CASE PRESENTATION

Presented by: Dr Asif Rahman K A

Moderated by : Dr Ambedkar
25/3/2022
PERSONAL INFORMATION

• Name: Tamilarasi
• Age: 57y
• Gender: Female
• Address: Villupuram –TN
• Marital status: Married
• Occupation: Daily wage worker
• Socio economic status: Lower middle class
CHIEF COMPLAINTS

• Lower abdominal pain since 5 months

• White discharge P/V since 4 months
• Bleeding P/V since 3 months
HISTORY OF PRESENTING ILLNESS
• 55y old post menopausal female, with no known co-morbidities pesented with
complaints of lower abdominal pain of 5 months duration. Pian was localized over
the lower abdomen. It was insidious in onset, gradually progressive, crampy in
character, radiating to the inner aspect of thighs, on and off throughout the day.
Initially pain was tolerable, which later became severe enough to restrict day to
day activities. There were no aggravating or relieving factors. Abdominal pain was
associated with minimal distention.
• She also had complaints of colourless and odourless discharge P/V of 4 months
duration. It was less volume initially which later became foul smelling and mixed
with blood.
• 2 months after the onset of pain, patient started frank bleeding P/V. Bleeding was
also insidious in onset, progressive, initially had less volume – where she had to
change 2 pads per day, which later became more in amount – where she had to
change 4-5 pads per day. There was associated passage of blood clots in later days.
There were no aggravating or relieving factors
• No resent H/O fever/ chills/ rigor
• No history of any prior episode of bleeding PV or intermittent spotting before this episode.
• No H/O persistent lower abdominal pain.
• No H/O any mass coming out per vaginum.
• No H/O multiple sexual partners or prior genital warts.
• No H/O any prior pap smears tests.
• No H/O intake of pills for contraception
• No H/O intake of any other chronic medications (HRT/ Tamoxifen)
• No H/o weight loss.
• No H/o localised bone pain, cough with expectoration or hemoptysis.
• No h/o blood in the urine/ stool.
• No H/O any visible swellings in the groin.
• No H/O swelling of lower limbs
• No H/O flank pain radiating to the groin or backache
• No h/o bleeding from any other sites
PAST HISTORY
• No history of
• Diabetes mellitus
• Hypertension
• Coronary heart disease
• Chronic kidney disease
• Chronic liver disease
• Bronchial asthma
• Seizure disorders
• Pulmonary Tuberculosis
• No past history of any gynecological diseases.
• No past history of any gynecological procedures or general surgeries
MENSTRUAL / OBSTETRIC HISTORY
• Menarche attained at – 14 years of age
• Menopause attained at the age of – 47 years
• Married at the age of 18 years
• First child birth at the age of 19 years
• P3 L3
• Last child birth at the age of 25 years
• All were full term normal vaginal deliveries
• All were breastfed
• No history of use of any contraception methods
• Sterilized after the last child birth by tubectomy.
• Patient used to have regular cycles, every 28-30 days, with bleeding lasting for 6-7 days.
Used to have moderate to heavy flow and associated lower abdominal pain.
PERSONAL HISTORY
• No h/o passive or active smoking
• No habit of use of any tobacco or alcohol
• Normal mixed diet
• Normal bowel and bladder habits
• Normal sleep
• No habit of regular exercising.
FAMILY HISTORY

• She is the second daughter of a non-consanguineous marriage, with 1 elder

sisters and 1 younger brother
• Her father and mother died due to old age
• No history of malignancies to any of the family members – Specifically Breast
or Colon malignancy.

