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Synchronous carcinomas of endometrium and ovary
GYNECOLOGIC
ONCOLOGY
33, 261-264 (1989)
CASE REPORT Synchronous Carcinomas of Endometrium and Ovary BENJAMIN PIURA, Division
of Obstetrics
M.D., MRCOG,’ AND MAREK GLEZERMAN, M.D.
and Gynecology, Soroka Medical Center, and Faculty of Health Ben-Gurion University of the Negev, Beer-Sheva, Israel
Sciences,
Received November 30, 1987
Five casesof synchronous carcinomas of uterine endometrium and ovary are reported. All uterine cancerswere typical endometrial adenocarcinomas. Among the ovarian cancers, four were serous papillary cystadenocarcinomas and one was an endometrioid carcinoma. There is much controversy with respect to staging and management of such casessince these tumors may represent either two synchronously occurring primaries or a single primary with metastases. It is suggested that when each tumor is confined within the limits of its tissue of origin the tumors may be considered as two separate primaries and surgery may be less aggressive. When there is evidence that at least one tumor is spreading to adjacent tissues and organs the question of two separateprimaries or one metastatic tumor becomesacademic only and aggressive surgical treatment with adjuvant chemotherapy is indicated. D rw9
assumption of synchronously tumors.
occurring two primary
CASE REPORTS
Case 1
A 40-year-old, gravida 0 woman presented in November 1966 with abnormal uterine bleeding. Pelvic examination revealed a large irregular central pelvic mass, comparable in size to a uterus of 18 weeks’ gestation. Diagnostic curettage was performed and histopathological examination of the curettings showed moderately well-differentiated typical endometrial adenocarcinoma. At lapaAcademic Press, Inc. rotomy a ruptured left ovarian tumor measuring 18x 15 x 15 cm and a diffusely enlarged uterus were discovered. The right ovary and the fallopian tubes appeared INTRODUCTION normal as did the other pelvic and abdominal viscera. When two or more tumors occur in a patient closely Total abdominal hysterectomy and bilateral salpingoin time they are termed synchronous tumors. Since the oophorectomy were performed. Histopathological exendometrium is a common site for metastases of ovarian amination of the surgical specimen revealed moderately carcinoma and the ovary is a common site for metastases well-differentiated typical endometrial adenocarcinoma of endometrial carcinoma, the synchronous occurrence with penetration of the inner third of the myometrium of endometrial and ovarian carcinomas may be interpreted and ovarian serous papillary cystadenocarcinoma. After either as two separate primaries or as one primary tumor an uneventful immediate postoperative recovery the pawith metastases. Among 156 patients with endometrial tient was given whole-abdomen irradiation followed by carcinoma and 152 patients with ovarian carcinoma di- chemotherapy with oral cyclophosphamide. Twenty-four agnosed at the Soroka Medical Center, Beer-Sheva, Israel, months later she died because of metastatic widespread from January 1961 through December 1986, five patients disease. presented with carcinomas synchronously involving the Comment. In 1966, staging procedures for ovarian canendometrium and ovary. cer were less extensive than today. It is therefore assumed Case reports of these patients are presented. On the that this patient may have been understaged. The least basis of clinical information and surgical protocols re- stage for endometrial carcinoma in this case is IB, grade trieved from the files, the extent of disease was staged 2 and for ovarian carcinoma, IC. according to FIGO, 1985 [l]. Staging was done on the Case 2 ’ To whom correspondence should be addressed: Division of Obstetrics and Gynecology, Soroka Medical Center, P.O. Box 151, Beer-Sheva, 84101, Israel.
A 49-year-old, gravida 9, para 2 woman was admitted in September 1977 because of postmenopausal bleeding.
261 0090-8258/89 $1SO Copyright 0 1989by AcademicPress,Inc. All rights of reproductionin any form reserved.
