A Rare Presentation of Endometrial Cancer recurrence with Scapular metastasis: A Case Report and Review of the Literature

Nagandla Kavitha (1), Noor Azura Noor Mohamad (1), Nirmala Kampan (2), Mohamad Nasir Shafiee (3)

1.Department of Obstetrics & Gynecology, International Medical University, Clinical Campus

2.Department of Obstetrics & Gynecology, Universiti Teknologi MARA

3.Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia

Correspondence to: Nagandla Kavitha; email: kavitha_nagandla@imu.edu.my

Received: 10 Jul 2021; Revised: 14 Nov 2021; Accepted: 26 Nov 2021; Available online: 2 Jan 2021

 

Abstract

Bone metastasis from endometrial cancer is rare. Most of the early stage endometrial cancers with endometrioid histology are confined to the uterus at the time of diagnosis and confer a good prognosis. Endometrial metastases to the bone are generally restricted to the axial skeleton, including the pelvis and thoracolumbar vertebrae. Skeletal metastases in the appendicular skeleton such as scapula, clavicle and extremities to tibia, and tarsus are rarely reported. We present the case of a 50-year-old woman with diagnosis of endometrioid adenocarcinoma of the endometrium, FIGO stage IB, grade 2, with lympho-vascular space invasion who developed recurrence within 10 months with bone metastasis to left scapula and extraosseous soft tissue mass over left shoulder. There are very few cases reported in literature of scapular metastases in an early-stage endometrial carcinoma. We discuss evaluation, treatment options, overall survival rates and provide a literature review of prior published reports.

 

Ann Afr Surg. 2022; 19(2): 125-129

DOI: http://dx.doi.org/10.4314/aas.v19i2.11

 

Keywords: Endometrial Carcinoma, Recurrence, Bone metastasis, Scapula

 

Funding: None.

© 2022 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

Introduction 

Endometrial  cancer  is  among  the  most  common gynaecologic  malignancy  accounting  for  6%  of  all cancers in women globally (1). Majority of cases are diagnosed in early stage, endometroid subtypes with favourable prognosis. The risk of recurrence is 10-15%and majority of recurrence are estimated to occur in three  years  from  primary  diagnosis  (2).  The  most common sites of recurrence include pelvic,  para-aortic lymph nodes, vagina, peritoneum, and lungs. These are considered as typical sites of recurrence in 80-90% ofcases  (3). However,  the  atypical  sites  of  recurrence include bones, brain, intra-abdominal organs, abdominal wall,  andmuscle  (4). The prevalence  of osseous metastases in endometrial carcinoma ranges from 4 to 7% (5), whereas the muscular and soft tissue metastases

is 2 to 6% (6).  Due to its atypical site, we report this case   of   endometrioid   adenocarcinoma   of   theendometrium  with  bone  metastasis  to  scapula  and extraosseous soft tissue mass. As to date, there is only one case that has been reported in the literature (7).

 

Case Report 

A 50-year-old woman para 3 presented with abnormal uterine bleeding and endometrial sampling revealed acomplex endometrial hyperplasia with atypia. Computed tomography of thorax, abdomen, and pelvis (CT TAP) was suggestive of endometrial mass with no locoregional extension. Following that, she underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy with pelvic and para-aortic lymphadenectomy. The histopathological examination showed moderately differentiated endometroid adenocarcinoma with tumour invading more than half of the myometrium, FIGO stage 1B with lymphovascular space invasion. According to ESMO-ESGO-ESTRO consensus on endometrial cancer 2016, the tumour was in the category of high intermediate-risk hence it was decided by a multidisciplinary team of gynecologic surgeons, pathologists, and oncologists to proceed with adjuvant radiotherapy. The patient received brachytherapy to the vaginal cuff with total dose of 24 Gray (Gy) (4 fractions of 6 Gy) which was completed 4 weeks following surgery. However, five months after the completion of radiotherapy, she presented with left shoulder swelling and pain and limited restricted of movements. A magnetic resonance imaging (MRI) of left shoulder revealed a 3x5x6 cm bony mass, suggestive of metastases (Figure 1).

Click to view figure 1: Figure 1; A magnetic resonance imaging (MRI) of left shoulder revealing a 3x5x6 cm bony mass, suggestive of metastases

Additional computed tomography showed an ill-defined lytic lesion at the left scapula, multiple lung metastasis, enlarged left supraclavicular, left axillary and abdominal lymph nodes. Positron emission tomography (PET)/CT of the whole body demonstrated an ill-defined lytic lesion with extensive soft tissue component seen in superior aspect of the left scapula with increased FDG uptake (SUV max 15.9) and multiple liver metastasis (Figure 2).