Invasive Endometrial Lesion in a Patient with Mental Retardation

Abstract

A 46-year-old Caucasian woman with mental retardation experienced discomfort and irregular menstrual bleeding, which had been increasing for 2 years. The physician from her group home sent her to a gynecologist, where a mass prolapsing through the cervix was noted on physical examination. Cervical and endometrial biopsies were done. Both showed polypoid fragments of endometrium with complex hyperplasia with cytologic atypia and squamous metaplasia (Figure ​(Figure11). A computed tomography scan showed the mass in the uterine cavity, but everything else appeared normal. She was referred to a gynecologic oncologist. Figure 1 Endometrial curettings. A low-power view demonstrating irregular atypical glands with very little intervening stroma. Squamous differentiation is present (arrow). The patient had three risk factors for endometrial cancer: obesity (she weighed 210 pounds, and her body mass index was 36 kg/m2), nulliparity, and hypertension. Both her hypertension and a seizure disorder were well controlled with medications. It was unclear if Pap smears had been done in the past. The probability of endometrial cancer was discussed with her, and she agreed to surgery. Informed consent was obtained through her brother, her legal guardian who also had medical power of attorney. Procedures included exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oopho-rectomy, and bilateral pelvic lymph node dissection. The findings at surgery were a normal appearing uterus, ovaries, and fallopian tubes, with no evidence of obvious disease. The left external iliac vein lymph node appeared pathologically enlarged to 2 cm. The remainder of the pelvic and paraaortic lymph nodes were of normal size, and no other gross abnormalities were seen in the abdomen or pelvis. Clear surgical margins were obtained. On gross pathological examination, the uterus was 223 g and measured 12.3 ⊠ 7 ⊠ 5.3 cm. A polypoid tumor, 9.5 ⊠ 3.2 ⊠ 3.5 cm, was identified, and gross involvement of the lower uterine segment was noted. The cervix and both ovaries were free of disease, both grossly and microscopically, but a right paratubal cyst and left hydrosalpinx were found. Microscopic examination revealed endometrial adenocarcinoma of the endometrioid type (Figure ​(Figure22). Myometrial invasion of 18/20 mm of myometrial thickness was present, and the lower uterine segment was involved up to the endocervical junction. In addition, multifocal lymphovascular invasion was present (Figure ​(Figure33). Figure 2 (a) Section of endomyometrium of the hysterectomy specimen, consisting predominantly of irregular atypical glands infiltrating the myometrium. Focus of solid tumor is present. (b) A high-power view of endometrial carcinoma, endometrioid type, FIGO grade ... Figure 3 Multifocal lymphovascular invasion present within the myometrium (single arrow). The tumor invades the myometrium (double arrow). A total of 28 lymph nodes were excised from the left pelvic, right pelvic, and paraaortic regions. One lymph node in the left pelvis showed metastatic adenocarcinoma, with the largest focus 1.5 cm (Figure ​(Figure44). Figure 4 Extensive involvement of the left pelvic lymph node by metastatic endometrial adenocarcinoma. Note the thin rim of lymph node tissue at the periphery (arrow). Estrogen receptor staining (2–3+) was present in 70% of tumor nuclei; progesterone receptor (3+), 75%; and MIB1, 20% and focally 40% to 50%.