PIURAANDGLEZERMAN Pelvic examination disclosed a left adnexal cystic mass measuring 10x 10x 10 cm and a nomal-sized uterus. Fractional curettage revealed well-differentiated typical endometrial adenocarcinoma extending into the endocervix. At laparotomy, a left ovarian intact cystic tumor measuring 10x 10x 10 cm was discoveredwhile the uterus and the opposite adnexa appeared grossly normal. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Histopathological examination of the surgical specimen showed atrophic endometrium and endocervix with no residual tumor, left ovarian serous papillary cystadenocarcinoma, and poorly differentiated invasive squamous cell carcinoma of the uterine cervix. The patient was given postoperative radiotheraphy with external pelvic irradiation and intravaginal brachytherapy. Today, more than 10 years after the surgery, the patient is alive and well with no evidence of recurrent disease. Comment. In this case endometrial carcinoma correspondedto stageIA, grade 1. (Extension of the endomettial cancer into the endocervix as observed during diagnostic curettage was probably a false-positive finding. See also the comment to Case 4.) Ovarian carcinomacorresponded to stage IA and cervical carcinoma to stage I3 occult.
and shapeand unpalpableadnexae.At fractional curettage hysterometry was 7 cm. Histopathological examination of the curettings revealed moderately well-differentiated typical endometrial adenocarcinoma in both endometrial and endocervical curettings. At laparotomy, apart from a right ovarian intact cystic tumor measuring 6x6x 6 cm, all pelvic and abdominal organs in particular the uterus, the left ovary, and the fallopian tubes, appeared grossly normal. Radical hysterectomy (Wertheim operation) including bilateral pelvic lymphadenectomy and bilateral salpingo-oophorectomy were performed. Histopathological examination of the surgical specimen disclosed moderately well-differentiated typical endometrial adenocarcinoma,with no evidenceof myometrial invasion and without spread into cervical tissues, and right ovarian serous papillary cystadenocarcinoma,with extension into the right fallopian tube. The patient was given postoperative chemotherapy with doxorubicin, &platinum, and cyclophosphamide and hormone therapy with progesterone. Eighteen months later she died of progressive widespread disease. Comment. The stage for endometrial carcinoma in this patient was probably IA, grade 2, notwithstanding the fact that on fractional curettage tumor cells were obtained from the endocervix. First, endocervical curettage in paCase 3 tients with endometrial carcinoma is, in up to 50% of A M-year-old gravida 2, para 2 postmenopausalwoman cases, false positive due to technical error. Second, the was referred in July 1980 because of a palpable pelvic surgical specimen in this particular case did not reveal mass. Pelvic examination confirmed the existence of a any tumor. The stage for ovarian carcinoma was IIA. large irregular central pelvic mass the size of 16 weeks’ gestation. No preoperative curettage was performed. At Case 5 laparotomy bilateral ruptured ovarian tumors, each meaA 61-year-old, gravida 0 postmenopausal woman was suring approximately 10x 10x 10 cm, and an enlarged admitted in August 1985 because of postmenopausal uterus the size of 8 weeks’ gestation were discovered. bleeding. Pelvic examination disclosed a uterus of normal All pelvic and abdominal peritoneal surfaceswere studded size and shape and unpalpable adnexae. At fractional with innumerable small tumor nodules. Total abdominal curettage hysterometry was 7.5 cm. Histopathological hysterectomy and bilateral salpingo-oophorectomy were performed. Histopathological examination of the surgical examination of the curettings revealed moderately wellspecimen revealed wellditferentiated typical endometrial differentiated typical endometrial adenocarcinomawithout adenocarcinoma with penetration of the inner third of involvement of the endocervix. At laparotomy all pelvic the myometrium and bilateral ovarian serous papillary and abdominal viscera, and in particular the uterus and cystadenocarcinoma.The patient was given postoperative its adnexae, appeared normal. Total abdominal hysterwhole-abdomenirradiaton followed by chemotherapy with ectomy and bilateral salpingo-oophorectomy were permethotrexate, 5-lluorouracil, and cyclophosphamide and formed. Histopathological examination of the surgical hormone therapy with progesterone. Sixteen months later specimen showed moderately well-differentiated typical endometrial adenocarcinoma with penetration into the she died because of widespread metastatic disease. Comment. Endometrial carcinoma corresponded to inner third of the myometrium, and left ovarian moderately stage IB, grade 1 and ovarian carcinoma at least to stage welldifferentiated endometrioid carcinoma without penetration of the ovarian capsule. The patient made an MB. uneventful postoperative recovery. She was given postoperative radiotherapy with external pelvic irradiation Case 4 and vaginal vault brachytherapy. Today, more than 2 A 57-yearold, gravida 2, para 2 postmenopausalwoman years after surgery, the patient is alive and well and with presented in December 1982with postmenopausal bleed- no evidence of recurrent disease. Comment. This is the only case in which both endoing. Pelvic examination revealed a uterus of normal size
