Japanese Journal of Clinical Oncology 31:337-340 (2001)
© 2001 Foundation for Promotion of Cancer Research
A Case of Lung Metastasis from Endometrial Adenoacanthoma 17 Years after Initial Treatment
1Division of Thoracic Surgery, 2Division of Thoracic Oncology, 3Division of Pathology and 4Division of Gynecology, Kanagawa Cancer Center, Yokohama, Japan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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In March 1982, a 60-old woman presented with an International Federation of Gynecology and Obstetrics grade 1, stage Ib endometrial adenoacanthoma, histological subtype of endometrial carcinoma. The patient underwent radical hysterectomy and was followed up for 10 years, without disease. In August 1998, an abnormal shadow in the right lung was suggested on a chest X-ray film at her routine health check-up and she came to our hospital for further evaluation. A thin-section computed tomographic scan of the chest suggested a malignant lung tumor, but the diagnosis remained tentative. Open biopsy was recommended, but the patient refused and was followed up on an outpatient basis. In November 1999, a thin-section computed tomographic scan of the chest revealed a slightly enlarged tumor and laboratory examination showed a high serum progastrin-releasing peptide concentration of 90.7 pg/ml. We performed partial resection of right upper lobe with video-assisted thoracic surgery. Pathological examination confirmed the lung tumor had metastasized from endometrial adenoacanthoma. Immunohistochemical stainings of estrogen receptor and progesterone receptor were positive both in the primary and lung tumor, only in the component of adenocarcinoma. After surgery, the serum progastrin-releasing peptide concentration remained unchanged. The patient is currently alive and free of disease.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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Solitary lung metastasis without other sites of recurrence is very rare after initial treatment of endometrial carcinoma, accounting for only 4–6% of all recurrences (1,2). Consequently, surgical resection for lung metastasis from endometrial carcinoma is rarely performed. The longest interval from initial treatment of endometrial carcinoma to detection of lung metastasis previously reported was 110 months (3), far shorter than in our patient (17 years).
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CASE REPORT |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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A 78-year-old woman was found to have an abnormal shadow in the right lung on a chest X-ray film at her routine health check-up; this had not been detected the previous year. The patient came to our hospital for further evaluation in August 1998. The patient had never smoked. Her family history was non-contributory. In March 1982, the patient was found to have an International Federation of Gynecology and Obstetrics (FIGO) grade 1, stage Ib uterine endometrial adenoacanthoma, histological subtype of endometrial carcinoma. Radical hysterectomy was performed and she was followed up for 10 years, without disease, and she subsequently voluntarily discontinued because of a move of residence. Instead of this follow-up, she visited another doctor and was checked by a chest X-ray several times. A thin-section computed tomographic (CT) scan of the chest revealed a solid round shadow without ground-glass opacity. The shadow involved the peripheral vessels, was located in S2 of the right lung and measured 1.0 x 1.0 cm (Fig. 1). On mediastinal contrast, the shadow was irregularly enhanced by contrast medium. These findings suggested the possibility of malignancy. Bronchoscopic examination and transbronchial biopsy were performed, but a definitive diagnosis was not possible. Tumor markers, including carcinoembryonic antigen (CEA), SCC and neuron-specific enolase (NSE) showed no clinically relevant abnormalities except for a slightly elevated progastrin-releasing peptide (pro-GRP) concentration of 68.4 pg/ml. These findings suggested a malignant lung tumor, possibly small cell carcinoma. Incisional biopsy with video-assisted thoracic surgery (VATS) was recommended, but she refused surgery and was followed up on an outpatient basis. In November 1999, a thin-section CT of the chest revealed a slightly enlarged tumor and the serum pro-GRP concentration had increased to 90.7 pg/ml. No lymph node swelling was evident on the chest CT scan. No other primary or metastatic lesions were found. On December 6, 1999, we performed partial resection of the right upper lobe with VATS. Intraoperative frozen section diagnosis strongly suggested metastatic adenoacanthoma from uterine endometrial carcinoma, so we did not perform further resection. Macroscopically, the tumor was a white, solid, elastic, hard mass with an irregular margin. It measured 1.3 cm in size (Fig. 2).
