Endometrioid adenocarcinoma is the most common form(nearly 80%) of endometrial carcinoma. These tumors arereferred to as ‘endometrioid’ because they resemble pro-liferative phase of the endometrium. It is common in post-menopausal women ([50 years) and presents as abnormalvaginal bleeding [1]. About 1–8% of these carcinomasoccur in women less than 40 years. Small numbers of caseshave been reported in women under the age of 30 years,the youngest being 15 years. It is unusual in younger agegroup and can be wrongly diagnosed [2,3]. Majority ofpatients present with clinical evidence of polycystic ovar-ian disease but in some reports the patients lacked thesefeatures [4]. With this background we present a case ofendometrial carcinoma in a young woman who presentedwith fibroid.
Miss X, a 30 year old presented with complaints of men-orrhagia since 6 months and abdominal pain since2 months. No other significant complaints noted. Herprevious menstrual history was normal and there was nohistory of diabetes, hypertension, and tuberculosis in thefamily. General physical examination was normal. Abdomi-nal examination revealed a 14–16 week size uterus whichwas non-tender. On vaginal examination, the uterus was14 weeks size and pushed to the right side.
Investigations
Blood investigations revealed Hb% of 7.6 g/dl, ESR of24 mm/h with other blood counts being normal. ChestX-ray was normal. Ultrasound showed ante-verted uterusmeasuring 7.89394.8 cm. Two fibroids noted, one inthe anterior wall measuring 6.796 cm and the other inthe posterior fundal area measuring 594.5 cm. Endo-metrium was 10 mm in thickness (Fig.1).
Case was posted for myomectomy following bloodtransfusion. Intra operative findings revealed a 14-weeksize uterus with an anterior wall fibroid measuring10 cm910 cm for which myomectomy was done. Uterinecavity was opened to look for the posterior fibroid. Acheesy material was drained and sent for histopathology.Myomectomy cut-section showed whorled appearance withcystic and hemorrhagic areas. Endometrial curetting sec-tions showed closely packed endometrial glands with back-to-back with no intervening stroma, pleomorphic stromalinfiltration and areas of necrosis. Histopathological diag-nosis was adeno-carcinoma (endometrioid) and leiomyoma(Figs.2,3).
We were in dilemma for further management consid-ering her age and fertility status. Patient was counseledregarding the management. Staging laparotomy was donewith Total abdominal hysterectomy with bilateral salpingooophorectomy and peritoneal sampling was negative.Gross pathology showed enlarged uterus with anteriormyomectomy scar. Cut section showed fleshy polypoidalgrowth infiltrating myometrium and endocervical canal(Figs.4,5).
SurgicopathologicalstagingwasAdenocarcinomaendometrium well differentiated (G1) Involving[1/2myometrium and endocervical canal (Stage II B) withnormal adnexae (Figs.6,7). Post operative radiotherapywas given. Patient was advised for follow up treatment.
The median age group of patients with endometrial carci-noma is 61 years with 75–80% being post menopausal.Only 3–5% is less than 40 years. In the present case it wassurprising to see endometrial carcinoma in the younger agegroup. Endometrial curette was not done pre operatively,keeping in mind the patient’s age, marital status andultrasound diagnosis.
Endometrial cancer is an estrogen dependent disease.Chronic exposure to estrogen without accompanying bal-ancing effect of progesterone is considered the major riskfor endometrial cancers. Unopposed estrogen condition(premenopausal anovulatory phase like PCOD and func-tioning ovarian tumors) predisposes to endometrial cancers[4,5].
There is considerable evidence that reproductive factorsplay a role in etiology of endometrial carcinoma [6].Nulliparity/Nulligravida is associated with increased riskand there is positive association between infertility andendometrial cancer in young women [7]. Age related riskfactors of endometrial cancer shows that there is knowninverse association between age at menarche. Women whostarted menstruating at 15 years had about 1/3 risk ofcancer compared to those at age 10 years or younger. Riskof endometrial cancer was higher among women who wereolder, heavier and had not been married.
High dose progesterone 200 mg/day has been reportedsuccessfully to reverse atypical hyperplasia and welldifferentiated endometrial adenocarcinoma in 16 (94%)premenopausal women younger than 40 years. Averagetreatment course required to achieve disease regression was9 months [8,9].
To conclude, in a case of fibroid, of more than a decadeof menstrual life, an effort should be made to excludeassociated neoplastic endometrial pathology, irrespectiveof the age.
