Case report: Spontaneous remission of synchronous endometrial and ovarian cancers following pregnancy

Abstract

INTRODUCTION: Endometrial cancer is one of the most common malignancies affecting women. It is uncommonly diagnosed in young women, particularly in the absence of abnormal vaginal bleeding symptoms. CASE PRESENTATION: A 28-year-old woman was referred to our department with lower abdominal pain. Transvaginal ultrasound showed a complex right adnexal mass with mixed echogenicity. Magnetic resonance imaging (MRI) identified a right-sided, torted, cystic solid ovarian mass, and a polypoid lesion in the uterine cavity. DIAGNOSIS: Following multidisciplinary team advice, hysteroscopic transcervical resection of endometrial polypoid mass and laparoscopic right salpingo-oophorectomy was performed. Histopathologic assessment of the endometrial tissue showed changes consistent with grade 1 endometrioid endometrial carcinoma, while the right ovarian mass showed a well-differentiated endometrioid carcinoma. INTERVENTION: The patient underwent hormonal treatment and surveillance whilst making a final decision regarding further surgical management. However, the patient stopped hormonal treatment after 2 weeks, went abroad and absconded from treatment for 8 months. On her return, she had conceived naturally and was in the first trimester of pregnancy. Further management was postponed until the patient was 7 weeks postnatal. The patient was not keen on any further surgical management and opted for close surveillance with ultrasound scans and hysteroscopies with endometrial biopsies. All subsequent endometrial biopsies showed normal endometrium, with no evidence of hyperplasia or malignancy. OUTCOME: To date, the patient remains on a 6-monthly surveillance plan and is considered to have had complete natural remission of her endometrial and ovarian cancers following pregnancy. CONCLUSION: This unique case demonstrates a natural phenomenon, in which the complete, natural remission of endometrial and ovarian cancers occurred following pregnancy and childbirth. The aetiology may be related to the high progesterone levels occurring in pregnancy.

Case Details

Disease Location

Endometrium, adnexa

Personal Characteristics

28-year-old female patient of indian ethnicity

Clinical Characteristics

With a few weeks’ history of right-sided lower abdominal pain, radiating to the right flank. An ultrasound scan performed in primary care showed a right adnexal solid cystic mass. Transvaginal ultrasound showed an anteverted, normally sized uterus, with an endometrial thickness of 16mm. Anechoic areas with doppler colour flow were seen in the endometrial cavity, suggestive of endometrial polyps. In the right adnexa, a solid cystic mass measuring 74 x 58 x 63 mm was seen, with the solid component measuring 40 mm with shadowing. Pelvic MRI showed a polypoid lesion in the uterine cavity. The right adnexal mass was identified within a pool of free ascitic fluid, which extended both behind and in front of the uterus. The mass had bright uptake on t1 weighted series and featured small cysts, suggestive of an enlarged, tortuous, solid cystic right ovarian mass. Laparoscopy confirmed an 8cm right-sided cystic and solid, tortuous mass with omental and peritoneal adhesions and minimal inflammatory ascites. Adhesiolysis followed by uncomplicated right salpingo-oophorectomy was performed and the specimen was removed. The endometrial polypoid tissue showed changes consistent with grade 1 endometrioid endometrial adenocarcinoma. Sections from the right ovarian mass showed features in keeping with a well-differentiated endometrioid ovarian carcinoma. The diagnosis was figo stage 1a, grade 1 endometrioid endometrial adenocarcinoma, and figo stage 1a well-differentiated endometrioid carcinoma of the right ovary, incompletely staged. Eight months later, the patient had conceived naturally and was 9 weeks pregnant at the time of assessment. The patient had an uncomplicated pregnancy and had a spontaneous vaginal delivery at term.

Remission Characteristics

7 days postpartum, a transvaginal ultrasound was unremarkable, with an endometrial thickness of 3.9mm, and a normally appearing left ovary. An endometrial biopsy obtained by pipelle showed hyalinised decidua and inactive endometrium, with no evidence of hyperplasia or neoplasia

Treatment & Mechanisms

Proposed Remission Mechanisms

The persistently high progesterone levels occurring in pregnancy are thought to arrest mitotic activity and suppress carcinogenesis during this period

Clinical Treatment

Adhesiolysis, right salpingo-oophorectomy

Non-Clinical Treatment

None reported