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Histologically, the tumor comprised large or small glandular formations with enlarged round nuclei and large central clumps of histologically benign squamous cells, associated with focal keratinization and formation of intercellular bridges (Fig. 3). The tumor compressed the alveoli. Its margin lacked a bronchioloalveolar pattern. These findings strongly suggested a metastatic adenoacanthoma. Pathological studies of the uterine endometrial carcinoma resected 17 years before revealed irregularly branching glands lined by cuboidal cells, with mild hyperchromatic nuclei focally combined. Squamous metaplasia was sporadically noted (Fig. 4). Intercellular bridges were seen in the areas of squamous metaplasia. There was superficial invasion into the myometrium. The parametria, lymph nodes, Fallopian tubes and ovaries were free of disease. The pathological diagnosis of the uterine endometrial carcinoma was adenoacanthoma, with the same histological features as the lung tumor. Immunohistochemical staining of uterine and lung tumor for estrogen receptor (ER) and progesterone receptor (PgR) was performed; they were strongly positive in both tumors, but only in the component of adenocarcinoma (Fig. 5). Immunohistochemical staining in both tumors for GRP, chromogranin A, synaptophysin and neuronal cell adhesion molecule (N-CAM) and Grimelius argrophilic staining were performed. In the lung tumor, GRP, chromogranin A and synaptophysin were focally positive and N-CAM was negative. In the primary lesion, all these stainings were negative. These findings confirmed that the lung tumor was a metastasis from the uterine endometrial adenoacanthoma diagnosed 17 years previously. No adjuvant treatments were given. The postoperative course was uneventful and the serum pro-GRP concentration remained unchanged. This patient is currently alive and free of disease 14 months after surgical resection.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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Among all metastases from endometrial carcinoma, the longest interval from initial treatment to recurrence previously reported was 26.5 years, but the patient reported had a local recurrence in the vagina (4). The longest interval until lung metastasis from endometrial carcinoma was 110 months (3). In our patient, lung metastasis from endometrial carcinoma was detected 17 years after initial treatment, which we believe is the longest interval to lung metastasis reported to date. Nearly 80% of all recurrences of endometrial carcinoma occur within 3 years after the onset of definitive treatment (1,5,6) and the median interval from initial treatment to detection of lung metastases is 12 months (5). The reported overall incidence of pulmonary metastases is 2.3–4.7% (1,2,5,6). Lung metastases without other sites of recurrence account for 34.5% of all metastases from endometrial carcinoma (2). Lung metastasis from endometrial carcinoma is characterized by multiple, bilateral involvement (2,5). Solitary metastasis, as found in our patient, accounts for only 12–18% (3,6) of all lung metastases from endometrial carcinoma.
Radiographically, lung metastases from uterine cancer are characterized by smooth borders with no cavitation (5), but these findings are non-specific for endometrial carcinoma. Radiographic studies alone often provide insufficient evidence for diagnosis. A gradual increase in the size of abnormal masses on imaging studies suggests the possibility of malignancy, but a definitive diagnosis requires confirmation of pathological and other characteristics.
In our patient, we initially suspected a malignant lung tumor, perhaps primary lung cancer, on the basis of the radiographic findings. The possibility of lung metastasis from the uterine endometrial carcinoma treated 17 years previously was not considered, because late development of solitary lung tumor is rare in patients with endometrial carcinoma. One year later, we confirmed this tumor, suspected to be lung cancer, because of the presentation of a solitary tumor and increased size. Another reason why we suspected primary lung cancer was the increased serum pro-GRP concentration, but it seemed to be accidental because of the unchanged postoperative serum level. The correspondence of the pathological findings of both tumors suggested a relation between the primary tumor and the metastatic tumor, and the results of immunohistochemical staining of ER and PgR, strongly positive only in the component of adenocarcinoma in both tumors, was conclusive evidence. The primary site of metastatic lung adenoacanthoma was the uterus, not other organs.
Lung metastases from endometrial carcinoma are usually treated by chemotherapy, hormone therapy and radiotherapy (7,8). Treatment with surgical resection is rare. Among all pulmonary metastases from endometrial carcinoma, the median interval from detection to death is only 5 months and 80% of patients die within 12 months after detection (5). Most reports do not specify the outcome of surgical resection of lung metastases from endometrial carcinoma (1–3,5) and the survival rate and median survival time after complete resection of lung metastases have not been reported because of the few surgical cases.
The risk of late solitary lung metastasis from endometrial carcinoma is very low, but not negligible. Early detection of lung metastases requires long-term follow-up of patients with a history of endometrial carcinoma. During follow-up, a newly appeared solitary pulmonary nodule detected on the chest radiography has some possibilities, including lung metastasis, primary lung cancer and other tumors. In case of increased size or suspected malignant tumor, surgical resection is necessary for treatment and to make a differential diagnosis from primary lung cancer.
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FOOTNOTES |
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+ For reprints and all correspondence: Hiroyuki Ito, Division of Thoracic Surgery, Kanagawa Cancer Center, 1–1–2 Nakao, Asahi-ku, Yokohama 241-0815, Japan. E-mail: JZA01742@nifty.com
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REFERENCES |
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Received December 5, 2000; accepted March 21, 2001.
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