GYNECOLOGIC

ONCOLOGY

39, 96-98

(19%)

CASE REPORT Breast Carcinoma Metastatic to Endometrial Polyp LAURA GEISEL SULLIVAN, M.D.,*? *Department

JEROME L. SULLIVAN, M.D.,

of Pathology and Laboratory Medicine, Medical University Center, Charleston, South Carolina 29425, and IGeorgetown

Received

of South Memorial

March

Carolina, Hospital,

AND

WILLIAM F. FAIREY, M.D.**9

tNava1 Hospital, and $Veterans Affairs Medical Georgetown, South Carolina 29440

15, 1990

Physical exam revealed an elderly, thin woman with an atrophic vagina, unremarkable cervix, and an irregular uterus enlarged to 16week gestational size. Adnexae could not be palpated. Except for a mild normochromic, normocytic anemia, laboratory data were essentially unremarkable. Abdominal ultrasound revealed a 14 x 12 x IO-cm mass in the area of the uterus. Intravenous pyelogram showed a 12-cm soft tissue mass associated with irregular calcifications thought to represent a fibroid uterus. An abdominal hysterectomy with bilateral salpingooophorectomy was performed. The uterus was opened in the operating room and a large intrauterine mass was shelled out of the uterine cavity. The surgeon interpreted the mass grossly as a submucosal leiomyoma. The postoperative course was complicated by subendocardial myocardial infarction with congestive heart failure and bilateral pneumonia.

An elderly woman presented with an enlarged uterus without uterine bleeding. The hysterectomy specimen contained a large, solitary intrauterine mass. Microscopic examination revealed metastatic poorly differentiated adenocarcinoma infiltrating an endometrial polyp. This metastatic tumor appeared histologically identical to the patient’s ductal carcinoma of the breast removed by modified radical mastectomy 6 years earlier. An extrapelvic primary carcinoma metastatic to an endometrial polyp is a very rare event but should be included in the differential diagnosis of 0 1990 Academic Press, Inc. endometrial carcinomas.

INTRODUCTION Extrapelvic carcinomas rarely metastasize to the female genital tract. When they do, the ovaries are involved in approximately 80% of the cases [I]. Metastasis to endometrium, without ovarian or myometrial involvement, is very unusual [2]. Metastasis of an extrapelvic carcinoma to a large solitary endometrial polyp is very rare. This case represents, to our knowledge, the third histologically documented case reported in the literature [3,41.

PATHOLOGIC

FINDINGS

The surgical specimen consisted of a large, light tan, multicystic mass submitted with the uterus, fallopian tubes, and ovaries. The mass measured 11.5 x 6 x 6 cm. On cut surface, numerous small cystic structures ranging from l-2 mm to several centimeters in diameter exuded a slightly mucoid, straw-colored material. The previously opened uterus weighed 430 g. The endometrial surface appeared somewhat roughened; the myometrium was thickened and contained numerous leiomyomata, many of which were calcified. Several large, calcified subserosal leiomyomata were also present. The fallopian tubes and ovaries were unremarkable. Microscopically the mass contained nests of poorly differentiated carcinoma which could be seen in virtually

CASE REPORT An 83-year-old black multipara was found to have an enlarged uterus during a routine pelvic exam. She had experienced no postmenopausal uterine bleeding. Six years earlier, the patient had undergone a left modified radical mastectomy for invasive ductal carcinoma. Two of seventeen axillary lymph nodes were involved by tumor. Estrogen receptor assay was positive with 81.3 fmole of estradiol/mg protein; progesterone receptor assay was negative. A solitary metastasis to skin near the mastectomy incision line measuring 6 x 3 x 2 mm was removed 2 years later. 96 0090-8258190 $1.50 Copyright 0 1990 by Academic Press, Inc. All rights of reproduction in any form reserved.