263
CASE REPORT
metrial and ovarian carcinoma harbored the same histologic subtype of malignancy. If in this case an endometrial cancer had spread to the ovary, then the stage should be III, and if an ovarian cancer had spread to the uterus then stage IIA should be assigned to the ovarian carcinoma. The very favorable outcome in this patient makes the assumption of widespread disease unlikely. Again, assuming two primaries, the endometrial carcinoma corresponded to stage IA, grade 2 and the ovarian cancer to stage IA. DISCUSSION The synchronous occurrence of endometrial and ovarian carcinomas, according to the literature, is not uncommon. The reported prevalence rate of endometrial carcinoma in patients with ovarian carcinoma ranges from 1.6% [21 to 67.0% [3] with a mean of approximately 20% [4,5]. The reported prevalence rate of ovarian carcinoma in patients with endometrial carcinoma is relatively lower and ranges from 0.7% [2] to approximately 10% [4]. In the present study we noted simultaneous carcinomas of the endometrium and ovary in 5 of 152 patients with ovarian carcinoma (3.28%) and 156 patients with endometrial carcinoma (3.20%). Endometrioid carcinoma of the ovary has been cited to be the histologic subtype of ovarian carcinoma most often associated with carcinoma involving the endometrium [4,6]. Like Rose et al. [2], we could not confirm this observation. Although all carcinomas involving the endometrium in our cases were typical endometrial adenocarcinomas, ovarian endometrioid carcinoma was found in only one case (case 5), whereas in the other four cases the ovarian carcinomas were of the serous papillary subtype. A patient presenting with synchronous carcinomas of the endometrium and ovary poses a diagnostic dilemma. If different histologic subtypes are present in the endometrium and ovary then one may assume the coexistence of two primary tumors. Still, Zaino et al. [4] stated that “the common finding of mixed epithelial neoplasms and the suggestion that epithelial tumors may differentiate in different directions make the argument less than compelling.” If both endometrium and ovary harbor the same histologic subtype of malignancy, no definite decision can be made as to whether a single metastatic tumor or two separate primary tumors are present. Accumulating experience [2-9] indicates a surprisingly good survival rate in patients with synchronous carcinomas of endometrium and ovary, even and especially if the same histologic subtype of malignancy is present in both endometrium and ovary, unless the endometrial cancer
is an unusual variant (papillary, clear cell, mutinous, or mixed) [7] or if it invades deeply into the myometrium
[41. Mounting data indicate that when both carcinomas are confined within the limits of their tissue of origin without evidence of spread into adjacent tissues or organs they should be considered as separately and synchronously occurring low-stage primaries. This is true whether the carcinomas are of the same or of different histologic subtypes. Two of our five patients (cases 2 and 5) corresponded to this description. Interestingly, one of these two patients presented with three primary gynecological cancers and is presented extensively elsewhere [9]. Indeed, the outcome in these two patients was excellent. Cases 1, 3, and 4 represent either synchronous carcinomas with at least one of the coexisting carcinomas in an advanced stage or a single advanced-stage carcinoma originating in either the endometrium or the ovary with metastases.The unfavorable outcome was probably related to the extent of widespread disease and not to the synchronicity of tumors. Appropriate therapy in cases of synchronous carcinomas of endometrium and ovary should be planned individually for each patient. Such parameters as stage, grade, and extent of myometrial invasion should be taken into consideration. We suggest that very-low-stage and -grade endometrial adenocarcinoma (i.e., FIG0 stage IA, grade 1) with minimal myometrial invasion associated with verylow-stage ovarian carcinoma (i.e., FIG0 stage IA) may require only total abdominal hysterectomy and bilateral salpingo-oophorectomy. However, we must admit that one cannot be so definite on this point since many authors feel that all stages of ovarian carcinoma, including low stages (obviously excluding the so-called borderline lesions), should also be treated with adjuvant chemotherapy. On the other hand, cases of more advanced stage and grade of either endometrial or ovarian carcinoma obviously require more extensive surgery with radiotherapy and/or adjuvant chemotherapy.
