Kieran Sultan, PGY4 Penrose St. Francis Hospital

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Augustine Floyd
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1 Kieran Sultan, PGY4 Penrose St. Francis Hospital 67 G3, P3 female with no routine medical care and PMH of DM-2. Presented to the ED 10 days after a road trip c/o SOB, intermittent nonproductive cough and crampy right calf pain. PE: unremarkable. CTA: extensive bilateral pulmonary thromboemboli. Admitted and placed on IV heparin & Coumadin with subsequent IVC filter. Vaginal US: thickened uterine lining. D/C after 3 days with recommendations to follow up with pulmonology and referred for an endometrial bx. 2 1

2 Continued anticoagulation under the care of a pulmonologist. FOBT and mammogram both negative. Did not f/u with gynecology. Increasingly tired and weak. 4-5 episodes of vaginal bleeding. gush of blood not followed by persistent bleeding 3 Was sent to ED by pulmonologist after appearing very pale at office visit. Labs: Hg 4.5, Hct 15.4, MCV 62, INR 3.0. Admitted and transfused 4u RBCs. Pelvic US: large (19.1 cm) multilobulated central pelvic mass, mostly c/w fibroid uterus. GYN service: multilobular palpable uterus above the level of the umbilicus. MR pelvis: hypervascular uterine mass leiomyosarcoma vs endometrial carcinoma vs fibroid. Surgery planning began including a pre-op uterine artery embolization. Referred to the gynecologic oncology service and scheduled for surgery. 4 2

parametria, upper vaginectomy, pelvic and

23 cm tan-white nodular myometrial mass with

3 Exploratory laparotomy with radical hysterectomy, bilateral SOO, bilateral parametria, upper vaginectomy, pelvic and aortic lymphadenectomies, and soft tissue samplings. Gross findings Markedly distorted uterus with a 23 cm tan-white nodular myometrial mass with areas of hemorrhage and necrosis. Unremarkable 0.1 cm thick tan-pink endometrium. No tumor noted in other organs

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7 Desmin CD10 Smooth Muscle Actin Cyclin D1 Bcl

9 Uterine leiomyosarcoma 23 cm in greatest dimension IHC Positive: smooth muscle actin Negative: CD10, Desmin, Cyclin D1, BCL-2 Involvement of parametrial and left-paraovarian tissue Margins uninvolved (<1 mm from serosal margin) 0/11 LN Extensive LVI pt1b, pn0 >5 cm and limited to the uterus. Endometrioid endometrial adenocarcinoma FIGO grade 1 Myometrial invasion: 5 mm (<50%) Focal LVI pt1a, pn0 17 No further therapy needed for pt1a endometrioid adenocarcinoma. Completed 6 cycles Gemzar and Taxotere. Persistent rash and itchiness, partially controlled with addition of Solumedrol and Dexamathasone. Developed SOB and bilateral LE edema after 4 th dose. Admitted for epistaxis and LUE cellulitis after 5 th dose. CA-125 initially dropped to 15 and increased to 37 in August and 46 in October. Surveillance CT 10/21 7 mm RLL nodule and moderate left hydronephrosis with ureteral thickening and periureteral fat stranding. 11/5 ureteral stent placed. 18 9

10 PET/CT 4 cm new PET avid left pelvic mass. FDG negative pulmonary nodule which is new from June and enlarged from CT in October. 12/28/15 Exploratory laparotomy with left pelvic dissection and excision of recurrent pelvic mass. Leiomyosarcoma present in soft tissue adjacent to right obturator LN, left pelvic sidewall and in presacral space mass. No features of adenocarcinoma. 19 Jan & Feb 2016 Consults with radiation oncology and sarcoma specialist team in Denver with consideration of clinical trials. F/U CT, 2/16/ cm local recurrence in left pelvis and progression of lung disease. 3/2/16 Began Doxil, 6-12 cycles Left foot neuropathy - controlled with gabapentin. As of April 26, the patient is tolerating Doxil and is scheduled for surveillance CT

Multiple gynecologic cancers are seen in approximately 1% of cases and are primarily endometrial and ovarian primaries.

components within the same lesion. Heterologous elements usually merge with the sarcoma component.

21 66F with 6 month h/o vaginal bleeding. EMBX revealed endometrial carcinoma. Hysterectomy Gross: 0.

11 Multiple gynecologic cancers are seen in approximately 1% of cases and are primarily endometrial and ovarian primaries. Carcinosarcomas account for <5% of uterine malignancies and are composed of a mixture of typically high-grade carcinomatous and sarcomatous components within the same lesion. Heterologous elements usually merge with the sarcoma component. Our case consisted of two morphologically distinct and spatially separate tumors rendering the diagnosis of two separate uterine primaries F with 6 month h/o vaginal bleeding. EMBX revealed endometrial carcinoma. Hysterectomy Gross: 0.9 cm fungating endometrial mass and underlying and distinctly separate 3 cm well-circumscribed myometrial nodule. Histology: well-differentiated endometrioid adenocarcinoma with minimal myometrial invasion and separate high-grade leiomyosarcoma

56F c/o pelvic pain and vaginal bleeding. Pelvic US: 4 mm thick endometrium and 9 cm solid & cystic right adnexal mass. Well-differentiated ovarian mucinous cystadenocarcinoma.

23 International Journal of Surgery Case Reports, Volume 22, 32-34. 60F with 4 yr h/o PMB. EMBX showed grade 2 endometrioid adenocarcinoma. Hysterectomy Grade 2 endometrioid adenocarcinoma 7.

12 56F c/o pelvic pain and vaginal bleeding. Pelvic US: 4 mm thick endometrium and 9 cm solid & cystic right adnexal mass. Well-differentiated ovarian mucinous cystadenocarcinoma. Well-differentiated endometrial endometrioid adenocarcinoma. Uterine leiomyosarcoma. 6 cycles of paclitaxel and carboplatinum. Disease free at 2 years. 23 International Journal of Surgery Case Reports, Volume 22, F with 4 yr h/o PMB. EMBX showed grade 2 endometrioid adenocarcinoma. Hysterectomy Grade 2 endometrioid adenocarcinoma 7.2 cm fungating anterior endometrial mass invading 92% of myometrial thickness and into the cervical stroma. Incidental 2.2 metastatic nodule in the right meso-ovarian soft tissue. Leiomyosarcoma Small component of 10.5 cm posterior myometrial mass that predominantly had features of a leiomyoma. Enlarged bilateral ovarian cystadenofibromas

13 25 Metaplasia of similar cells at different locations under the same oncogenic stimuli. Shared hormonal receptors of different primary tumors in predisposing tissues

Female Genital Tract Lab. Dr. Nisreen Abu Shahin Assistant Professor of Pathology University of Jordan

Female Genital Tract Lab. Dr. Nisreen Abu Shahin Assistant Professor of Pathology University of Jordan Female Genital Tract Lab Dr. Nisreen Abu Shahin Assistant Professor of Pathology University of Jordan Ovarian Pathology A 20-year-old female presented with vague left pelvic pain. Pelvic exam revealed