Case Report: 77 Year old Female with PostMenopausal Bleeding

77 year old female with complaint of post-menopausal bleeding. Known case of Diabetes mellitus and hypothyroidism. Had US outside shows enlarged endometrial cavity and left adnexal cyst. Initially endometrial curettage dome: Specimen labeled as “endometrial curettage”. It consists of multiple tan fragments in aggregate of about 3.5 x 3 cm. Histopathology diagnosis came: Serous carcinoma. MRI of pelvis and CT Chest and Abdomen recommended for staging. Elevated tumor marker: CA 125* H 1,580 U/mL (HI) Normal Low 0 Normal High 35 CA 15-3 H 31 U/mL (HI), CA 19-9 * 36 U/mL. Abstract


Imaging
: T2 sagittal (a,g),Coronal (b), axial (d,f) and T2 fat sat axial (c)> The uterus is enlarged, anteverted measuring 8x7.9x17 cm with distention of the endometrium( measuring up to 6 cm )as well as the cervical canal( measuring 5 cm) which are filled with T2 bright signal intensity fluid.

Cancer Therapy & Oncology International Journal
There are numerous polypoid soft tissue lesions seen along the periphery of the endometrial cavity abutting the junctional zone, the largest measuring 2.8 x 2 cm at the right lateral uterine wall ( Figure 1). They demonstrate intermediate low T2 signal intensity (shown by thick arrow in image #b,c,d,e &f). The junctional zone appears infiltrated mainly on right side, no evidence of definite myometrial invasion. Parametrial fat is preserved. Urinary bladder is minimally distended. Distended cervical ca-nal with narrowing of cervico-vaginal region (shown by thin arrow in image (a). Incidentally noted left adnexal cystic lesion with high T2 signal (shown by vertical arrow in image #b) multiple small sigmoid diverticula (shown by curved arrow in image a & b) and lower lumbar spine degenerative changes (shown by triangle in image # a) ( Figure 2). Left adnexal cyst show no diffusion restriction (thin arrow in Image # b) and reveals sign through artifact in corresponding ADC (thin arrow in image # B).

Conclusion of MRI Pelvis
i.
Distended endometrial and cervical cavity with numerous polypoid lesions along its periphery, no definite parametrial invasion. Imaging findings suggest endometrial cancer stage I. Possible stenosis at tip of cervix. ii.
Left adnexal cystic lesion, no features of malignancy.

Surgery was done: Report from System
Procedure: Radical hysterectomy and bilateral salpingo-ooophorectomy and Omentectomy Specimen Source a.
Omentum ii. Minute microscopic focus of endometriosis seen.
iii. Fallopian tube with no specific histopathologic findings.
iv. Negative for malignancy.

Discussion
Endometrial cancer is one of the common pelvic gynecologic malignancy and accounts for 13% of all cancers in women. The most common endometrial cancer is endometroid carcinoma and accounts for 75-80% and is associated with estrogen related endometrial hyperplasia. Serous carcinoma is uncommon type of endometrial cancer that comprises only 5-10% of endometrial carcinoma which usually seen in older age compared to endometrioid cell type and arises from atrophic endometrium and psamomma bodies are found in one third of cases [3]. MRI is more helpful for diagnosis and proper local staging while CT shows non-specific findings usually as enlarged heterogeneous endometrial cavity with heterogeneous enhancement. If calcification present CT is best in detection of calcification. In our case there was no calcification seen by CT. No evidence of metastatic disease seen. Incidentally noted left adnexal cyst with benign imaging feature and histopathologically proven Mucinous cystadenoma.
Serous papillary adenocarcinoma of the endometrium can be misdiagnosed as a metastatic ovarian carcinoma due to psammoma bodies as well as this endometrial malignancy demonstrates many of the same clinical features as ovarian cancer, including a high metastatic potential and response to platinum-based chemotherapy; serum CA 125 level is a useful indicator of disease response or progression in patients with papillary serous carcinoma of the endometrium [2,4]. It is considered type II endometrial adenocarcinoma and has a clinically aggressive form with an early extension of the tumour via Fallopian tubes into the peritoneum and peritoneal seeding which accounts for its poorer prognosis compared to the other adenocarcinomas of the uterus [5].
In conclusion uterine serous carcinoma (USC) is considered type II endometrial adenocarcinoma as uncommon histologic type of mainly seen in post-menopausal women, that may present with extra uterine spread, resulting in high relapse rate and poor prognosis. MRI is most reliable in evaluation of endometrial carcinoma and evaluation of myometrial invasion, parametrial extension and cervical extension as well as lymph node detection. MRI is excellent modality of choice for staging, patient selection for treatment and detection of disease recurrence.