ALLERGIC HISTORY
• No known allergens
GENERAL EXAMINATION
• Conscious and co-operative
• ECOG - 1
• Well oriented to time, place and person
• Well build and moderately nourished
• Height:150cm Weight:48 Kg BMI:19.72
• Mild Pallor present
• No Icterus
• No Cyanosis
• No Clubbing
• No Generalized lymphadenopathy
• No Pedal edema
• No feeding tubes or output tubes
• VITALS
• BP: 120/80 mmHg
• Pulse: 94/min, regular rhythm and character
• RR: 18/min
• SpO2: 99% on RA
• Temperature: Afebrile

• Supraclavicular fossa is free

• No palpable inguinal nodes
• No palpable lumps in the breast
• No palpable thyroid swellings
SYSTEMIC EXAMINATION

• RESPIRATORY SYSTEM :
• B/L Normal vesicular breath sounds
• No added sounds
• CVS:
• S1 S2 Normal
• No murmurs audible
• CNS:
• No focal neurological deficit
• Per Abdomen:
• Soft
• No visible masses
• Mild tenderness over the hypogastrium
• Normal Bowel sounds
• No palpable masses
• No dilated veins
• No shifting dullness
 Local Examination
•On inspection of the external genitalia
•Mons pubis, clitoris, urethral meatus, fourchette, vulva and anal verge appear normal.
•No visible lesion or warts on the vulva / peri anal area
•No fullness in the groin
•No genital Prolapse
•Serosanguinous discharge present
•P/S Examination
•Proliferative growth replacing the cervix with bleeding spots seen.
•Fornices are full
•Vaginal walls are free. Blood mixed discharge seen over the wall
•P/V Examination
•Proliferative growth replacing both cervical lips.
•All fornices are involved
•Vaginal walls are free
•Uterus is retroverted and bulky

•
• P/V/R examination:
• Right parametria free
• Left parametrium –lesion extending upto lateral pelvic wall.
• Rectal mucosa is free
• Recto vaginal septum is free
SUMMARY
• 57Y old post menopausal female with no known comorbidities presented
with complaints of lower abdominal pian and bleeding P/V of 5 months
duration. On examination patient had a bulky uterus with lesion extending
to left lateral pelvic wall.
DIFFERENTIAL DIAGNOSIS
• Pelvic inflammatory disease
• Endometrial Tuberculosis
• Endometrial polyps
• Uterine fibroids
• Uterine adenomyosis
• Endometrial Carcinoma
• Endometrial hyperplasia
• Cervical carcinoma
• Endometrial leiomyosarcoma
• Endometrial lymphoma
INVESTIGATIONS
1. Routine Blood investigation;
• Complete Hemogram
• RFT with serum electrolytes
• LFT
• Serology
2. Pelvic or transvaginal sonography
3. Chest X Ray
4. Pelvic MRI
• Origin of tumor (Endocervical vs Endometrial)
• Local extend of the disease
• Planning for surgery
• Indication for CECT TAP?
• High grade carcinoma – to r/o mets
• If clinically indicated to r/o mets
• If Carcinoma incidentally detected post surgery
• Incompletly staged CA with risk factors
• Indications for further metastatic workup – with
CECT TAP or PET CT:
• Abnormal physical examination findings
• Bulky uterine tumor
• Vaginal or extra uterine involvement
• Delay in presentation or treatment
• Abdominal / pulmonary symptoms
5. Endometrial Biopsy:
• Office endometrial biopsy
• endometrial curettage (D&C)
• hysterectomy specimen
6. Serum CA 125 –
• Recommended in non endometroid histology
• useful for predicting extrauterine disease
• monitoring clinical response.
MRI:
• Uterus appears bulky, with a T1 hypointense and T2 hyperintense lesion noted involving the endometrial
cavity, and cervix, measuring ~ 4.9 x 4.3 x 7.3 cm.
• The lesion is involving more than half to entire thickness of the myometrium at places.
• Inferiorly, the lesion is extending into the entire cervix and extending into the posterior fornix from the left
lateral aspect.
• Multiple areas of serosal breach is seen - left adnexal region apparently involving the left ovary, right
parametrium etc. Mild free fluid is also seen anteriorly. Sigmoid colon is very closely abut in the posterior
aspect of the lesion.
• No obvious involvement of rest of vagina.
• No extension into the pelvic side wall.
• Multiple rounded T2 hyperintense right common, bilateral external iliac, obturator and inguinal lymph
nodes noted, few showing perinodal stranding and irregular margin - maximum SAD ~ 1.3 cm in right
external iliac level - likely involved.
Treatment Paradigm
• If disease limited to the uterus:
• Principles of Surgery:
• TAH+ BSO and lymph node assessment is the primary treatment for uterine confined
endometrial carcinoma
• It should be removed en bloc to optimize outcome
• Surgery can be performed via any route (laparoscopic, robotic, vaginal or abdominal).
Standard recommendation is to chose minimally invasive approach.
• Lymph nodes to be assessed includes – Pelvic(External iliac, internal iliac, common
iliac and obturator nodes) and para aortic
• Para aortic evaluation is important especially in high gade morphologies, histologies
other than endometroid and deeply invasive lesions.
• Surgery should also include visual examination of peritoneal, diaphragmatic and
serosal surfaces with biopsy from suspicious lesions.
• Omental biopsy is recommended in non endometroid histologies
FIGO STAGING FOR ENDOMETRIAL
CARCINOMA
Adjuvant treatment following Surgical staging is based on the risk of
disease recurrence, which in turn depends on
• Stage
• Histology
• Pathological grade
• Depth of myometrial invasion
• LVSI status
• Tumor size
• Patients age
• Lower uterine segment involvement
Risk stratification in Endometrial Carcinoma (ESMO/ESTRO/ESGO)
LOW RISK ENDOMETRIAL CA
• Risk of nodal involvement is <5%
• Vaginal Brachy may reduce the risk of local recurrence without any improvement in OS.