W.D.,*,$

CASEREF'ORT

all portions of the mass. The tumor cell nests were generally small and solid though often a cribriform pattern could be appreciated. The individual tumor cells had abundant cytoplasm and enlarged vesicular nuclei with prominent nucleoli, and bore a marked similarity to the previously diagnosed ductal carcinoma of breast. Distinctly separate and uninvolved by the tumor were cystically dilated endometrial glands lined by a single layer of flattened cuboidal to low columnar epithelium (Fig. 1). The stroma contained many thick-walled, dilated blood vessels. These findings were interpreted as consistent with a large, atrophic endometrial polyp infiltrated by metastatic tumor of breast origin. Microscopic study of the uterus, ovaries, and tubes revealed inactive endometrium, multiple leiomyomata, atrophic ovaries, and unremarkable fallopian tubes. No other metastases were found. DISCUSSION Metastases to the female genital tract occur most often by the contiguous spread of neighboring tumors or by extensive peritoneal implantation [ 1,2]. Tumors metastasizing to pelvic structures from distant primaries do so primarily by hematogenous spread to the ovaries [I ,2]. Weingold and Boltuch [5] proposed that metastases then spread from the ovaries via lymphatics to the uterus. Ovarian metastases were seen in approximately 80% of 147 cases of extrapelvic metastases to the female genital tract in one series [I]. The ovaries were involved in nearly two-thirds of Kumar and Hart’s [2] 63 cases of uterine corpus metastases from extragenital cancers. Metastases of extrapelvic primaries to the uterine corpus nearly always involve the myometrium [2,3]. Endometrial involvement usually seems to occur by contiguous spread from the myometrium. Of their cases with myometrial involvement, Kumar and Hart [2] found that one-third also involved the endometrium. Endometrial metastases alone, without ovarian or myometrial involvement, are very unusual. Of Kumar and Hart’s 43 autopsy cases with uterine corpus metastases from distant primaries, only two patients had metastases confined to the endometrium [2]. Metastases to the uterus from distant primaries are presumably hematogenous when the ovaries are not affected. Metastasis to an endometrial polyp from a distant extrapelvic primary is very rare. Only two histologically documented cases have been previously reported [3,4]. Kumar and Schneider [3] described one case of ductal carcinoma of the breast metastasizing to an endometrial polyp in their review of 11 cases of uterine metastases of extrapelvic origin. Takeda et al. [4] described a single case of cutaneous melanoma metastasizing to an endometrial polyp. Kumar and Hart [2], in the largest study

97

to date of 63 cases of metastases to the uterus from extragenital cancers, did not report a single case of metastasis to an endometrial polyp. Similarly, di Bonito et al. [6], in their study of 17 cases of primary breast carcinoma metastatic to the uterus, also did not describe any cases involving an endometrial polyp. Involvement of leiomyomas by metastatic extrapelvic carcinomas has been reported much more frequently than metastases involving endometrial polyps. Kumar and Hart [2] found uterine leiomyomata involved in a total of 13 cases, with metastases restricted to a leiomyoma in 6 cases. Banooni et al. [7], Weingold and Boltuch 151, and di Bonito et al. [6] have each reported a case of metastatic carcinoma within a leiomyoma. Banooni et al. 171 also found 8 additional cases previously reported in the literature. Our patient had numerous leiomyomata, but none were found to contain metastatic carcinoma. This patient’s metastatic breast carcinoma was exclusively limited to the large endometrial polyp. The polyp was af the atrophic type, suggesting that it had probably been present for many years. Endometrial polyps are found relatively commonly in postmenopausal women; peak incidence occurs in the middle years of life [8]. They are not true neoplasms, but probably represent circumscribed foci of hyperplasia [8]. Our patient’s large endometrial polyp contained many thick-walled dilated vessels which presumably increased the likelihood that malignant cells would find their way to the endometrium and additionally aided in the establishment of these metastatic cells. Perhaps also the endometrial polyp environment was favorable for this estrogen receptor-positive carcinoma. Breast carcinoma is the most common extrapelvic tumor that metastasizes to endometrium [2,6], accounting for over half of the reported cases. Breast carcinoma was the primary in our patient and in Kumar and Schneider’s patient with metastatic tumor to an endometrial polyp [3]. The primary was cutaneous melanoma in the patient described by Takeda et al. [4]. Other extrapelvic primary sites associated with metastases to the uterus include colon, stomach, pancreas, gallbladder, lung, melanoma of skin, urinary bladder, and thyroid [2]. Post et al. [9] maintain that the frequencies of these tumors metastasizing to the uterus may simply reflect the relative incidence of primaries in the adult female population. The propensity of certain tumors for hematogenous spread may also be a factor in determining the relative frequencies of primaries that selectively involve endometrium. There are several examples in the medical literature in which diagnosis of a uterine metastasis prompted the search and subsequent discovery of a distant primary