REFERENCES 1. Announcement: changes in definitions of clinical staging for carcinoma of the cervix and ovary: International Federation of Gynecology and Obstetrics, Amer. J. Obstet. Gynecol. 156, 263-264 (1987). 2. Rose, P. G., Herterick, E. E., Boutselis, J. G., Moesberger, M., and Sachs, L. Multiple primary gynecologic neoplasms, Amer. J. Obstet. Gynecol. 157, 261-267 (1987). 3. Docker@, M. B. Primary and secondary ovarian adenocanthoma, Surg. Gynecol. Obstet. 99, 392-400 (1954). 4. -0, R. J., Unger, E. R., and Whitney, C. Synchronous carcinomas of the uterinecorpus and ovary, Gynecol. Oncol. 19,329-335 (1984). 5. Axelrod, J. H., Fruchter, R., and Boyce, J. C. Multiple primaries
264
PIURA AND GLEZERMAN
among gynecologic malignancies, Gynecol. Oncol. l&359-372 (1984). 6. Czemobilsky, B., Silverman, B. B., and Mikuta, J. J. Endometrioid carcinoma of the ovary, Cancer 26, 1141-l 152 (1972). 7. Eifel, P., Hendrickson, M., Ross, J., Ballon, S., Martinez, A., and Kempson, R. Simultaneous presentation of carcinoma involving the ovary and uterine corpus, Cancer 50, 163-170 (1982).
8. Mahock, D. L., Salem, F. A., Charles, E. H., and Savage, E. W. Synchronous multiple neoplasms of the upper female genital tract, Gynecol. Oncol. 13, 271-277 (1982). 9. Glezerman, M., Piura, B., and Leiberman, J. R. Long term survival in a patient with synchronous endometrial cervical and ovarian carcinomas. Submitted for publication.
ONCOLOGY
33, 261-264 (1989)
CASE REPORT Synchronous Carcinomas of Endometrium and Ovary BENJAMIN PIURA, Division
of Obstetrics
M.D., MRCOG,’ AND MAREK GLEZERMAN, M.D.
and Gynecology, Soroka Medical Center, and Faculty of Health Ben-Gurion University of the Negev, Beer-Sheva, Israel
Sciences,
Received November 30, 1987
Five casesof synchronous carcinomas of uterine endometrium and ovary are reported. All uterine cancerswere typical endometrial adenocarcinomas. Among the ovarian cancers, four were serous papillary cystadenocarcinomas and one was an endometrioid carcinoma. There is much controversy with respect to staging and management of such casessince these tumors may represent either two synchronously occurring primaries or a single primary with metastases. It is suggested that when each tumor is confined within the limits of its tissue of origin the tumors may be considered as two separate primaries and surgery may be less aggressive. When there is evidence that at least one tumor is spreading to adjacent tissues and organs the question of two separateprimaries or one metastatic tumor becomesacademic only and aggressive surgical treatment with adjuvant chemotherapy is indicated. D rw9
assumption of synchronously tumors.
