0090-8258/92 $1.50 Copyright 0 1992 by Academic Press, Itic. All rights of reproduction in any form reserved.
117
CASE REPORT
FIG. 1. Cytology of pouch of Douglas washing revealing a cluster of malignant cells bearing close resemblance to the endometrial (Papanicolaou, X 200).
the possibility of dissemination of carcinoma cells in the peritoneal cavity has increased. Beyth et al. [9] and others [lo] demonstrated the reflux of endometrial tissue during irrigation of the endometrial cavity or during hysteroscopy. The prognostic significance of this reflux in cases of endometrial carcinoma is unknown and needs further investigation; it may be innocent, although it can be very
tumor
dangerous if a poor prognosis is found. In our case the dissemination of malignant cells by the hysteroscopic procedure is highly possible but not a certainty. The question of further treatment as suggested by DiSaia and Creasman [ll] or observation only was raised. The recurrence of the disease in our case may be bad luck, or a sign that the presence of these cells has di-
FIG. 2. Histologic section showing a papillary adenocarcinoma of the endometrium. corner (H&E, x200).
Minimal
stromal invasion is seen at the lower right
118
ROMAN0
agnostic meaning. Whether the prognosis is good or is without significance, there is no doubt that further investigation is required.
ET AL.
6.
7.
REFERENCES Bartosik, D., Jacobs, S. L., and Kelly, L. J. Endometrial tissue in peritoneal fluid, Fe&. Steril. 46(5), 796-800 (1986). 2. Yazigi, R., Piver, M. S., and Blumenson, L. Malignant peritoneal cytology as prognostic indication in stage I endometrial cancer, 1.
Obstet. 3.
Gynecol.
62, 359-362
Gynecol.
73(3),
335-338
8.
9,
(1983).
Hiram, Y., Fujimoto, I., Yamauchi, K., et al. Peritoneal fluid cytology and prognosis in patients with endometrial carcinoma, Obstet.
10.
(1989).
Ide, P. Prognostic value of peritoneal fluid cytology in patients with endometrial cancer stage I, Eur. J. Obstet. Gynecol. Reprod. Biol. 18, 343-349 (1984). 5. Keettel, E., Pixley, E., and Buchsbaum, H. J. Experience with
peritoneal cytology in the management of gynecologic malignancies, J. Obstet. Gynecol. 120, 174-178 (1974). Menczer, J., Modan, M., and Goor, E. The significance of positive tubal cytology in patients with endometrial adenocarcinoma, Gynecol. Oncol. 10, 249-252 (1980). Creasman, W. T., DiSaia, P. J., Blessing, J., et al. Prognostic significance of peritoneal cytology in patients with endometrial cancer and preliminary data concerning therapy with intraperitoneal radiopharmaceuticals, Am. J. Obstet. Gynecol. 141,921-929 (1981). Mazurka, J. L., Krepart, G. V., and Lotocki, R. J. Prognostic significance of positive peritoneal cytology in endometrial carcinoma, Am. J. Obstet. Gynecol. 158, 3036 (1988). Beyth, Y., Yaffe, H., Levis, I. S. H., et al. Retrograde seeding of endometrium, sequela of tubal flushing, Fertil. Steril. 26, 1094 (1975). Nagel, T. C., Kopher, R. A., Tagate, G. E., et al. Tubal retlux of endometrial tissue during hysteroscopy, in Hysteroscopy: Principles and practice (A. M. Sigler and H. J. Lindemann, Eds.), Lippincott, Philadelphia, p. 45 (1984). DiSaia, P. J., and Creasman, W. T. In Clinical gynecologic oncology, (S. Bircher, Ed.), Mosby, St. Louis, 3rd ed., p. 175 (1989). Am.
4.
11.