98

SULLIVAN,

FIG.

1.

Endometrial

SULLIVAN,

AND FAIREY

polyp with metastatic breast carcinoma surrounding inactive endometrial gland. Hematoxylin-eosin,

[2,3,10-121. With any tumor found in an endometrial curettage or hysterectomy specimen, the possibility of metastasis should be considered [ 11,131.

8.

REFERENCES 1. Mazur, M. T., Hsueh, S., and Gersell, D. J. Metastases to the female genital tract, Cancer 53, 1978-1984 (1984). 2. Kumar, N. B., and Hart, W. R. Metastases to the uterine corpus from extragenital cancers: A clinicopathologic study of 63 cases, Cancer 50, 2163-2169 (1982). 3. Kumar, A., and Schneider, V. Metastases to the uterus from extrapelvic primary tumors, Znr. J. Gynecol. Puthol. 2, 134-140 (1983). 4. Takeda, M., Diamond, M., De Marco, M., and Quinn, D. M. Cytologic diagnosis of malignant melanoma metastatic to the endometrium, Acta Cytol. 22, 503-506 (1978). 5. Weingold, A. B., and Boltuch, S. M. Extragenital metastases to the uterus, Amer. J. Obstet. Gynecol. 82, 1267-1272 (1961). 6. di Bonito, L., Patriarca, S., and Alberico,

7.

S. Breast carcinoma

9.

10.

11. 12.

13.

x 100.

metastasizing to the uterus, Eur. J. Gynaecol. Oncol. 6, 211-217 (1985). Banooni, F., Labes, J., and Goodman, P. A. Uterine leiomyoma containing metastatic breast carcinoma, Amer. J. Obstet. Gynecol. 111, 427-430 (1971). Peterson, W. F., and Novak, E. R. Endometrial polyps, Obstet. Gynecol. 8, 40-49 (1956). Post, R. C., Cohen, T., Blaustein, A. U., and Shenker, L. Carcinoid tumor metastatic to the cervix and corpus uteri, Obster. Gynecol. 27, 171-175 (1966). Leiberman, J., Chaim, W., Cohen, A., and Czernobilsky, B. Primary carcinoma of stomach with uterine metastasis, Brit. J. Obstet. Gynaeco/. 82, 917-921 (1975). Alenghat, E., and Talerman, A. Adenocarcinoma of the vermiform appendix presenting as a uterine tumor, Gynecol. Oncol. 13, 265 268 (1982). Bauer, R. D., McCoy, C. P., Roberts, D. K., and Fritz, G. Malignant melanoma metastatic to the endometrium, Obstet. Gynecol. 63, 264-267 (1984). Puira, B., Bar-David, J., and Goldstein, J. Abnormal uterine bleeding as a presenting sign of metastatic signet ring cell carcinoma originating in the breast: Case report, Brir. J. Obster. Gynaecol. 92, 645-648 (1985).

Breast carcinoma metastatic to endometrial polyp.

An elderly woman presented with an enlarged uterus without uterine bleeding. The hysterectomy specimen contained a large, solitary intrauterine mass. ...
832KB Sizes 0 Downloads 0 Views