occurring two primary
CASE REPORTS
Case 1
A 40-year-old, gravida 0 woman presented in November 1966 with abnormal uterine bleeding. Pelvic examination revealed a large irregular central pelvic mass, comparable in size to a uterus of 18 weeks’ gestation. Diagnostic curettage was performed and histopathological examination of the curettings showed moderately well-differentiated typical endometrial adenocarcinoma. At lapaAcademic Press, Inc. rotomy a ruptured left ovarian tumor measuring 18x 15 x 15 cm and a diffusely enlarged uterus were discovered. The right ovary and the fallopian tubes appeared INTRODUCTION normal as did the other pelvic and abdominal viscera. When two or more tumors occur in a patient closely Total abdominal hysterectomy and bilateral salpingoin time they are termed synchronous tumors. Since the oophorectomy were performed. Histopathological exendometrium is a common site for metastases of ovarian amination of the surgical specimen revealed moderately carcinoma and the ovary is a common site for metastases well-differentiated typical endometrial adenocarcinoma of endometrial carcinoma, the synchronous occurrence with penetration of the inner third of the myometrium of endometrial and ovarian carcinomas may be interpreted and ovarian serous papillary cystadenocarcinoma. After either as two separate primaries or as one primary tumor an uneventful immediate postoperative recovery the pawith metastases. Among 156 patients with endometrial tient was given whole-abdomen irradiation followed by carcinoma and 152 patients with ovarian carcinoma di- chemotherapy with oral cyclophosphamide. Twenty-four agnosed at the Soroka Medical Center, Beer-Sheva, Israel, months later she died because of metastatic widespread from January 1961 through December 1986, five patients disease. presented with carcinomas synchronously involving the Comment. In 1966, staging procedures for ovarian canendometrium and ovary. cer were less extensive than today. It is therefore assumed Case reports of these patients are presented. On the that this patient may have been understaged. The least basis of clinical information and surgical protocols re- stage for endometrial carcinoma in this case is IB, grade trieved from the files, the extent of disease was staged 2 and for ovarian carcinoma, IC. according to FIGO, 1985 [l]. Staging was done on the Case 2 ’ To whom correspondence should be addressed: Division of Obstetrics and Gynecology, Soroka Medical Center, P.O. Box 151, Beer-Sheva, 84101, Israel.
A 49-year-old, gravida 9, para 2 woman was admitted in September 1977 because of postmenopausal bleeding.
261 0090-8258/89 $1SO Copyright 0 1989by AcademicPress,Inc. All rights of reproductionin any form reserved.
PIURAANDGLEZERMAN Pelvic examination disclosed a left adnexal cystic mass measuring 10x 10x 10 cm and a nomal-sized uterus. Fractional curettage revealed well-differentiated typical endometrial adenocarcinoma extending into the endocervix. At laparotomy, a left ovarian intact cystic tumor measuring 10x 10x 10 cm was discoveredwhile the uterus and the opposite adnexa appeared grossly normal. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Histopathological examination of the surgical specimen showed atrophic endometrium and endocervix with no residual tumor, left ovarian serous papillary cystadenocarcinoma, and poorly differentiated invasive squamous cell carcinoma of the uterine cervix. The patient was given postoperative radiotheraphy with external pelvic irradiation and intravaginal brachytherapy. Today, more than 10 years after the surgery, the patient is alive and well with no evidence of recurrent disease. Comment. In this case endometrial carcinoma correspondedto stageIA, grade 1. (Extension of the endomettial cancer into the endocervix as observed during diagnostic curettage was probably a false-positive finding. See also the comment to Case 4.) Ovarian carcinomacorresponded to stage IA and cervical carcinoma to stage I3 occult.
and shapeand unpalpableadnexae.At fractional curettage hysterometry was 7 cm. Histopathological examination of the curettings revealed moderately well-differentiated typical endometrial adenocarcinoma in both endometrial and endocervical curettings. At laparotomy, apart from a right ovarian intact cystic tumor measuring 6x6x 6 cm, all pelvic and abdominal organs in particular the uterus, the left ovary, and the fallopian tubes, appeared grossly normal. Radical hysterectomy (Wertheim operation) including bilateral pelvic lymphadenectomy and bilateral salpingo-oophorectomy were performed. Histopathological examination of the surgical specimen disclosed moderately well-differentiated typical endometrial adenocarcinoma,with no