• Adjuvant treatment is not recommended in low risk.

• Pelvic RT in low risk is associated with increased risk of death and treatment related
toxicities.
Low Risk
INTERMEDIATE RISK ENDOMETRIAL CA
• Pelvic RT is recommended
• Decreased LRR from 14% to 4% without improvement in OS
• Significantly increased the risk of toxicities
Intermediate Risk
HIGH INTERMEDIATE RISK ENDOMETRIAL CA
This subset was formed according to PORTEC ! and GOG 99 trial results
• Most suitable treatment Adjuvant Pelvic RT to decreased LRR
HIGH RISK ENDOMETRIAL CA
• Have increased risk of pelvic recurrence and distant mets.
• Adjuvant treatment even though recommended OS is unclear
• IIIC disease definitely have improved OS after Adjuvant RT

• Here CTRT is recommended

• RT will benefit for LRR
• CT will benefit for Distant mets control
• Adjuvant treatment Stage wise:
• When there is suspected or gross cervical involvement
• When Extra uterine disease is suspected
• When incompletely staged:
Principles of EBRT
• EBRT dose for microscopic disease should be 45-50Gy
• If there is gross residual disease a total dose of 60-70 Gy should be
given.
• For gross nodal disease, consider boost to 60-65Gy.
• For NART, doses of 45-50Gy are used.
Principles of Brachytherapy
• Brachytherapy should be initiated within 6-8Weeks post surgery.
Should not exceed 12 weeks.
Principles of Systemic therapy
• Preferred Regimens for primary/ Adjuvant / Metastatic/ Recurrent
treatment used for Uterine confined disease – Carboplatin + Paclitaxel
TREATMENT HISTORY (presented case)
• With the above mentioned complaints, patient consulted outside hospital, Endometrial
curettage and MRI of pelvis was taken, diagnosed with CA Endometrium.
• She defaulted further treatment due to COVID pandemic.
• She presented with similar complaints in March 2021 to JIPMER, where she was
evaluated in OG and PET CT was taken – which showed locally advanced disease along
with multiple metastasis.
• She was discussed in Multi disciplinary tumor clinic and was planned for Chemotherapy
followed by assessment for surgery.
• She has taken 6 cycles of Paclitaxel and Carboplatin chemotherapy under Medical
oncology and RA PET CT showed partial response.
• Currently being treated under Radiation Oncology for hemostatic RT in view of
persistent bleeding P/V.
THANK YOU