evidenceof myometrial invasion and without spread into cervical tissues, and right ovarian serous papillary cystadenocarcinoma,with extension into the right fallopian tube. The patient was given postoperative chemotherapy with doxorubicin, &platinum, and cyclophosphamide and hormone therapy with progesterone. Eighteen months later she died of progressive widespread disease. Comment. The stage for endometrial carcinoma in this patient was probably IA, grade 2, notwithstanding the fact that on fractional curettage tumor cells were obtained from the endocervix. First, endocervical curettage in paCase 3 tients with endometrial carcinoma is, in up to 50% of A M-year-old gravida 2, para 2 postmenopausalwoman cases, false positive due to technical error. Second, the was referred in July 1980 because of a palpable pelvic surgical specimen in this particular case did not reveal mass. Pelvic examination confirmed the existence of a any tumor. The stage for ovarian carcinoma was IIA. large irregular central pelvic mass the size of 16 weeks’ gestation. No preoperative curettage was performed. At Case 5 laparotomy bilateral ruptured ovarian tumors, each meaA 61-year-old, gravida 0 postmenopausal woman was suring approximately 10x 10x 10 cm, and an enlarged admitted in August 1985 because of postmenopausal uterus the size of 8 weeks’ gestation were discovered. bleeding. Pelvic examination disclosed a uterus of normal All pelvic and abdominal peritoneal surfaceswere studded size and shape and unpalpable adnexae. At fractional with innumerable small tumor nodules. Total abdominal curettage hysterometry was 7.5 cm. Histopathological hysterectomy and bilateral salpingo-oophorectomy were performed. Histopathological examination of the surgical examination of the curettings revealed moderately wellspecimen revealed wellditferentiated typical endometrial differentiated typical endometrial adenocarcinomawithout adenocarcinoma with penetration of the inner third of involvement of the endocervix. At laparotomy all pelvic the myometrium and bilateral ovarian serous papillary and abdominal viscera, and in particular the uterus and cystadenocarcinoma.The patient was given postoperative its adnexae, appeared normal. Total abdominal hysterwhole-abdomenirradiaton followed by chemotherapy with ectomy and bilateral salpingo-oophorectomy were permethotrexate, 5-lluorouracil, and cyclophosphamide and formed. Histopathological examination of the surgical hormone therapy with progesterone. Sixteen months later specimen showed moderately well-differentiated typical endometrial adenocarcinoma with penetration into the she died because of widespread metastatic disease. Comment. Endometrial carcinoma corresponded to inner third of the myometrium, and left ovarian moderately stage IB, grade 1 and ovarian carcinoma at least to stage welldifferentiated endometrioid carcinoma without penetration of the ovarian capsule. The patient made an MB. uneventful postoperative recovery. She was given postoperative radiotherapy with external pelvic irradiation Case 4 and vaginal vault brachytherapy. Today, more than 2 A 57-yearold, gravida 2, para 2 postmenopausalwoman years after surgery, the patient is alive and well and with presented in December 1982with postmenopausal bleed- no evidence of recurrent disease. Comment. This is the only case in which both endoing. Pelvic examination revealed a uterus of normal size
263
CASE REPORT
metrial and ovarian carcinoma harbored the same histologic subtype of malignancy. If in this case an endometrial cancer had spread to the ovary, then the stage should be III, and if an ovarian cancer had spread to the uterus then stage IIA should be assigned to the ovarian carcinoma. The very favorable outcome in this patient makes the assumption of widespread disease unlikely. Again, assuming two primaries, the endometrial carcinoma corresponded to stage IA, grade 2 and the ovarian cancer to stage IA. DISCUSSION The synchronous occurrence of endometrial and ovarian carcinomas, according to the literature, is not uncommon. The reported prevalence rate of endometrial carcinoma in patients with ovarian carcinoma ranges from 1.6% [21 to 67.0% [3] with a mean of approximately 20% [4,5]. The reported prevalence rate of ovarian carcinoma in patients with endometrial carcinoma is relatively lower and ranges from 0.7% [2] to approximately 10% [4]. In the present study we noted simultaneous carcinomas of the endometrium and ovary in 5 of 152 patients with ovarian carcinoma (3.28%) and 156 patients with endometrial carcinoma (3.20%). Endometrioid carcinoma of the ovary has been cited to be the histologic subtype of ovarian carcinoma most often associated with carcinoma involving the endometrium [4,6]. Like Rose et al. [2], we could not confirm this observation. Although all carcinomas involving the endometrium in our cases were typical endometrial adenocarcinomas, ovarian endometrioid carcinoma was found in only one case (case 5), whereas in the other four cases the ovarian carcinomas were of the serous papillary subtype. A patient presenting with synchronous carcinomas of the endometrium and ovary poses a diagnostic dilemma. If different histologic subtypes are present in the endometrium and ovary then one may assume the coexistence of two primary tumors. Still, Zaino et al. [4] stated that “the common finding of mixed epithelial neoplasms and the suggestion that epithelial tumors may differentiate in different directions make the argument less than compelling.” If both endometrium and ovary harbor the same histologic subtype of malignancy, no definite decision can be made as to whether a single metastatic tumor or two separate primary tumors are present. Accumulating experience [2-9] indicates a surprisingly good survival rate in patients with synchronous carcinomas of endometrium and ovary, even and especially if the same histologic subtype of malignancy is present in both endometrium and ovary, unless the endometrial cancer
is an unusual variant (papillary, clear cell, mutinous, or mixed) [7] or if it invades deeply into the myometrium
[41. Mounting data indicate that when both carcinomas are confined within the limits of their tissue of origin without evidence of spread into adjacent tissues or organs they should be considered as separately and synchronously occurring low-stage primaries. This is true whether the carcinomas are of the same or of different histologic subtypes. Two of our five patients (cases 2 and 5) corresponded to this description. Interestingly, one of these two patients presented with three primary gynecological cancers and is presented extensively elsewhere [9]. Indeed, the outcome in these two patients was excellent. Cases 1, 3, and 4 represent either synchronous carcinomas with at least one of the coexisting carcinomas in an advanced stage or a single advanced-stage carcinoma originating in either the endometrium or the ovary with metastases.The unfavorable outcome was probably related to the extent of widespread disease and not to the synchronicity of tumors. Appropriate therapy in cases of synchronous carcinomas of endometrium and ovary should be planned individually for each patient. Such parameters as stage, grade, and extent of myometrial invasion should be taken into consideration. We suggest that very-low-stage and -grade endometrial adenocarcinoma (i.e., FIG0 stage IA, grade 1) with minimal myometrial invasion associated with verylow-stage ovarian carcinoma (i.e., FIG0 stage IA) may require only total abdominal hysterectomy and bilateral salpingo-oophorectomy. However, we must admit that one cannot be so definite on this point since many authors feel that all stages of ovarian carcinoma, including low stages (obviously excluding the so-called borderline lesions), should also be treated with adjuvant chemotherapy. On the other hand, cases of more advanced stage and grade of either endometrial or ovarian carcinoma obviously require more extensive surgery with radiotherapy and/or adjuvant chemotherapy.
REFERENCES 1. Announcement: changes in definitions of clinical staging for carcinoma of the cervix and ovary: International Federation of Gynecology and Obstetrics, Amer. J. Obstet. Gynecol. 156, 263-264 (1987). 2. Rose, P. G., Herterick, E. E., Boutselis, J. G., Moesberger, M., and Sachs, L. Multiple primary gynecologic neoplasms, Amer. J. Obstet. Gynecol. 157, 261-267 (1987). 3. Docker@, M. B. Primary and secondary ovarian adenocanthoma, Surg. Gynecol. Obstet. 99, 392-400 (1954). 4. -0, R. J., Unger, E. R., and Whitney, C. Synchronous carcinomas of the uterinecorpus and ovary, Gynecol. Oncol. 19,329-335 (1984). 5. Axelrod, J. H., Fruchter, R., and Boyce, J. C. Multiple primaries
264
PIURA AND GLEZERMAN
among gynecologic malignancies, Gynecol. Oncol. l&359-372 (1984). 6. Czemobilsky, B., Silverman, B. B., and Mikuta, J. J. Endometrioid carcinoma of the ovary, Cancer 26, 1141-l 152 (1972). 7. Eifel, P., Hendrickson, M., Ross, J., Ballon, S., Martinez, A., and Kempson, R. Simultaneous presentation of carcinoma involving the ovary and uterine corpus, Cancer 50, 163-170 (1982).
8. Mahock, D. L., Salem, F. A., Charles, E. H., and Savage, E. W. Synchronous multiple neoplasms of the upper female genital tract, Gynecol. Oncol. 13, 271-277 (1982). 9. Glezerman, M., Piura, B., and Leiberman, J. R. Long term survival in a patient with synchronous endometrial cervical and ovarian carcinomas. Submitted for publication.